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Emphysematous pyelonephritis successfully treated with laparoscopic nephrectomy
British Journal of Medical and Surgical Urology (2009) 2, 204—207
CASE REPORT
Emphysematous pyelonephritis successfully treated with laparoscopic nephrectomy Justine Royle ∗, Rachel Williamson, Mark Strachan, Marie O’Donnell, Simon Jackson, Thanos Argryopoulos, Alan McNeill Western General Hospital, Edinburgh, United Kingdom Received 1 April 2009; accepted 7 May 2009
KEYWORDS Emphysematous pyelonephritis; Laparoscopic nephrectomy
Abstract Emphysematous pyelonephritis is a severe life-threatening infection which continues to carry significant morbidity and mortality. We present a case recently managed at our institution by laparoscopic nephrectomy. The patient survived, and in comparison to some of the more conventionally managed patients in the literature, made an extremely speedy recovery. We would advocate this option to be seriously considered when patients are suitable and appropriately trained surgeons are available. © 2009 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A morbidly obese (BMI = 40) 50-year-old NIDDM lady was admitted under the physicians with diabetic ketoacidosis (DKA). Her sister reported that she had been unwell with vomiting for two days and had increasing shortness of breath. Investigations on admission showed a haemoglobin of 174 g/l, white cell count 22 × 109 /l (neutrophilia), creatinine 189 mol/l, urea 11.8 mmol/l, Na 139 mmol/l, K 5.9 mmol/l, pCO2 1.9 kPa, pO2 16.9 kPa, H+ 94 nmol/l, BE −25.3 mmol/l, CRP 656 mg/l, lactate −2.8 mmol/l. Urinalysis revealed presence of blood, protein,
∗
Corresponding author. Tel.: +44 7946410793. E-mail address: [email protected] (J. Royle).
glucose and ketones. She was treated for her DKA with insulin and intravenous fluid resuscitation. Twenty-four hours after admission, she was less acidotic (H+ 55 nmol/l), and complained of leftsided abdominal pain. She was digitised for her atrial fibrillation, although this failed to control her rate. The possibility of ischaemic bowel was raised. A further 24 h later her abdominal pain had resolved, but she became pyrexial 38.2 ◦ C, she remained acidotic and was still fibrillating. A CT scan of the abdomen was requested. This was performed on a Siemens Somaton Sensation 16 scanner using Gastrografin oral contrast from Schering and Omnipaque 300 intravenous contrast from GE. This showed a globally poorly perfused right kidney with no evidence of hydrohephrosis/hydroureter and patent renal artery/vein at the time of scanning. No evidence of stone disease. Parenchymal
1875-9742/$ — see front matter © 2009 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2009.05.004
Emphysematous pyelonephritis successfully treated with laparoscopic nephrectomy
205
Fig. 3 Intra operative photography of the laparoscopic nephrectomy showing intra operative pus. Fig. 1 Pre operative CT scan demonstrating peri and intra renal air.
Fig. 2 Pre op CT scan demonstrating intra and peri renal air.
206 and perinephric/retroperitoneal gas was present but no gas was seen within the collecting system. A small amount of perinephric fluid was noted. The overall impression was one of Class 3B emphysematous pyelonephritis (Figs. 1 and 2). At this point she was cardiovascularly stable, treated with meropenem and antifungals, although still acidotic (H+ 49 nmol/l, pO2 12.4 kPa, BE −8.1 mmol/l). Having remained stable for a further twenty hours on conservative therapy, her condition deteriorated .The decision was made to proceed to a laparoscopic nephrectomy. Although a technically challenging procedure, with pus seem coming from the kidney intraoperatively (Fig. 3), it was completed in 120 min (AMcN) with minimal blood loss, using a standard 4-port transperitoneal approach. Postoperatively she was ventilated in intensive care unit with noradrenaline to maintain cardiac output, but by the next morning she was extubated and within twenty hours was off all inotropic support, although she remained persistently acidotic. She was ward-fit within 48 h and could have been discharged home within five days of surgery, if not for social issues (the patient had been housebound due to her obesity for several months prior to admission). Although her discharge was delayed due to social reasons the patient was fit and well one-year post operation with good control of her diabetes.
Discussion Emphysematous pyelonephritis is a life-threatening condition which carries a serious risk of morbidity and mortality no matter how it is treated. Modern series report mortality of up to 45%, even in tertiary care centres [1]. It is characterized by a gas forming infection within the renal substance or surrounding tissues. It can be subdivided on CT dependent on the amount and position of the gas and various systems have been devised but few linked to prognosis [2,3]. The most common organisms isolated are E. coli and Klebsiella. It is more commonly seen in diabetics, particularly those that are poorly controlled and it has a female preponderance. It is thought that high glucose levels provide a substrate for fermentation by Gram-negative aerobic bacteria (most often Escherichia coli), or rarely fungi. Pathologically, our specimen showed evidence of thrombosis of segmental renal vessels and resulting infarction as well as fibrin deposition which is consistent with the findings of other authors [3]. See Figs. 4 and 5.
