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OBJECTIVE To explore the diagnostic value of noncontrast computed tomography (NCCT) in differentiating pyonephrosis from nonpyogenic hydronephrosis on the basis of CT values (in Horsfield unit [HU]). METHODS Data from patients diagnosed with obstructive uropathy at the First affiliated hospital of University of South China from November 2017 to January 2021 were subjected to retrospective analysis. In accordance with the gold standard-the presence of pus during the operation-all patients were divided into the nonpyogenic hydronephrosis group and the pyonephrosis group. The relationship between CT values and the presence or absence of pyonephrosis was performed using binary logistic regression. A receiver operating characteristic (ROC) curve was constructed to determine threshold values for classification on the basis of mean HU. RESULTS A total of 207 patients, including 100 males and 107 females, were enrolled. Out of the 207 cases, 124 cases of obstructive uropathy were nonpyogenic hydronephrosis and 83 cases were of pyonephrosis. The CT values of the pyonephrosis group were significantly higher than that of the nonpyogenic hydronephrosis group (t = 9.15, P

Introduction. Timely unresolved upper urinary tract (UUT) obstruction in patients with infection can cause severe complications, such as sepsis, pyonephrosis and even death. There are no clear recommendations regarding the methods and timing of drainage. At the same time, this issue is still the subject of discussion in publications of recent years.Purpose of the study. To optimize the timing of lithotripsy after drainage of the UUT in patients with urolithiasis and obstructive uropathy (OU).Materials and methods. At the first stage, 90 patients with OU caused by the stone of the ureteropelvic junction underwent drainage of the UUT using a percutaneous nephrostomy. Subsequently, percutaneous nephrolithotripsy (PNLT) was performed at various times after drainage. The level of inflammatory markers (IL-8) and profibrotic factor (MCP-1) in the urine was determined. The calculated concentrations of urinary biomarkers were normalized by the level of urinary creatinine. Urine sampling for the analysis was carried out during and after the PCN placement (nephrostomy urine) 7 days later, and then once weekly before surgery. The coefficient K was calculated using a patented formula to evaluate the process of kidney remodeling. Urine sampling was performed for culture to determine the bacterial spectrum and antibiotic sensitivity.Results. The values of K ≤ 1.85 were observed in 11 patients of the group with OU (12.2%), K > 1.85 in 79 (87.8%) by day 21. The values of K ≤ 1.85 were achieved in 70 patients (88.6%) by day 28 and 4 patients (80.0%) by day 35. PNLT was performed on 21 days in patients with K ≤ 1.85 (11 patients), no complications were noted in the postoperative period., PNLT was performed in patients with K ≤ 1.85 (70 patients) by day 28, exacerbation of pyelonephritis and the development of chronic kidney disease were not noted. Six patients with values of K ˃ 1.85 underwent PNLT by day 28. In the postoperative period, all patients had an exacerbation of calculous pyelonephritis, 50% had a decrease in glomerular filtration rate within 3 months after surgery. The bacteria in urine were detected in 55 (61.0%) patients. Escherichia coli (63.0%), Proteus mirabilis (18.0%), Enterococcus faecalis (14.5%), Streptococcus haemolyticus (2.5%) were identified most often.Conclusion. The use of the developed remodeling index allows optimizing the surgery timing and minimizing the development of complications during the postoperative period. The presence of bacteria is associated with a long process of renal parenchymal remodeling.

Nephrobronchial fistula is an extremely rare complications of renal infections. We present a case of nephrobronchial fistula in a middle age immunocompetent woman who complained cough and weight loss, with underlying asymptomatic nephrolithiasis. She underwent a chest X-ray that showed left lower lobe infiltrate and abdominal ultrasound. Abdominal ultrasound showed a complicated pyonephrosis ; CT of chest-abdomen-pelvis with intravenous contrast was performed in order to stage and define the extension of the pathology. At CT, a suspected diagnosis of stage III xanthogranulomatous pyelonephritis complicated with pyonephrosis and a nephrobronchial fistula was formulated. A nephrostomy tube was placed, and the patient was treated with antibiotics. Follow up CT, performed after 15 days, showed the healing of the fistulous connection between the perinephric abscess and bronchi; the patient underwent nephrectomy with no airway complication during intubation. Histopathological diagnosis confirmed the presence on complicated xanthogranulomatous pyelonephritis.

Background A pyonephrosis caused by an obstructing calculus is typically accompanied by fever, loin pain, and other signs of urinary tract infection. Occasionally, severe thinning of the renal parenchyma in pyonephrosis allows direct forniceal rupture into the retroperitoneum and very rarely into the anterior abdominal wall, misconstruing it as an isolated abdominal wall abscess. Case presentation Diabetes-related 55-year-old diabetic male presented with abscess in his periumbilical region extending into right lumbar region. He did not exhibit any urinary symptoms, and contrast enhanced computed tomography [CECT] abdominal and pelvic examinations revealed right pelvic calculus with pyonephrosis. There is a 7.5 mm defect in the lower pole of the right kidney with 171 cc of collection adjacent to the kidney communicating with 150 cc of superficial abdominal wall collection through a 15 mm defect. Incision and drainage of abdominal and retroperitoneal abscesses were done at first. Right DJ stenting was performed. Right lateral decubitus was placed for dependent drainage. Resolution of residual collections was confirmed by subsequent ultrasonography KUB, and drain was then removed. Right DJ stenting done, and patient was discharged. Two months later, DTPA scan done and revealed GFR of 30 ml/min of right kidney. Patient underwent right percutaneous nephrolithotomy. Conclusion The sudden rupture of pyonephrosis is a rare event. Even rarer is the presentation of pyonephrosis as an abscess on the anterior abdominal wall. The correct diagnosis and search for the source of the abscess must be undertaken before intervention. An aggressive and prompt management is needed to prevent further complications from occurring. This case is being presented to add to the literature with regard to abnormal presentations of ruptured pyonephrosis and its management.

