Annals of the Royal College of Surgeons of England (1983) vol.

65

ASPECTS OF TREATMENT*

The management of pyonephrosis

G S M HARRISON FRCS Senior Registrar in Urology, St James's Hospital, Leeds
Key words: PYONEPHROSIS; HYDRONEPHROSIS; CALCULI; NEPHRECTOMY

Summary The treatment of 63 cases ofpyonephrosis is described. The primary procedure in 39 patients (62% ) was nephrectomy. A drainage procedure, usually nephrostomy, was performed in the remainder and in 10 cases an obstructing stone was removed. In 13 cases (21%) a useful functioning kidney resulted from conservative surgery. The indications for the different treatments are discussed. Introduction The classical treatment of a pyonephrosis is drainage by surgical nephrostomy. Occasionally this is all that is necessary but it is usually followed by nephrectomy as a secondary procedure or less commonly by a reconstructive operation. More recently reports have appeared advocating nephrectomy as the primary procedure (1) and others have advocated percutaneous nephrostomy as an alternative to surgical nephrostomy (2). Sixty-three cases of pyonephrosis are reviewed. A pyonephrosis is defined as an obstructed infected kidney that has ceased or virtually ceased to function. The renal pelvis contains pus that is thicker than urine and there is variable destruction of renal parenchyma. Patients and methods Sixty-three cases of pyonephrosis were treated in the urological departments of the' Bradford Royal Infirmary, the General Infirmary at Leeds, and St James's University Hospital, Leeds, betweenJanuary 1967 and December 1979. There were four treatment groups (1) primary nephrectomy, (2) nephrostomy and secondary nephrectomy, (3) nephrostomy alone, and (4) conservative surgery. Patients were allocated to primary operative treatment or percutaneous nephrostomy after assessment of the clinical features and radiology. The final decision was frequently made on the basis of the operative findings. Intravenous urography was done in all but two cases who presented with anuria affecting a known solitary kidney. Ultrasonography, arteriography, micturating cystography,'and retrograde ureterograms were performed in selected cases. Antibiotics were administered according to the clinical condition and the results of cultures of urine, blood, and renal pelvic contents. Surgical nephrostomy was performed through a loin incision and the pelvis cleared of all stones and debris. A large self retaining catheter (20-24 FG) was placed as a nephrostomy. Percutaneous nephrostomy was established under X-ray control using a 10-12 FG catheter. 'Nephrectomy was usually approached through a loin incision. A transverse anterior transperitoneal approach was used on two occasions and in a third patient nephrectomy was combined with total cystectomy through a vertical abdominal incision. The Editor would welcome any comments on this paper by readers
*

Results There were 15 male and 48 female patients with an age range of 9-91 years (mean 50 years). Twenty-two patients (350o,) were over the age of 60 years. The left kidney was involved in 30 cases and the right in 33 cases. Obstruction was due to stones in the renal pelvis in 29 cases and to pelviureteric junction obstruction in a further 11 instances. The ureter was obstructed bv stones in 11 cases, by transitional cell tumours in three cases and by endometriosis in one case. There were two ureteric strictures and one hydronephrosis secondary to bladder outflow obstruction. The aetiology was uncertain in five cases. Intravenous urography demonstrated a nonfunctioning kidney in 42 patients. A nephrogram was seen in nine cases and a hydronephrosis with gross delay in excretion of contrast in a further ten. The presence of a nonfunctioning hydronephrotic kidney with little cortex was confirmed by ultrasound in three patients and, before this technique was available, by arteriography in two cases. Retrograde ureterograms confirmed pelviureteric junction obstruction in four patients and demonstrated ureteric stones in three.
PRIMARY NEPHRECTOMY

Thirty-nine patients (620o ) underwent primary nephrectomy. Eighteen operations were to the left kidney and 21 to the right. There were no operative deaths. The surgeon considered the procedure difficult in 19 cases (12 right, 7 left). In these difficult cases subcapsular nephrectomy was employed on four occasions and mass ligation of the pedicle in a further seven cases. The use of these two techniques was not associated with complications. Three major complications occurred. The inferior vena cava was injured on two occasions during right sided nephrectomy but in each case the cava was successfully repaired. A duodenal injury was recognised and repaired during one operation. This resulted in a duodenal fistula which was explored but the patient eventually died. There were no intrapleural or other intraperitoneal complications. One patient suffered a hemiparesis postoperatively. Five persistent wound sinuses required excision and in one case this involved full re-exploration of the renal bed. One patient developed an incisional hernia in a loin wound.
DRAINAGE AND SUBSEQUENT NEPHRECTOMY

