Pielonefritis xantogranulomatosa: un reto actual para la laparoscopia.

OBJECTIVE: To present the results of our case series on laparoscopic nephrectomy in xanthogranulomatous pyelonephritis (XGP). METHODS: A retrospective study was conducted that included 143 patients treated with laparoscopic nephrectomy for non-functioning kidney, of whom 15 had XGP, within the time frame of 2011 to 2019. The demographic and clinical data were collected, along with the intraoperative results, complications, and days of hospital stay. RESULTS: Transperitoneal laparoscopic nephrectomy was successfully performed on 15 patients with XGP, with no need for conversion. Mean intraoperative time was 124.4 minutes (range 70-240) and intraoperative blood loss was 148.5 ml (range 30-550), with no blood transfusion required. No intraoperative complications occurred but there was one postoperative complication (6.6%), classified as Clavien-Dindo I (surgical wound infection). Mean hospital stay was 2.85 days (range 2-7). CONCLUSIONS: Nephrectomy is the definitive management for XGP, and the laparoscopic approach should be considered a treatment modality, despite the fact that the pathology involves a severe chronic inflammatory process. Its benefits are reduced surgery duration, less blood loss, a lower complication rate, and fewer days of hospital stay, when performed by a skilled and experienced surgeon.

OBJETIVO: Presentar los resultados de nuestra serie de nefrectomía laparoscópica en pielonefritis xantogranulomatosa (PXG). MÉTODO: Se realizó un estudio retrospectivo que incluyó 143 pacientes tratados con nefrectomía laparoscópica por exclusión renal, de los cuales 15 fueron por PXG, en el periodo comprendido de 2011 a 2019. Se recolectaron datos demográficos y clínicos, resultados transoperatorios, complicaciones y días de estancia hospitalaria. RESULTADOS: Se realizó nefrectomía laparoscópica transperitoneal de forma exitosa en 15 pacientes con PXG, sin necesidad de conversión. El tiempo transoperatorio promedio fue de 124.4 minutos (rango: 70-240). El sangrado transoperatorio fue de 148.5 ml (rango: 30-550), sin requerimiento de transfusión sanguínea. No se reportaron complicaciones transoperatorias; se presentó una complicación en el posoperatorio (6.6%) clasificada como Clavien-Dindo I (infección de la herida quirúrgica). La estancia hospitalaria promedio fue de 2.85 días (rango: 2-7). CONCLUSIONES: El manejo definitivo de la PXG es la nefrectomía, y el abordaje laparoscópico debe ser considerado como una modalidad de tratamiento a pesar de ser una patología que presenta un proceso inflamatorio grave y crónico, obteniéndose beneficios como disminución en el tiempo quirúrgico, menor sangrado, menor tasa de complicaciones y menos días de estancia hospitalaria cuando es realizado por un cirujano experimentado.

Perioperative outcomes and risk factors for major complications associated with nephrectomy for Xanthogranulomatous pyelonephritis: a multicenter study.

PURPOSE: To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy. METHODS: A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed. RESULTS: A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications. CONCLUSION: Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.

Xanthogranulomatous pyelonephritis in a pediatric patient.

INTRODUCTION: Xanthogranulomatous pyelonephritis consists of a chronic infectious and inflammatory process of the renal parenchyma, a variant of chronic obstructive pyelonephritis. It is more prevalent in middle-aged adults, rare in pediatric patients, with less than 300 cases reported in children worldwide. REPORT: Preschooler, aged 2 years and 11 months, male, with 2 months of abdominal distention, increased temperature and intense pallor, associated with microcytic anemia refractory to the use of ferrous sulfate. 1 week before, he had a bulging in his left flank and a hard palpable mass there. Imaging exams (ultrasound and tomography) revealed an overall enlargement of the left kidney, destruction of the renal parenchyma and intense calyceal dilation, forming the "bear's paw" sign, with a staghorn calculus in the pelvis. He underwent treatment with antibiotic therapy and total nephrectomy, with a specimen sent for pathological examination. DISCUSSION: a disease of uncertain incidence in the pediatric age group, xanthogranulomatous pyelonephritis is more prevalent in male children and affects mainly the left kidney, being frequently associated with the presence of stones. Clinically, it has nonspecific symptoms, the most common being abdominal distension and asthenia. Laboratory exams shows microcytic, leukocytosis, thrombocytosis and increased inflammation, pyuria, hematuria and proteinuria, in addition to bacterial growth in urine culture. The diagnosis is anatomopathological, but it can be hinted by contrasted CT scan, with the classical sign of the "bear's paw". Treatment may include nephrectomy and broad-spectrum antibiotic therapy.