Faris Abushamma,1,2 Mahfouz Ktaifan,1 Abdoh Abdallah,1 Mohammad Alkarajeh,1 Mosab Maree,1,3 Ahmed Awadghanem,1,3 Ahmad Jaradat,1,2 Amir Aghbar,1,2 Sa’ed H Zyoud,4,5 Francis X Keeley Jr6 1Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine; 2Department of Urology, An-Najah National University Hospital, Nablus, 44839, Palestine; 3Department of Radiology, An-Najah National University Hospital, Nablus, 44839, Palestine; 4Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine; 5Clinical Research Center, An-Najah National University Hospital, Nablus, 44839, Palestine; 6Bristol Urological Institute, North Bristol NHS Trust, Bristol, UKCorrespondence: Faris AbushammaDepartment of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, PalestineEmail farisabushamma@hotmail.comPurpose: Acute ureteric colic (AUC) is generally one of the most common reasons for emergency department attendance. Expectant management is recommended in non-complicated ureteral calculi. However, data regarding the optimal duration of observation or indications of early intervention (EI) are not well understood. This article describes the clinical and radiological factors that promote EI in AUC.Patients and Methods: This was an observational and retrospective cohort study. Patients with AUC diagnosed based on non-contrast computerized tomography (NCCT) between 2019 and 2020 were enrolled in the study. These patients were classified into two main categories: spontaneous passage of stone (SSP) and EI. In addition, a comparative analysis was performed to identify clinical and radiological variables that promote EI.Results: One-hundred and sixty-one patients were included. High WBCs are associated with a significant increase in EI. Forty-three percent (n=37) of patients with serum WBCs higher than 10 had an EI, while 23% had SSP (n=17;p< 0.001). High CRP level is also significantly associated with EI (n=36; 86%; p< 0.001). Upper and middle ureteral calculi are statistically associated with EI (n=54; 62%) in comparison to the SSP cohort (n=22; 30%;p< 0.001). EI is also linked to the maximal length of ureteric calculi (MCL) of 9 mm (6– 13mm), and HU density of stone of 700 (430– 990) H.U (p< 0.001). Ureteric stone volume of 0.2 (0.06– 0.3) cm3 is significantly associated with EI (p< 0.001). Ureteral wall thickness of 3 (2– 3 mm), the presence of extrarenal pelvis (n=20; 23%), and AP diameter of renal pelvis 18 (13– 28 mm) are all significantly associated with a higher rate of EI (p< 0.001). Multiple binary logistic regression analysis showed that MCL is the strongest predictor of EI.Conclusion: MCL is an independent and robust predictor of EI in AUC. Biochemical variables and radiological characteristics can also act as an adjunct to promote EI.Keywords: ureteral calculi, medical expulsive therapy, spontaneous stone passage, maximal length of ureteral calculi, pyonephrosis

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.

Objective: To study effectiveness of EUA colour coding system in performing urological procedures during COVID-19 Methodology: It is descriptive Study during three waves of COVID 19, conducted in Department of Urology at Institute of Kidney Diseases Hayatabad Peshawar, Pakistan from March 24, 2020 till March 30, 2021. Total numbers of 3066 operated patients were included in the study. We followed the EUA guidelines of color coding for prioritization of surgical procedures. All the data of the patients and doctors were recorded on structured proforma and was analyzed on SPSS version 20. Results" Total numbers of 3066 surgeries were performed during three waves of COVID 19, that included 937 (30.5 %)) emergency Procedures with code black , 1272 (59.74%) high Priority labeled as code red, 636 (29.8%) as code yellow in intermediate priority and 221 (10.3%) as code green in. Regarding emergency surgeries code black, Obstructive uropathy remained high with 566 patients (60.4 %) patients, Pyonephrosis in 187(19.9%), Genito-urinary trauma in 93 (9.9%), miscellaneous in 91 (9.7%). The 1272 patients with high priority were dominated by Complicated Urolithiasis and High grade Urooncology. The preoperative nasopharyngeal PCR of 206 patients (22 %) in emergency procedures came positive for COVID-19. The rate of positive seroconvesrion was recorded in 82(6%) in high and 9 (1.5%)in intermediate priority and no seroconvesrion was recorded in code green . Conclusion:The EUA guidelines is a useful tool in prioritization of urological procedure.

Background: Imaging plays a very important role in the diagnosis of renal infection. It assists diagnosis and differentiates between different types of renal infection. It also helps to detect and manage the associated complications through image-guided drainage and aspiration. Contrast-enhanced CT is the most useful study. A contrast-enhanced study is essential for a complete evaluation of patients with renal inflammatory disease to demonstrate alterations in the renal parenchymal perfusion and excretion of the contrast material, which occur as a result of the inflammatory process. Objective: To detect the role of multidetector CT in diagnosis of renal infection. Materials and methods: This prospective study was conducted on sixty patients. The study was carried out at Diagnostic Radiology Departments of Menoufia University Hospital. The patients were presenting with fever (< 38°C) mainly and loin pain. Results: From 60 patients with renal infection, 18 cases were diagnosed as pyonephrosis, 16 cases were diagnosed as renal abscess, 12 cases were diagnosed as pyelonephritis, 4 cases were diagnosed as xanthogranulomatous pyelonephritis, 4 cases were diagnosed as perinephric abscess, 2 cases were diagnosed as emphysematous pyelonephritis, 2 cases were diagnosed as fungal ball, 2 cases were diagnosed as urinoma. The mean age was (39.4 ± 15.7). Conclusion: Contrast enhanced computed tomography is a perfect diagnostic modality to assess the severity of inflammatory process and reaching the diagnosis of renal infection. It also helps to reach the cause, predisposing factors, associations, complications and the extent of the disease.

Background Patients with obstructive pyonephrotic nonfunctioning kidney (OPNK) often require simple nephrectomy for long-term severe clinical symptoms. We aimed to analyze the outcomes of retroperitoneal laparoscopy versus open surgery for OPNK. Methods The study included clinical data of 69 patients with non-tuberculous OPNK from January 2015 to June 2019 in a single center. The patients were divided into laparoscopic group (LS, N=33) and open surgery group (OS, N=36). Those whose pathological findings were xanthogranulomatous inflammation or tuberculous granuloma were excluded. Statistical analysis compared the two groups in terms of basic demographic characteristics, preoperative laboratory examination results, and intraoperative and postoperative observation indicators. Results The results showed that non-tuberculous OPNK were more common in women (female/male =4:1). Compared with the LS group, patients in the OS group had higher white blood cells (WBC; P=0.010) and neutrophils (P=0.005) counts before surgery. The main clinical symptoms were low back pain, pyuria, and fever; among them, low back pain combined with pyuria was in the majority. More intraoperative hypotension events were observed in the OS group (P=0.007). Notably, subgroup analysis showed larger stone size happened in the OS group (OR 3.538, 95% CI, 1.337, 9.208). No statistical difference was found in the duration of surgery between the two groups while the length of postoperative hospitalization and retroperitoneal drainage, and postoperative blood transfusion rate increased significantly in the OS group. Postoperative use of non-steroidal anti-inflammatory drugs was more common in the LS group, while opioid analgesics were in the OS group (P=0.0006). There was no statistical difference in other complications. Conclusions In conclusion, considering the advantages of LS in terms of postoperative blood transfusion, surgical drainage and length of hospital stay, we recommend it for non-tubercular OPNK when the stone load of pyonephrosis side was less than 280 mm2 and the preoperative WBC and neutrophil count were within the normal range.