Seven patients were initially treated by nephrostomy and later underwent nephrectomy. Six of these presented with septicaemia and were found' to have pelviureteric junction obstruction. The seventh patient had an infiltrating bladder tumour obstructing the ureter. Four nephrostomies were surgical and three were performed percutaneously. Drainage

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The management of pyonephrosis

was not adequate following one percutaneous procedure and a surgical nephrostomy was required. Nephrectomy was performed within three weeks of the drainage in four patients and three were performed after an interval of three months. Two of the earlier nephrectomies were considered difficult and one of the later ones required a portion of diaphragm to be excised. There were no complications.
DRAINAGE ALONE

127

In five patients nephrostomy was the only procedure performed. One patient with an inoperable ureteric tumour died shortly afterwards. The remaining four patients had their nephrostomy tubes removed. Two patients required nephrectomy within two years for persistent urinary tract infection. The other two patients remained without symptoms five and seven years later.
CONSERVATIVE SURGERY

The 13 cases in which the kidney was preserved were younger than the group as a whole (mean age 42 years). There was evidence of function on the intravenous urogram in six instances. In seven cases the kidney did not function and in five of these there was probably an obstructing stone. At the initial surgical procedure stones were removed from the ureter (three cases), the renal pelvis (f.ie cases) and both ureter and pelvis (two cases). Nephrostomy drainage was established in five of these patients and a ureterostomy in two. The three cases without stones were each drained by surgical nephrostomy. Nine patients required further surgery to relieve obstruction. In 2 cases a fistula developed following removal of the nephrostomy tube but both closed following ureteric catheter drainage. Strictures developed in the upper ureter in two patients after a ureterolithotomy and were successfully treated by Davis intubated ureterotomy. A stricture of the lower ureter was repaired with a Boari flap. The remaining four patients required respectively, upper pole heminephrectomy, Anderson Hynes pyeloplasty, ureterolithotomy for cystine stone, and bilateral re-implantation of ureters. One patient with a solitary kidney required a short period of peritoneal dialysis. One patient, who suffered from multiple sclerosis, developed a perinephric abscess of the contralateral kidney and died three months later without leaving hospital. The patient who had a pyeloplasty suffered a hemiparesis thirteen years later and was found to be hypertensive. The kidney was small and scarred and as investigations indicated it was the cause of the hypertension a nephrectomy was performed. The remaining patients are well 2-14 years (mean 6 years) after treatment of their pyonephrosis.

agreement with recent published reports (1). It has been suggested that it is more difficult to perform a nephrectomy following a period of nephrostomy drainage but this was not the experience in this series. All the major complications occurred during primary right nephrectomy. The anterior transperitoneal approach may be useful in the difficult case. Subcapsular nephrectomy and mass ligation of the pedicle are helpful in avoiding injury to adjacent structures. The classical treatment of pyonephrosis, nephrostomy and secondary nephrectomy, was only employed in seven patients. Six presented with septicaemia and this was the main indication for nephrostomy drainage prior to nephrectomy. Percutaneous nephrostomy is particularly suited to draining a large renal pelvis but has not been used when the obstruction was associated with stones. The traditional time to perform a secondary nephrectomy is about three months after the drainage procedure but it seems safe to perform nephrectomy within three weeks. Once drainage is established residual infection can be rapidly controlled with antibiotics but the precise timing of nephrectomy will obviously depend on the condition of the patient. Conservative surgery should be considered if there is good renal substance. If there is doubt and particularly if the contralateral kidney is diseased a nephrostomy should be performed. The majority of kidneys that were conserved contained stones. Evidence of a functioning kidney on the intravenous urogram strongly suggests that there is useful recoverable function but non-function does not exclude su'ch recovery especially when the obstruction is due to stones. Ultrasound examination is quickly and easily performed even in ill patients and has been helpful in confirming hydronephrosis when the kidney is not seen to function on urography. It may also give an indication of the thickness of the cortex. This experience suggests that nephrostomy is indicated when the patient is severely ill or the kidney is expected to recover function. If the kidney can be confidently shown to have little or no remaining cortex by ultrasonography a percutaneous nephrostomy is probably the procedure of choice. Otherwise surgical nephrostomy with removal of stones and debris is advised. Severely damaged kidneys should usually be treated by primary nephrectomy particularly if the contralateral kidney is normal.

Discussion Primary nephrectomy has been the most commonly performed procedure for severely damaged kidneys. This is in

J Urol 1978;120:287-9. 2 Barbaric ZL, Davis RS, Frank IN, Linke CA, Lipchik EO, Cockett ATK. Percutaneous nephropyelostomy in the management of acute pyohydronephrosis. Radiology 1976; 118:567-73.

References 1 JimenezJF, Lopez Pacios MA, Llamazares G, ConejeroJ, SoleBaecells F. The treatment of pyonephrosis: a comparative study.