Fistula reno-apendicular como presentación inusual de pielonefritis xantogranulomatosa: reporte de caso / Reno-appendicular fistulus as an unusual presentation of xanthogranulomatous pyelonephritis: a case report

Resumen La fístula uro-entérica es una comunicación patológica entre la vía urinaria y digestiva. El compromiso del apéndice es infrecuente y son pocos los casos de fístulas reno-apendiculares en la literatura. Se presenta el caso de un paciente con clínica de fiebre, dolor lumbar e hidronefrosis derecha severa secundaria a cálculo coraliforme en la tomografía de vías urinarias. Manejado inicialmente con antibióticos y nefrostomía bajo fluoroscopia, posteriormente suspendida por paso de contraste al intestino. Se realizó una tomografía contrastada que reportó fístula del riñón al intestino. Se llevó a nefrectomía y se encontró fistula hacía el apéndice, por lo cual se realizó apendicectomía concomitante con mejoría clínica evidente. La patología reportó pielonefritis xantogranulomatosa y apendicitis secundaria. La fístula reno-apendicular posee una clínica inespecífica, la tomografía contrastada es una herramienta diagnóstica y la mayoría se detectan como un hallazgo intraoperatorio. El tratamiento usualmente es quirúrgico, con nefrectomía y reparación del segmento intestinal. MÉD. UIS.2021;34(3): 79-84.

Abstract Uro-enteric fistula is a pathological communication between the urinary and digestive tract. Compromise of the appendix is infrequent and few cases of reno-appendicular fistulas have been described in the literature. The case of patient with symptoms of fever, low back pain and severe right hydronephrosis secondary to staghorn calculus on urinary tract tomography is presented. Initially managed with antibiotics and nephrostomy under fluoroscopy, subsequently suspended by passing contrast to the intestine. A contrasted tomography was performed which reported a fistula from the kidney to the intestine. A nephrectomy was carried out and a fistula was found to the appendix, for which a concomitant appendectomy was performed with evident clinical improvement. The pathology reported xanthogranulomatous pyelonephritis and secondary appendicitis. Reno-appendicular fistula has nonspecific symptoms, contrasted tomography is a diagnostic tool and most are detected as an intraoperative finding. Treatment is usually surgical, with nephrectomy and intestinal segment repair. MÉD.UIS.2021;34(3): 79-84.

La importancia de la evidencia y de la adherencia a los protocolos clínicos en bienestar de los pacientes. Caso clínico de morbimortalidad / The importance of timely and safe care. Report of one case

We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.

Colorenal fistula and urinary tract infection in a pediatric patient with acute lymphoblastic leukemia. / Fístula colorrenal e infección de vías urinarias en paciente pediátrico con leucemia linfoide aguda.

INTRODUCTION: Colorenal fistula is rare in the pediatric population. It may occur at any segment involved by ischemia, chronic inflammation, or necrosis. It is typically associated with a preliminary renal lesion that may arise as a result of interventional procedures, inflammatory conditions, colon tumor, and xanthogranulomatous pyelonephritis, among others. CASE REPORT: 15-year-old female patient diagnosed with acute lymphoblastic leukemia admitted at our institution for baseline condition management. During her stay, she experienced gastrointestinal and urinary infectious events. In the assessment and management of those, a left colorenal fistula was found. Surgical treatment was decided upon. DISCUSSION: Colorenal fistula typically occurs secondary to renal inflammation or infection. Clinical signs are highly variable, and treatment is surgical, with the fistulous tract being resected in all cases.