Background To develop a machine learning (ML)-assisted model capable of accurately identifying patients with calculous pyonephrosis before making treatment decisions by integrating multiple clinical characteristics. Methods We retrospectively collected data from patients with obstructed hydronephrosis who underwent retrograde ureteral stent insertion, percutaneous nephrostomy (PCN), or percutaneous nephrolithotomy (PCNL). The study cohort was divided into training and testing datasets in a 70:30 ratio for further analysis. We developed 5 ML-assisted models from 22 clinical features using logistic regression (LR), LR optimized by least absolute shrinkage and selection operator (Lasso) regularization (Lasso-LR), support vector machine (SVM), extreme gradient boosting (XGBoost), and random forest (RF). The area under the curve (AUC) was applied to determine the model with the highest discrimination. Decision curve analysis (DCA) was used to investigate the clinical net benefit associated with using the predictive models. Results A total of 322 patients were included, with 225 patients in the training dataset, and 97 patients in the testing dataset. The XGBoost model showed good discrimination with the AUC, accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 0.981, 0.991, 0.962, 1.000, 1.000, and 0.989, respectively, followed by SVM [AUC =0.985, 95% confidence interval (CI): 0.970-1.000], Lasso-LR (AUC =0.977, 95% CI: 0.958-0.996), LR (AUC =0.936, 95% CI: 0.905-0.968), and RF (AUC =0.920, 95% CI: 0.870-0.970). Validation of the model showed that SVM yielded the highest AUC (0.977, 95% CI: 0.952-1.000), followed by Lasso-LR (AUC =0.959, 95% CI: 0.921-0.997), XGBoost (AUC =0.958, 95% CI: 0.902-1.000), LR (AUC =0.932, 95% CI: 0.878-0.987), and RF (AUC =0.868, 95% CI: 0.779-0.958) in the testing dataset. Conclusions Our ML-based models had good discrimination in predicting patients with obstructed hydronephrosis at high risk of harboring pyonephrosis, and the use of these models may be greatly beneficial to urologists in treatment planning, patient selection, and decision-making.

Introduction. Renoalimentary fistulas represent infrequent pathology with 27 literature reports. The oldest report is from the year 1953. Nowadays, they usually arise after the cryoablation of renal tumors. In this case, we reported secondary renocolic fistula as an unusual complication of pyonephrosis, as well as the treatment modality, providing a literature review that favors a conservative or minimally invasive approach in most cases of renocolic fistula. Case report. In our case, the patient was a young female with a long course of kidney disease, which eventually led to pyonephrosis with renocolic fistula. Initially, the patient was hospitalized due to life-threatening urosepsis, successfully treated with a conservative approach. Afterward, we decided to proceed with surgical treatment. Regarding the poor right kidney function of the patient and the presence of concurrent sepsis, the right hemicolectomy with primary ileocolic anastomosis and the right nephrectomy were performed. The postoperative course was without complications, and the patient was discharged from the hospital on the 10th day. Follow-up did not reveal any complications. Conclusion. Regarding the available literature, a conservative and minimally invasive approach is most frequently employed in such cases. However, in cases of haemorrhage, sepsis, and impaired kidney function, surgery offers the only chance for cure. In patients with concurrent gastrointestinal pathology, surgery is usually the only option. Kidney preservation should be imperative in all cases, except in the case of impaired kidney function. The laparoscopic approach can be utilized in selected cases.

Introduction. Simultaneous ipsilateral coexistence of renal cell carcinoma (RCC) and upper urinary tract urothelial carcinoma (UTUC) rarely occurs. Balkan endemic nephropathy (BEN) is a chronic degenerative tubulointerstitial renal disease, strongly associated with UTUC. Case outline. ? 60-year-old man from the region of BEN was referred to our clinic due to right flank pain, fever, and purulent discharge from the cutaneous fistulous opening in the right lumbar area. Multislice computed tomography urography scan showed right-side pyonephrosis and nephrocutaneous fistulous tract between the kidney and the skin in the right lumbar region. Cystoscopy detected a papillary tumor protruding from the right ureteric orifice. Right-side nephroureterectomy with bladder cuff excision was performed. Histopathological examination revealed rhabdoid RCC of the kidney and multifocal urothelial carcinoma of the ureter. Conclusion. Our case report and literature review indicate that due to rising incidence of multiple primary malignant neoplasms (MPMNs), when treating patients with RCC or UTUC, and especially those from the region of BEN, one should keep in mind the likelihood of synchronous or metachronous occurrence of these tumors.

Aim: To observe the safety and efficacy of tubeless percutaneous nephrolithotomy (PCNL). Materials and methods: Since January 2016 to 2019, 210 consecutive tubeless PCNL performed at our hospital were enrolled into this retrospective chart review. The average age of the patients (134 males and 76 females) was 57 ± 11.8 years, and 7 patients were between 8 to 12 years. The stone characteristics were 71 pelvic or calyceal solitary stones, 62 non-complete staghorn kidney stones, 17 ureteral stones, 32 kidney + ureteral stones (concomitant kidney and ureteral stones), and 28 complete staghorn stones. Mean stone size range 3. 5+2.8[range 0.7cm to 11.8 cm]. Patient’s position was prone. Tract size varied from 26 F to 30 F and number of tracts varied single tract to 4 tracts. Results: The average operative time was 85.0 ± 29.4 minutes. Average hospital stay was 21.7 hrs (6 patients had longer stay due to fever) and the blood transfusion rate was 1.4%. Postoperative fever was noted in 19 (9.02%) patients, no urosepsis was noted. No Pulmonary complications and mortality noted. No re exploration was done. No major leak was noted. Angioembolisation rate 0.95%. We did not use any haemoseal ent or cautery in the tracts. Conclusion: PNT serves purpose of relook PCNL and drainage of urine if there is pyonephrosis or surgeon has doubt about PUJ competency like edema, perforation etc., but other factors like bleeding, fever, sepsis, AV aneurysm, AV fistula, pulmonary complications if puncture is in upper calyx, mortality are comparable to standard PCNL and advantage of tubeless PCNL are reduced post-operative pain which leads to lesser analgesia requirement, less apprehension as no tube is there, therefore more comfort, early discharge and indirectly less hospital expenses, early return to work. Our observation is that Tubeless PCNL is effective and safe. There is limitation of our study that our sample size is small and it is not a case-control study, therefore significance was not established.