J. Royle et al.
Fig. 4 Nephrectomy specimen macroscopic photograph of the kidney showing the surface covered by fibrin and with extensive foci of haemorrhagic infarction which is black in colour.
In one large series stage 1 and 2 EP treated with percutaneous or ureteric drainage and aggressive antibiotics all patients survived without nephrectomy, whereas other authors advocate early nephrectomy in virtually all patients with this condition. Most series note that in hospital stay is
Fig. 5 Microscopic views of the specimen demonstrating necrosis of the renal tissues.
Emphysematous pyelonephritis successfully treated with laparoscopic nephrectomy shortened with nephrectomy as opposed to percutaneous drainage [4]. Ours is only the second case in the reported literature of a laparoscopic nephrectomy for emphysematous pyelonephritis. The outcome in both cases [5] was successful with a shortened hospital stay in comparison to conventionally treated patients or those treated with other minimally invasive options (e.g. percutaneous drainage). This demonstrates that in the hands of experienced laparoscopic surgeons emphysematous pyelonephritis can be safely treated with laparoscopic nephrectomy. This offers a good alternative to open nephrectomy with its increased morbidity and even percutaneous drainage in a bid to shorten the disease course and improve prognosis, and we have altered our practice accordingly.
207
References [1] Dutta P, Bhansali A, Singh SK, et al. Presentation and outcome of emphysematous renal tract disease in patients with diabetes mellitus. Urol Int 2007;78(1):13—22. [2] Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis. J Urol 2007 Sep;178(3 Pt 1):880-5; quiz 1129. Epub 2007 Jul 16. [3] Huang Jeng-Jong, Tseng Chin-Chung. Emphysematous pyelonephritis. Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000; 160:797—805. [4] Abdul-Halim H, Kehinde EO, Abdeen S, Lashin I, Al-Hunayan AA, Al-Awadi KA. Severe emphysematous pyelonephritis in diabetic patients: diagnosis and aspects of surgical management. Urol Int 2005;75(2):123—8. [5] Bauman N, Sabbagh R, Hanmiah R, Kapoor A. Laparoscopic nephrectomy for emphysematous pyelonephritis. Can J Urol 2005;12(4):2764—8. Aug.
Available online at www.sciencedirect.com
CASE REPORT
Emphysematous pyelonephritis successfully treated with laparoscopic nephrectomy Justine Royle ∗, Rachel Williamson, Mark Strachan, Marie O’Donnell, Simon Jackson, Thanos Argryopoulos, Alan McNeill Western General Hospital, Edinburgh, United Kingdom Received 1 April 2009; accepted 7 May 2009
KEYWORDS Emphysematous pyelonephritis; Laparoscopic nephrectomy
Abstract Emphysematous pyelonephritis is a severe life-threatening infection which continues to carry significant morbidity and mortality. We present a case recently managed at our institution by laparoscopic nephrectomy. The patient survived, and in comparison to some of the more conventionally managed patients in the literature, made an extremely speedy recovery. We would advocate this option to be seriously considered when patients are suitable and appropriately trained surgeons are available. © 2009 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A morbidly obese (BMI = 40) 50-year-old NIDDM lady was admitted under the physicians with diabetic ketoacidosis (DKA). Her sister reported that she had been unwell with vomiting for two days and had increasing shortness of breath. Investigations on admission showed a haemoglobin of 174 g/l, white cell count 22 × 109 /l (neutrophilia), creatinine 189 mol/l, urea 11.8 mmol/l, Na 139 mmol/l, K 5.9 mmol/l, pCO2 1.9 kPa, pO2 16.9 kPa, H+ 94 nmol/l, BE −25.3 mmol/l, CRP 656 mg/l, lactate −2.8 mmol/l. Urinalysis revealed presence of blood, protein,
∗
Corresponding author. Tel.: +44 7946410793. E-mail address: [email protected] (J. Royle).
glucose and ketones. She was treated for her DKA with insulin and intravenous fluid resuscitation. Twenty-four hours after admission, she was less acidotic (H+ 55 nmol/l), and complained of leftsided abdominal pain. She was digitised for her atrial fibrillation, although this failed to control her rate. The possibility of ischaemic bowel was raised. A further 24 h later her abdominal pain had resolved, but she became pyrexial 38.2 ◦ C, she remained acidotic and was still fibrillating. A CT scan of the abdomen was requested. This was performed on a Siemens Somaton Sensation 16 scanner using Gastrografin oral contrast from Schering and Omnipaque 300 intravenous contrast from GE. This showed a globally poorly perfused right kidney with no evidence of hydrohephrosis/hydroureter and patent renal artery/vein at the time of scanning. No evidence of stone disease. Parenchymal
1875-9742/$ — see front matter © 2009 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2009.05.004
Emphysematous pyelonephritis successfully treated with laparoscopic nephrectomy
205
Fig. 3 Intra operative photography of the laparoscopic nephrectomy showing intra operative pus. Fig. 1 Pre operative CT scan demonstrating peri and intra renal air.