INTRODUCCION: Las fístulas colorrenales son infrecuentes en la población pediátrica. Pueden desarrollarse en cualquier segmento afectado por isquemia, inflamación crónica o necrosis. Suelen estar asociadas a una lesión primitiva en el riñón que puede producirse por procedimientos intervencionistas, enfermedades inflamatorias, tumorales del colon, pielonefritis xantogranulomatosa, entre otras. CASO CLINICO: Paciente femenina de 15 años, con diagnóstico de leucemia linfoide aguda, ingresa a la institución para recibir manejo de su enfermedad de base. Durante su evolución, desarrolla eventos infecciosos (gastrointestinales y urinarios), y en evaluación y manejo de estos se documenta fístula colorrenal izquierda, motivo por el cual se da un enfoque de tratamiento quirúrgico. COMENTARIOS: La fístula renocólica generalmente se presenta secundaria a procesos inflamatorios o infecciosos renales; su presentación clínica es muy variada, y el tratamiento es quirúrgico, incluyendo siempre la resección del trayecto fistuloso.

[The importance of timely and safe care. Report of one case]. / La importancia de la evidencia y de la adherencia a los protocolos clínicos en bienestar de los pacientes. Caso clínico de morbimortalidad.

We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.

Xanthogranulomatous pyelonephritis with calculus migration into the psoas abscess: an unusual complication

Xanthogranulomatous pyelonephritis (XGP) is a rare variant of chronic pyelonephritis. It is characterized by progressive parenchymal destruction caused by chronic renal obstruction due to calculus, stricture, or rarely tumor, resulting in kidney function loss. Herein, we describe the case of a 36-year-old female who presented with left loin pain, left lower limb pain, and dysuria. On contrast-enhanced computed tomography (CECT), multiple abscesses and an obstructive staghorn calculus were depicted in the left kidney with the classical appearance of "Bear Paw Sign." An abscess with calculi was also present within the left psoas muscle. Though psoas muscle abscess in association with XGP was described, a ureteric fistula and calculi within the psoas muscle have not yet been reported in the literature. Left nephrostomy was performed, which came out to be positive for E. coli on culture. The patient underwent left nephrectomy, and the histopathological report of the surgical specimen confirmed XGP.

Pielonefritis xantogranulomatosa secundaria a litiasis obstructiva en un paciente pediátrico / Pyelonephritis Xanthogranulomatous Secundary to Obstructive Lithiasis in Pediatric Patient

Introducción La pielonefritis xantogranulomatosa (XGPN), es una enfermedad inflamatoria crónica del parénquima renal, de rara presentación en pediatría. Su etiología es multifactorial comenzando con un proceso obstructivo del tracto urinario por litiasis e infección hasta el daño renal crónico. Su diagnóstico se logra por sospecha clínica, estudio imagenológico e histopatológico, lo que require tratamiento definitivo en la mayoría con nefrectomía simple. Materiales y métodos Paciente masculino de 4 años de edad con infección de la vía urinaria y dilatación de pelvis y uréter causada por cálculos que genera un proceso inflamatorio crónico y destrucción del parénquima renal. Sin respuesta clínica a tratamiento antibiótico quien requirió manejo en unidad de cuidados intensivos y nefrectomía. Discusión Se presenta entre la cuarta a sexta década de vida, con reportes de caso en edad pediátrica. Cursa con fiebre, dolor abdominal y masa palpable. Puede presentar en cambio de cursar con leucocitosis, anemia y piuria. Estudio radiológico de XGPN se puede apreciar de forma focal o difusa. A la histopatología se evidencia necrosis tisular crónica con macrófagos espumosos en su interior entremezclados con células inflamatorias. El tratamiento definitivo requiere nefrectomía de unidad renal disfuncional. Conclusiones Se presenta el caso de paciente pediátrico con XGPN por obstrucción urinaria litiásica; entidad de baja frecuencia en ese grupo poblacional, requiere una adecuada correlación clínico-imagenológica e histológica para lograr el diagnóstico final y puede ser tratado con manejo médico y quirúrgico.