Acute pyelonephritis is a bacterial infection of the renal parenchyma and collecting system. Diagnosis is based on clinical findings of fever, flank pain, and urinary tract infection. Computed tomography findings include renal enlargement with wedge-shaped heterogeneous areas of decreased enhancement, known as a "striated nephrogram." Imaging is primarily used to diagnose complications such as emphysematous pyelonephritis, renal abscess, and pyonephrosis. Chronic pyelonephritis can have varying appearances on imaging ranging from xanthogranulomatous pyelonephritis or, in extreme cases, renal replacement lipomatosis.

Acute renal infection or acute pyelonephritis (AP) denotes the process of inflammation of the renal parenchyma and its collecting system and the urothelium following infection. Uncomplicated AP commonly affects otherwise healthy, young women without structural or functional urinary tract abnormalities and without relevant comorbidities. More severe and complicated AP occurs in patients with a structurally or functionally abnormal genitourinary tract, or in persons with a predisposing medical condition like immune compromised state and diabetes. Complicated AP is characterized by a broader spectrum of clinical presentations, a wider variety of infecting organisms, and a greater risk of progression to a complication, such as intrarenal or perinephric abscess or emphysematous pyelonephritis and has the capacity to damage the organ and at times maybe life threatening. Role of imaging in renal infection is secondary, and in most situations, imaging is done to confirm the clinical diagnosis, map progression of disease in immune-compromised group of patients, or to evaluate for potential complications and therapeutic interventions. This article attempts to discuss the pathophysiology of AP from the standpoint of medical imaging and also brings out illustrative examples of various manifestations of AP and its complications. It provides imaging insight into various stages of inflammation, development of complication, and a roadmap for understanding AP through cross-sectional imaging.

Background: Management of the distal ureter in radical nephroureterectomy and bladder cuff excision (RNUBCE) is paramount, directly influencing oncologic outcomes. Herein, we analyze the natural history of patients who have undergone robotic radical nephroureterectomy without formal bladder cuff excision and retained ureteral stump and compare this cohort with patients undergoing formal RNUBCE for high-risk upper tract urothelial carcinoma (UTUC). Methods: From February 2008 to October 2018, all patients who underwent robotic RNUBCE by multiple surgeons in a single institution for high-risk UTUC were reviewed. Preoperative, perioperative, and postoperative variables were investigated. Overall survival, cancer specific survival, local recurrence-free survival, distant recurrence-free survival, and bladder recurrence-free survival were compared between the two cohorts. Further management treatments were explored for patients with retained ureteral stump. Follow-up consisted of abdominopelvic/chest imaging and cystoscopy at regular intervals. Results: A total of 105 patients underwent robotic RNU during the above time period. Of patients with documented 6-month follow-up, approximately 6.6% of patients had retained ureteral stump. Median follow-up for the entire cohort was 31.5 months with a range of 6 to 114.2 months. Factors that precluded formal BCE were densely, fibrotic reaction near the ureterovesical junction due to prior vascular or pelvic surgery in 5 patients, severe pyonephrosis and continued anesthetic risk in one patient, and surgeon choice (patient co-morbidities) in another patient. Three patients died with metastatic disease and one patient succumbed to cardiovascular compromise. Two additional patients developed local recurrence only at the level of the ureteral stump, with one patient undergoing eventual distal excision, contralateral RNUBCE and radical cystectomy. Conclusions: In these cases, responsibilities assumed by the surgeon demand the utmost in judgement and skill; however, at times, circumstances prevail such as patient factors and nature/biology of the disease. These factors may prevent adequate excision the complete ureter, ureterovesical junction, and bladder cuff at the time of RNU. In this robotic cohort of patients undergoing RNUBCE for UTUC, not excising the most distal part of the ureter directly translates to inferior oncologic outcomes. Complete ureteral excision with bladder cuff should be performed where possible as this is an integral part of the radical nephroureterectomy. Also, if feasible, adjunctive chemotherapy/immunotherapy treatments should be considered.

Primary mucinous adenocarcinoma of the renal pelvis is a rare malignant disease that is difficult to diagnose preoperatively. There are still no characteristic symptoms, radiological features, or standard treatment for this tumor with only ~100 cases reported. The prognosis is poor. We report a case of a 66-year-old man who presented with a 2-month history of fever and right waist pain. He was misdiagnosed with calculous pyonephrosis and underwent percutaneous nephrostomy (PCN) at a local hospital. Gelatinous material was drained via a PCN catheter. He was then transferred to our hospital. He had elevated CEA and CA19-9. We performed an open radical nephrectomy and found polypoid, gelatinous material and stones filling the renal pelvis. He was diagnosed with primary mucinous adenocarcinoma of the renal pelvis by pathology. He refused adjuvant chemotherapy and there was no sign of recurrence after one year of follow-up. By assessing a literature review of all of the cases reported since 2000, we recommend that careful history taking, serum tumor markers, and CT scans may improve the diagnostic accuracy rates and radical nephrectomy with total ureterectomy accompanied by adjuvant therapy may improve the prognosis.

Pyonephrosis is gross accumulation of pus within an obstructed renal collecting system that, if left untreated, can lead to potentially fatal septic shock. Treatment requires urgent decompression coupled with systemic antibiotics. Percutaneous nephrostomy (PCN) placement, first described in 1976 for the treatment of pyonephrosis, is now widely utilized for emergent decompression in these patients. When performed by an experienced interventional radiologist, PCN is a safe procedure with technical success rates of over 96 to 99%. This article will address the clinical presentation of pyonephrosis, and will discuss the indications, technique, complications, and outcomes of emergent PCN placement. Additionally, the expanded indications for PCN placement in nonemergent scenarios will also be described.