Fig. 2 Pre op CT scan demonstrating intra and peri renal air.
206 and perinephric/retroperitoneal gas was present but no gas was seen within the collecting system. A small amount of perinephric fluid was noted. The overall impression was one of Class 3B emphysematous pyelonephritis (Figs. 1 and 2). At this point she was cardiovascularly stable, treated with meropenem and antifungals, although still acidotic (H+ 49 nmol/l, pO2 12.4 kPa, BE −8.1 mmol/l). Having remained stable for a further twenty hours on conservative therapy, her condition deteriorated .The decision was made to proceed to a laparoscopic nephrectomy. Although a technically challenging procedure, with pus seem coming from the kidney intraoperatively (Fig. 3), it was completed in 120 min (AMcN) with minimal blood loss, using a standard 4-port transperitoneal approach. Postoperatively she was ventilated in intensive care unit with noradrenaline to maintain cardiac output, but by the next morning she was extubated and within twenty hours was off all inotropic support, although she remained persistently acidotic. She was ward-fit within 48 h and could have been discharged home within five days of surgery, if not for social issues (the patient had been housebound due to her obesity for several months prior to admission). Although her discharge was delayed due to social reasons the patient was fit and well one-year post operation with good control of her diabetes.
Discussion Emphysematous pyelonephritis is a life-threatening condition which carries a serious risk of morbidity and mortality no matter how it is treated. Modern series report mortality of up to 45%, even in tertiary care centres [1]. It is characterized by a gas forming infection within the renal substance or surrounding tissues. It can be subdivided on CT dependent on the amount and position of the gas and various systems have been devised but few linked to prognosis [2,3]. The most common organisms isolated are E. coli and Klebsiella. It is more commonly seen in diabetics, particularly those that are poorly controlled and it has a female preponderance. It is thought that high glucose levels provide a substrate for fermentation by Gram-negative aerobic bacteria (most often Escherichia coli), or rarely fungi. Pathologically, our specimen showed evidence of thrombosis of segmental renal vessels and resulting infarction as well as fibrin deposition which is consistent with the findings of other authors [3]. See Figs. 4 and 5.
J. Royle et al.
Fig. 4 Nephrectomy specimen macroscopic photograph of the kidney showing the surface covered by fibrin and with extensive foci of haemorrhagic infarction which is black in colour.
In one large series stage 1 and 2 EP treated with percutaneous or ureteric drainage and aggressive antibiotics all patients survived without nephrectomy, whereas other authors advocate early nephrectomy in virtually all patients with this condition. Most series note that in hospital stay is
Fig. 5 Microscopic views of the specimen demonstrating necrosis of the renal tissues.
Emphysematous pyelonephritis successfully treated with laparoscopic nephrectomy shortened with nephrectomy as opposed to percutaneous drainage [4]. Ours is only the second case in the reported literature of a laparoscopic nephrectomy for emphysematous pyelonephritis. The outcome in both cases [5] was successful with a shortened hospital stay in comparison to conventionally treated patients or those treated with other minimally invasive options (e.g. percutaneous drainage). This demonstrates that in the hands of experienced laparoscopic surgeons emphysematous pyelonephritis can be safely treated with laparoscopic nephrectomy. This offers a good alternative to open nephrectomy with its increased morbidity and even percutaneous drainage in a bid to shorten the disease course and improve prognosis, and we have altered our practice accordingly.
207
References [1] Dutta P, Bhansali A, Singh SK, et al. Presentation and outcome of emphysematous renal tract disease in patients with diabetes mellitus. Urol Int 2007;78(1):13—22. [2] Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis. J Urol 2007 Sep;178(3 Pt 1):880-5; quiz 1129. Epub 2007 Jul 16. [3] Huang Jeng-Jong, Tseng Chin-Chung. Emphysematous pyelonephritis. Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000; 160:797—805. [4] Abdul-Halim H, Kehinde EO, Abdeen S, Lashin I, Al-Hunayan AA, Al-Awadi KA. Severe emphysematous pyelonephritis in diabetic patients: diagnosis and aspects of surgical management. Urol Int 2005;75(2):123—8. [5] Bauman N, Sabbagh R, Hanmiah R, Kapoor A. Laparoscopic nephrectomy for emphysematous pyelonephritis. Can J Urol 2005;12(4):2764—8. Aug.
Available online at www.sciencedirect.com