Introduction Xanthogranulomatous pyelonephritis (XGPN) is a chronic inflammatory disease of the renal parenchyma, rare in pediatrics. Etiology is multifactorial ranging from an obstructive urinary tract process through lithiasis and infection generating chronic kidney amage. Its diagnosis is achieved by clinical suspicion, imaging and histopathology, which requires definitive treatment in the majority with simple nephrectomy Materials and Methods A 4-year-old male patient with urinary tract infection and dilation of the pelvis and ureter caused by calculus that generate a chronic inflammatory process and destruction of the renal parenchyma. No clinical response to antibiotic treatment that required management and intensive care unit and nephrectomy. Discussion It occurs between the fourth and sixth decade of life, with case reports in pediatric age. Patients have fever, abdominal pain and palpable mass. They can occur with leukocytosis, anemia and pyuria. Radiological study of XGPN can be seen in focal or diffuse form. Histopathology looks a chronic tissue necrosis with foamy macrophages and inflammatory cells. Definitive treatment requires nephrectomy of damaged renal unit. Conclusions We report the case of pediatric patients with XGPN due to urinary obstruction of the lithiasis; Low frequency entity in this population group, requires an adequate clinical-imaging and histological correlation to achieve final diagnosis and can be treated with medical and surgical management.

Extensive renal sinus lipomatosis in xanthogranulomatous pyelonephritis simulating liposarcoma

ABSTRACT Renal replacement lipomatosis is a condition characterized by varying degrees of renal parenchymal atrophy and perirenal fibrofatty proliferation secondary to chronic inflammation such as xanthogranulomatous pyelonephritis. In severe cases, imaging findings can be misdiagnosed as retroperitoneal liposarcoma.

Laparoscopic nephrectomy outside gerota fascia and en bloc ligation of the renal hilum for management of inflammatory renal diseases

ABSTRACT Objectives This study aims to improve laparoscopic nephrectomy techniques for inflammatory renal diseases (IRD) and to reduce complications. Materials and Methods Thirty-three patients underwent laparoscopic nephrectomy for IRD, with a method of outside Gerota fascia dissection and en-bloc ligation and division of the renal pedicle. Operative time, blood loss, complications, analgesia requirement, post-operative recovery of intestinal function and hospital stay were recorded. The degrees of perinephric adhesion were classified based on the observation during operation and post-operative dissection of the specimen, and the association of different types of adhesion with the difficulty of the procedures was examined. Results Among 33 cases, three were converted to hand-assisted laparoscopy, and one was converted to open surgery. Mean operative time was 99.6±29.2min, and blood loss was 75.2±83.5 mL. Postoperative recovery time of intestinal function was 1.6±0.7 days and average hospital stay was 4.8±1.4 days. By classification and comparison of the perinephric adhesions, whether inflammation extending beyond Gerota fascia or involving renal hilum was found to be not only an important factor influencing the operative time and blood loss, but also the main reason for conversion to hand-assisted laparoscopy or open surgery. Conclusions In laparoscopic nephrectomy, outside Gerota fascia dissection of the kidney and en-bloc ligation of the renal pedicle using EndoGIA could reduce the difficulty of procedure and operative time, with satisfactory safety and reliability. Inflammation and adhesion extending beyond Gerota fascia or involving renal hilum is an important predictor of the difficulty related to laparoscopic nephrectomy for IRD.

Extensive renal sinus lipomatosis in xanthogranulomatous pyelonephritis simulating liposarcoma.

Renal replacement lipomatosis is a condition characterized by varying degrees of renal parenchymal atrophy and perirenal fibrofatty proliferation secondary to chronic inflammation such as xanthogranulomatous pyelonephritis. In severe cases, imaging findings can be misdiagnosed as retroperitoneal liposarcoma.

Laparoscopic nephrectomy outside gerota fascia and En bloc ligation of the renal hilum for management of inflammatory renal diseases.

OBJECTIVES: This study aims to improve laparoscopic nephrectomy techniques for inflammatory renal diseases (IRD) and to reduce complications. MATERIALS AND METHODS: Thirty-three patients underwent laparoscopic nephrectomy for IRD, with a method of outside Gerota fascia dissection and en-bloc ligation and division of the renal pedicle. Operative time, blood loss, complications, analgesia requirement, post-operative recovery of intestinal function and hospital stay were recorded. The degrees of perinephric adhesion were classified based on the observation during operation and post-operative dissection of the specimen, and the association of different types of adhesion with the difficulty of the procedures was examined. RESULTS: Among 33 cases, three were converted to hand-assisted laparoscopy, and one was converted to open surgery. Mean operative time was 99.6±29.2min, and blood loss was 75.2±83.5 mL. Postoperative recovery time of intestinal function was 1.6±0.7 days and average hospital stay was 4.8±1.4 days. By classification and comparison of the perinephric adhesions, whether inflammation extending beyond Gerota fascia or involving renal hilum was found to be not only an important factor influencing the operative time and blood loss, but also the main reason for conversion to hand-assisted laparoscopy or open surgery. CONCLUSIONS: In laparoscopic nephrectomy, outside Gerota fascia dissection of the kidney and en-bloc ligation of the renal pedicle using EndoGIA could reduce the difficulty of procedure and operative time, with satisfactory safety and reliability. Inflammation and adhesion extending beyond Gerota fascia or involving renal hilum is an important predictor of the difficulty related to laparoscopic nephrectomy for IRD.