Direct hemoperfusion using polymyxin B-immobilized fiber (PMX-DHP) is an established treatment method for septic shock caused by Gram-negative infections. We report one instance in which PMX-DHP therapy has been used successfully in a 33-year-old woman with septic shock from urosepsis. Although there is lack of recommendations in latest Surviving Sepsis Campaign Guidelines, evidence of PMX-DHP efficacy in this subset of patients is growing.

Wilms' tumor (WT) is the most common renal malignancy in children. Its clinical and radiologic presentation may mimic other pediatric renal diseases, including pyonephrosis or renal abscess. The authors report a case of a 3-year-old girl presenting with pyelonephritis and right renal mass suggestive of a renal abscess, not responding to antibiotics. Further investigations were conducted, including a percutaneous renal needle core biopsy. A stage I fully necrotic WT was finally diagnosed. This amazing case of a fully necrotic WT at diagnosis demonstrates the importance of anatomopathologic analyses in pediatric renal masses, even when the infection is suspected.

Ectopic kidney is a congenital anomaly of renal position, which is commonly asymptomatic. Symptoms arising from pelvic kidneys can closely mimic pathological processes of nearby organs and vice versa. We report an 18-year-old girl who presented with acute onset of a painful lump in the right iliac fossa. Although the clinical features mimicked an appendicular abscess, the judicious use of cross-sectional imaging aided in the proper diagnosis. Pyonephrosis of a right-sided lumbar kidney was confirmed on further imaging and nephrectomy was performed. This case has been presented to highlight the significance of renal imaging in patients suspected of an appendicular abscess.

Villous adenoma is uncommonly seen in the urogenital tract and is even more rarely seen in the upper urinary tract and renal pelvis. Like colorectal adenomas, these neoplasms can transform into adenocarcinoma. The preoperative diagnosis is challenging due to their frequent association with hydronephrosis. Herein, we present the case of a villous adenoma of the renal pelvis in a 62-year-old man presenting with recurrent urinary tract infection. The computed tomography scan showed marked hydronephrosis but no suspicious mass in the right kidney. A laparoscopic right nephrectomy was performed. Gross examination revealed a dilated renal pelvis with an irregular exophytic lesion in the renal pelvis’s upper surface. The histopathological examination showed slender, elongated villi with thin fibrovascular cores, consistent with villous adenoma morphology. Isolated villous adenomas have a favorable prognosis. However, the pathologist should undertake a search for an invasive component.

In March 1891, a patient, 33 years old, married, did not give birth, turned to the author with symptoms of cystitis. The undertaken treatment was of little use, on the contrary, soon there were even symptoms of a disease of the right kidney. Since the patient also had gynecological suffering, she was sent to the Moscow University Gynecological Clinic, where, according to the patient's examination, pyonephritis et salpyngo-oophoritis duplex was suggested. In May of the same year, it was performed by the patient prof. Snegirevym removal of the kidney and uterine appendages (the ovaries were found cystically degenerated, and the common tubes were calcified, thickened and adhered to the surrounding tissues).

Pyonephrosis secondary to an obstructing calculus in renal pelvis, pelviureteric junction or ureter usually presents clinically with fever, loin pain and other signs of urinary tract infection

To evaluate the predictive value of attenuation value (HU) in renal pelvis urine for detecting renal pelvis urine culture (RPUC) positivity in obstructed urinary systems.The study group consisted of patients who had nephrostomy insertion performed because of obstructed system and suspicion of pyonephrosis and percutaneous nephrolithotomy (PCNL) patients who had obstructed calculi. Group 1 consisted of RPUC positive 28 patients during nephrostomy insertion or needle access in PCNL and group 2 consisted of 23 patients with negative RPUC. RPUC results and non-contrast computed tomography measurements [Hounsfield unit (HU)] were compared between group 1 and group 2. A cut-off value was determined for HU. All patients were grouped according to whether they were above or below this value.The median HU calculated from the renal pelvis was - 8.5 (range - 29/- 1) and 10 (range- 4/+ 17) (p 0.001) in group 1 and group 2, respectively. The cut-off value of HU that predicted positive RPUC was 0. Sensitivity and specificity of HU when considering this cut-off value were 100% and 96%, respectively (p 0.001). Whereas RPUC positivity was found in 96.6% (28/29) of patients with HU 0, there were no patients with HU 0 where RPUC positivity was detected (p 0.001).In this cohort, we found that HU of the urine in the renal pelvis can be used to predict RPUC positivity.

Background The kidney is the most common site of metastatic disease to the urinary tract. However, tumor characteristics are commonly deceptive, and the diagnosis of metastatic disease to the kidney may be challenging. Case presentation A 76- year old male was submitted to a total left nephrectomy with splenectomy due to pyonephrosis. At gross examination, the kidney presented a distorted anatomy, with firm parenchyma and an extensively necrotic lesion occupying the renal pyelo-calix and ureter. The spleen had a white pericapsular lesion measuring 1.2 cm. Histologic sections demonstrated a high grade solid carcinoma with rare areas of tubular differentiation. The tumor was highly infiltrative, with invasion of the renal sinus, perirenal fat and spleen. Considering the tumor location, high grade and infiltrative growth pattern, the diagnostic hypothesis of collecting duct carcinoma and urothelial carcinoma were drawn and investigated. Furthermore, a suspicion of metastatic disease was raised after a thorough investigation of the patient’s chart, which revealed a previous history of colorectal carcinoma 4 years earlier. Immunohistochemical studies demonstrated expression of CK20 and CDX-2 and negativity for CK7, CK5, PAX-8, Vimentin, CD117, GATA3 and p63; therefore, the patient was diagnosed with a poorly differentiated metastatic colorectal adenocarcinoma. Conclusion A high degree of suspicion is necessary for the diagnosis of metastatic disease to the kidney, which should ruled out before the final diagnosis of an unclassified renal cell carcinoma. A careful examination of the patient’s history and adequate communication with the attending physician is recommended for the correct diagnosis of these cases.

Urinary tract infection (UTI) is among the most common of bacterial infections. Imaging studies are only required in cases of complicated UTIs. Ultrasound remains the first-line imaging method; however, CT is the gold standard for evaluation of UTIs. MR imaging's improved contrast resolution and absence of ionizing radiation may recommend its use for assessment of lower UTIs. Furthermore, MR imaging performs with diagnostic accuracy at least similar to CT in complicated UTIs, except for the identification of calculi and emphysematous pyelonephritis. In this article, the role of MR imaging for the evaluation of infectious and inflammatory disease processes of the urinary tract is reviewed.