Pielonefritis Xantogranulomatosa / Xanthogranulomatous Pyelonephritis

Introducción: la pielonefritis xantogranulomatosa es una enfermedad infecciosa, inflamatoria, crónica e inusual que afecta el parénquima renal. El tratamiento definitivo es la nefrectomía. Objetivos: presentar un nuevo caso de pielonefritis xantogranulomatosa, así como la secuencia diagnóstica y terapéutica adoptada. Métodos: paciente masculino de 61 años de edad, con antecedentes de hipertensión arterial, diabetes mellitus tipo II e infecciones urinarias a repetición, que asistió al cuerpo de guardia del Hospital Militar Central Dr. Luis Días Soto, por presentar dolor lumbar y en flanco derechos, de 2meses de evolución, intenso y punzante, asociado a fiebre de 40̊ C, escalofríos y marcada toma del estado general. En el examen del hemiabdomen derecho presentaba una masa tumoral de unos 10cm de diámetro, dolorosa, ligeramente movible y de superficie lisa. El urocultivo reportó Escherichiacoli. El ultrasonido abdominal evidenció una imagen compleja en el riñón derecho, y la tomografía axial computarizada un tumor heterogéneo, que medía 10,7x7, 6 cm de contornos regulares, que distorsionaba la grasa perirrenal con densidades de hasta 73 UH. Resultados: el paciente fue sometido a nefrectomía total derecha transperitoneal, por sospecha de tumor renal, proceder que transcurrió sin complicaciones. Los hallazgos microscópicos de la pieza quirúrgica revelaron infiltración de linfocitos, histiocitos y macrófagos llenos de lípidos, compatible con pielonefritis xantogranulomatosa. La evolución fue satisfactoria. Conclusiones: aunque el diagnóstico definitivo de la pielonefritis xantogranulomatosa es histopatológico, la forma tumoral de presentación de la misma, es uno de los diagnósticos diferenciales a tener en cuenta en pacientes diabéticos con infecciones recurrentes del tracto urinario(AU)

Introduction: Xanthogranulomatous pyelonephritis is an infectious, inflammatory, chronic, and unusual disease that affects the renal parenchyma. The definitive treatment is nephrectomy. Objectives: Present a new case of xanthogranulomatous pyelonephritis, as well as the diagnostic and therapeutic sequence adopted. Methods: A 61-year-old male patient with a history of hypertension, type II diabetes mellitus and recurrent urinary tract infections attended Dr. Luis Díaz Soto Central Military Hospital, for presenting intense and stabbing lumbar and right flank pain, of 2 months of evolution, associated with fever of 40 ° C, chills and marked the general condition. In the examination of the right abdomen a tumor mass was found of about 10 cm in diameter, painful, slightly movable and of smooth surface. The urine culture reported escherichiacoli. Abdominal ultrasound showed a complex image in the right kidney, and computed tomography scan showed a heterogeneous tumor, measuring 10.7x7.6 cm of regular contours, distorting the perirenal fat with densities of up to 73 UH. Results: The patient underwent transperitoneal right total nephrectomy, due to suspicion of renal tumor. This procedure had no complications. Microscopic findings of the surgical specimen revealed infiltration of lymphocytes, histiocytes, and lipid-filled macrophages, consistent with xanthogranulomatous pyelonephritis. The evolution was satisfactory. Conclusions: Although the definitive diagnosis of xanthogranulomatous pyelonephritis is histopathological, the tumoral presentation form is one of the differential diagnoses to be considered in diabetic patients with recurrent urinary tract infections(AU)

Late complication of a renal calculus: fistulisation to the psoas muscle, skin and bronchi.

Kidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.

Late complication of a renal calculus: fistulisation to the psoas muscle, skin and bronchi

ABSTRACTKidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.