Background and Purpose: Fungal renal abscesses are rare entities associated with significant morbidity and mortality. Affected kidneys can have microabscess, pyelonephritis, pyonephrosis, or papillary necrosis. Case report: Herein, we reported an unusual case of a large renal abscess cause by Candida tropicalis in a diabetic patient. The entity presented as a lump in the abdomen and later was diagnosed to be an abscess on computed tomography scan. Candida tropicalis was confirmed on the culture of the aspirate. The abscess was successfully treated by percutaneous drainage and administration of amphotericin B deoxycholate. Conclusion: Candida tropicalis is now a global concern because of its rising prevalence and high virulence. The growing resistance of this Candida species to azoles, as in our case, calls for a more judicious usage of antifungal agents. Empirical therapy with either amphotericin or echinocandins is an option in case of high azole resistance. This case highlights the importance of timely diagnosis and implementation of aggressive management in cases suffering from fungal abscesses.

Pelvic organ prolapse (POP) can lead to acute bilateral obstructive pyelonephritis (ABOP) due to bilateral ureteral compression. When this occurs, conservative treatment through POP reduction, intravenous antibiotics and supportive care seems to provide an interesting option in the wait of definitive management of POP. The cornerstone of ABOP management, which is the emergent urinary drainage, seems to have many drawbacks in this context due to both technical and patient-related criteria, making it invasive and compromising patient safety and comfort in many settings. Here, we review the management of ABOP and provide a case of an acute obstructive pyelonephritis due to POP., Lay abstract Pelvic organ prolapse (POP) is a common condition arising in a considerable number of women. While its main repercussions include pelvic pain or discomfort, disruption of sexuality and quality of life, pelvic organ prolapse may also lead to life-threatening conditions, namely acute obstructive pyelonephritis (AOP). We hereby expose the case of an AOP due to POP while performing a review of the literature on the proposed management and how it differs from the classic management of AOP.

Urinary tract infections (UTIs) are the most frequent community-acquired and healthcare-associated bacterial infections. UTIs are heterogeneous and range from rather benign, uncomplicated infections to complicated UTIs (cUTIs), pyelonephritis and severe urosepsis, depending mostly on the host response. Ultrasound and computed tomography represent the imaging processes of choice in the diagnosis and staging of the pathology in emergency settings. The aim of this study is to describe the common ultrasound (US) and computed tomography (CT) features of pyonephrosis. US can make the diagnosis, demonstrating echogenic debris, fluid/fluid levels, and air in the collecting system. Although the diagnosis appears to be easily made with US, CT is necessary in non-diagnostic US examinations to confirm the diagnosis, to demonstrate the cause and moreover to stage the pathology, defining extrarenal complications. In emergency settings, US and CT are differently used in the diagnosis and staging of pyonephrosis.

Fistula formation between the kidney and the colon is a rare occurrence. Colorenal fistulas have been reported after renal cryoablation, calculous pyonephrosis, and renal cell carcinoma. Fistula formation is reported in as many as 35% of patients with Crohn's disease. Crohn's-related urinary fistulas may include enterovesical, enteroureteral, rectourethral, urethrocutaneous, and entero-urachal fistulas. Here, we report a rare case of a patient who was found to have a left colorenal fistula in the setting of a left staghorn calculus and recurrent urinary tract infections with a question about the eventual definitive management of the patient.

There are many acute and chronic infections affecting the urinary tract including bacterial, fungal and viral infections. Urinary tract infections (UTIs) can present in many different patterns with variable degrees of severity varying from asymptomatic and uncomplicated forms to life threatening complicated infections. Cross-sectional imaging techniques—including both computed tomography (CT) and magnetic resonance imaging (MRI)—have become very important tools not only for evaluation of UTIs, but also for detection of associated complications. Selection of either CT or MRI in the UTI evaluation depends on several factors such as the presence of contraindication, experience, cost and availability. CT and MRI help in early detection and management of UTIs that reduce the prevalence and severity of complications. In this article we will present the radiologic findings at CT and MRI in different types of upper and lower UTIs including acute pyelonephritis, intrarenal and perinephric abscesses, pyonephrosis, chronic pyelonephritis, emphysematous UTIs, xanthogranulomatous pyelonephritis, tuberculosis (TB), bilharziasis, fungal infection, corynebacterium infection, ureteritis, cystitis, prostatitis, prostatic abscess and urethritis.

Background Calculous pyonephrosis is a disease characterized by infectious hydronephrosis associated with pyogenic destruction of the renal parenchyma, with complete or almost complete loss of renal function. Methods The clinical data of laparoscopic nephrolithotomy performed at Peking University People’s Hospital from May 2017 to June 2020 were analyzed retrospectively. Eight patients (2 men; 6 women) aged 27 to 65 years (average age, 45.8 years) were included. Among them, 7 patients were treated with retroperitoneal approach and 1 patient by transperitoneal approach. All patients had received more than one endoscopic lithotripsy before nephrectomy. Renal dynamic imaging and computed tomography revealed the absence of function in pyonephrosis before nephrectomy. General clinical data and perioperative data were recorded. All nephrectomies were performed by the same physician. Results Laparoscopic surgery was successfully performed in 7 patients; however, 1 patient underwent open surgery because of bleeding. The operation time, average operation time, and blood loss were 1.5–4.5 h, 3.4 h, and 100–1000 ml (average, 300 ml), respectively. The postoperative pathology showed inflammatory renal disease in 6 patients, xanthogranulomatous pyelonephritis in 1 patient, and high-grade urothelial cancer in 1 patient. The average postoperative hospital stay was 5.3 days. One patient had a Clavien–Dindo Grade IIIb complication (severe hematuria), which required laparotomy, and was found that there was bleeding of ureteral stump. None of the patients experienced poor healing of endoscopic wounds. Conclusion For patients with complicated calculous pyonephrosis, renal inflammation could not be effectively controlled, and renal function was seriously damaged. Thus, kidneys should be immediately resected. With laparoscopy, patients may recover quickly, but surgeons require enough experience when performing laparoscopy to achieve safety.

Objectives To evaluate the efficacy of the non-contrast-enhanced computed tomography (NCECT) renal pelvis Hounsfield unit (HU) values in differentiating between the hydronephrosis and pyonephrosis in dilated urinary systems. Materials and methods Patients who underwent percutaneous nephrostomy (PN) due to urinary system obstruction in the last three years were retrospectively evaluated. Pyonephrosis and hydronephrosis groups were differentiated according to the clarity of percutaneous needle aspiration. The patients’ renal pelvic anteroposterior (AP) diameter, renal pelvic area, and mean HU values were measured on NCECT and compared between two groups. Results PN was performed on a total of 523 patients. The study included 159 patients and 214 renal units. Hydronephrosis was detected in 176 renal units and pyonephrosis in 38 renal units. No statistically significant difference was observed between the measured AP diameter and renal pelvic area in the two groups (28.45 ± 10.1 mm vs. 31.13 ± 14.4 mm, p = 0.36 and 658.51 ± 433.1 mm2 vs. 755.14 ± 470.6 mm2, p = 0.22, respectively). The mean HU value of the pyonephrosis group was significantly higher (2.30 ± 5.02 vs. 10.97 ± 6.68, p < 0.001). At the cut-off value of 8.46, HU had a sensitivity of 68.4% and specificity of 92.6% in the diagnosis of pyonephrosis. Conclusions It is possible to determine differential diagnosis between pyonephrosis and hydronephrosis easily and without additional cost by performing dilated renal pelvis HU measurements on NCECT.

We aimed to assess the role of computerized tomography attenuation values (Hounsfield unit—HU) for differentiating pyonephrosis from hydronephrosis and for predicting postoperative infectious complications in patients with obstructive uropathy. We analysed data from 122 patients who underwent nephrostomy tube or ureteral catheter placement for obstructive uropathy. A radiologist drew the region of interest for quantitative measurement of the HU values in the hydronephrotic region of the affected kidney. Descriptive statistics and logistic regression models tested the predictive value of HU determination in differentiating pyonephrosis from hydronephrosis and in predicting postoperative sepsis. A HU cut-off value of 6.3 could diagnose the presence of pyonephrosis with 71.6% sensitivity and 71.5% specificity (AUC 0.76; 95%CI: 0.66–0.85). At multivariable logistic regression analysis HU ≥ 6.3 (p ≤ 0.001) was independently associated with pyonephrosis. Patients who developed sepsis had higher HU values (p ≤ 0.001) than those without sepsis. A HU cut-off value of 7.3 could diagnose the presence of sepsis with 76.5% sensitivity and 74.3% specificity (AUC 0.79; 95%CI: 0.71–0.90). At multivariable logistic regression analysis, HU ≥ 7.3 (p ≤ 0.001) was independently associated with sepsis, after accounting for clinical and laboratory parameters. Measuring HU values of the fluid of the dilated collecting system may be useful to differentiate pyonephrosis from hydronephrosis and to predict septic complications in patients with obstructive uropathy.

Ureteric calculi are a common cause of emergency presentation to hospitals in the United Kingdom and worldwide. A significant and life threatening complication of those stones that obstruct the ureter is pyonephrosis, bacteraemia and resulting sepsis. Whilst the majority of such cases present with the typical symptoms of loin pain and fever, here we describe the case of a 57 year old patient with asymptomatic bilateral obstructing ureteric calculi that led to bacteraemia from a rare bacterial pathogen, Lactobacillus jensenii, and subsequent severe bacterial endocarditis requiring emergency aortic valve replacement.

BACKGROUND & OBJECTIVE: There is disagreement in the use of ureteral double-J stent before the extracorporeal shock wave lithotripsy (ESWL), although most of the urologists suggest using stent in shock wave lithotripsy technique for stones bigger than 20mm, for preventing the risk of developing steinstrasse. To compare the success of ESWL with and without DJ stenting in proximal ureteric stone. METHODOLOGY: A total of 60 patients form both genders, between 15 to 55 years of age, with a single proximal ureteric stone, were included. Patients with solitary functioning kidney, multiple stones, pregnancy, pyonephrosis and sepsis were excluded. In Group-A, ESWL without DJ stenting was completed while in Group-B, ESWL with DJ stent placement was done. In all patients, at least 4 sessions were done fortnightly. Patients were followed regularly and final success was noted after one month of completion of ESWL sessions. RESULTS: The mean age was 36.85 ± 8.61 years. From 60 patients, 29 (48.33%) were men and 231 (51.67%) were women.Mean body mass index (BMI) was 28.30±2.20 kg/m . The average size of the stone was 12.47 ± 2.57 mm. Success (according to stone removal) of Group-A (ESWL without DJS) was seen in 26 (86.67%) patients while in Group-B (ESWL with DJS) was seen in 16 (53.33%) patients with P-value of 0.005. CONCLUSION: This study concluded that success (in terms of stone clearance) of extracorporeal shock wave lithotripsy (ESWL) without DJ stenting is higher compared to with DJ stenting in upper ureteric stone.

An 11 yr old female spayed shih tzu was referred for treatment of left ureterolithiasis with complete obstruction of the left ureter and pyonephrosis. A ureteral stent was placed surgically to relieve the obstruction and pyonephrosis was treated with antibiotics. Three and a half years following stent placement, the patient developed an abscess on the left flank with chronic purulent discharge. Diagnostic imaging confirmed the presence of a left uretero-cutaneous fistula and renal abscess. A left ureteronephrectomy was performed. The dog was euthanatized 4 mo later for cardiac insufficiency unresponsive to medical treatment. This is the first report of a uretero-cutaneous fistula and renal abscessation as a complication of ureteral stenting in a dog.

To compare percutaneous nephrostomy tube versus JJ stent as an initial urinary drainage procedure in kidney stone patients presenting with acute kidney injury.Between January 2017 and January 2019, 143 patients with acute kidney injury secondary to obstructive kidney stone were prospectively randomized into the percutaneous nephrostomy tube group (71 patients) and JJ stent group (72 patients) at Beni-Suef University Hospital, Beni-Suef, Egypt. Exclusion criteria included candidates for acute dialysis, fever (38°C), pyonephrosis, pregnancy and uncontrolled coagulopathy. The period required for serum creatinine normalization, failure of insertion, operative and fluoroscopy time were recorded. Definitive stone management for proximal ureteral stones1.5 cm consisted of percutaneous nephrolithotomy for the percutaneous nephrostomy group and ureteroscopic laser lithotripsy for the JJ stent group. For stone size1.5 cm, ureteroscopy or shockwave lithotripsy was carried out for both groups. Percutaneous nephrolithotomy was carried out for renal stones2 cm, and shockwave lithotripsy for stones2 cm. Distal and mid ureteral stones were treated by ureteroscopy.The percutaneous nephrostomy group had shorter operative time (P = 0.001). There was no significant difference in the recovery period for normalization of serum creatinine between both groups (P = 0.120). Procedural failure, ureteric mucosal injury and perforations increased in the case of male sex, stone size1.5 cm and upper ureteric stones in the JJ stent group. Procedural failure, pelvic perforations and intraoperative bleeding increased in case of male sex, mild hydronephrosis and stone size2.5 cm in the percutaneous nephrostomy group. Suprapubic pain, urethral pain and lower urinary tract symptoms were significant in the JJ stent group. The presence of a JJ stent directed us toward ureteroscopy (P = 0.002) and the presence of a percutaneous nephrostomy directed us toward percutaneous nephrolithotomy (P = 0.001).Percutaneous nephrostomy facilitates subsequent percutaneous nephrolithotomy, especially when carried out by a urologist, and it has a higher insertion success rate, a shorter operative time and a lesser incidence of postoperative urinary tract infection than a JJ stent. A JJ stent facilitates subsequent ureteroscopy, but operative complications can increase in the case of proximal ureteral stones1.5 cm.

For obstructed uropathy causing pyonephrosis, immediate decompression by urinary diversion is the temporary mode of treatment. The type of procedure should be individualised depending on the size and position of stone, the degree of obstruction and the definite treatment planned for the obstruction in the near future. Percutaneous Nephrostomy (PCN) and retrograde Double J (DJ) stenting are the most widely used methods. According to currently available literature, there is no significant difference between these procedures with regards to availability, technical success, percentage of complications and the effect on quality of life of patients. Here, the authors present a case of a six-year-old male where internal drainage with two DJ stents did not drain the pyonephrosis. He had a right flank pain and fever on evaluation; was found to have right renal pelvic calculus with pyonephrosis. Even after putting two double J stent of size 3.6 French (Fr) the pyonephrosis could not be drained, eventually, right PCN of 6 Fr was placed, symptoms relieved and later on stone cleared with percutaneous nephrolithotomy.

Introduction: Retroperitoneal abscess is a rare condition which is difficult to diagnose and treat because of its insidious onset and nonspecific clinical manifestations. Case Report: 55 years old male, underlying DM, Hypertension, Gouty arthritis. Referred to us for right Hypochondriac pain with persistent fever for past 2 days duration. Abdominal examination showed soft, tender over right side of abdomen, localized guarding. An abdominal CT scan showed right pyonephrosis complicated by a large right perirenal collection.Right Nephrostomy was performed. 1 week later, patient had fever and persistent right sided abdominal pain with increasing septic parameters. CT abdomen performed and showed Right pyonephrosis complicated by a large right perinephric abscess extending into the pelvic and inguinal region. Right Perinephric drainage performed. Patient developed worsening sepsis, repeated CT abdomen revealed residual multiloculated right perinephric collection. Open retroperitoneal drainage was performed, noted retroperitoneal abscsess, caccon right kidney and peritoneal, slough ,unhealthy tissue and necrotic debris over right psoas muscles.1 week after surgery, patient still not improving, repeated CT Abdomen showed features of D2 ischemia with focal retroperitoneal perforation causing large and recurrent right perinephric inflammation with increasing intraabdominal free fluid and enlarging right perinephric collection. Laparotomy done shiwed 1L clear ascites intraperitoneally, no pus collection seen. Cocoon inflammatory mass involving hepatic flexure and duodenum to the retroperitoneum, hepatic flexure appeared normal with no intraluminal mass.Right retroperitoneal exploration done, noted adhesion between hepatic flexure to Gerota's fascia, pus ~30ml at upper part of Gerota's fascia. Repeated CT abdomen showed slightly larger right paracolic gutter collection with similar right perinephric collection. Discussion: Retroperitoneal abscess is very rare. Retroperitoneal abscess may result from a variety of causes, such as pyelonephritis, pancreatitis, retroperitoneal appendicitis, diverticulitis, peptic ulcer disease, perforated cancer, infammatory bowel disease, spinal infection, trauma, and post instrumentation. For our patient ,the exact aetiology of retroperitoneal collection and peri renal collection are still unknown.

Congenital hydronephrosis is the most common cause of a palpable neonatal abdominal mass, of which ureteropelvic junction (UPJ) obstruction is the most likely cause. UPJ stenosis is also the most common cause of antenatal hydronephrosis. The upper tract dilatation classification is useful to predict outcome and document follow-up. Fifty percent of UPJ stenoses are associated with other congenital urological abnormalities. UPJ stenosis is largely caused by an intrinsic aperistaltic segment of ureter; however, occasionally extrinsic and secondary causes are implicated. Not all UPJ stenoses (stenoses) requires surgery. Indications for surgery include a split function

PURPOSETo evaluate therapeutic efficacy of two minimally invasive surgical methods in managing acute ureteral obstruction and severe infection caused by upper urinary tract calculi (UUTC).PATIENTS AND METHODSData of 47 patients diagnosed with acute upper urinary tract obstruction and severe infection caused by ureteral calculus using X-ray CT between September 2014 and January 2019 were retrospectively analyzed. All patients were treated with immediate renal drainage and, after infection and ureteral obstruction were relieved, UUTC removal. Renal drainage was performed by ultrasound-guided percutaneous nephrostomy and retrograde ureteral catheterization was performed using cystoscopy. Kidney and ureteral stones were removed; renal function and the urinary tract were examined by X-ray during follow-up.RESULTSPercutaneous nephrostomy was performed in 29 patients in a critical condition including intolerance to surgery, high-grade hydronephrosis, or failure of retrograde ureteric stent placement. In other 18 patients diagnosed with small stones (≤10 mm) and low-grade hydronephrosis, indwelling double-J ureteral stents were temporally installed by a cystoscope. Acute infection and ureteral obstruction were relieved; white blood cell counts returned to normal values within 3 to 7 days after drainage in all patients. In the second-stage treatment, percutaneous nephrolithotomy (PCNL), ureteroscopic lithotripsy, extracorporeal shock wave lithotripsy and nephrectomy were performed in 24, 10, 8 and 5 patients, respectively. No patients developed severe complication after stone removal surgery. All patients were followed up for 3 months to 4.5 years. Renal function was significantly recovered; 17/29 (59%) patients with elevated serum creatinine returned to normal and serum creatinine in 12/29 (41%) patients improved significantly after drainage, with a pre-operation level of 285±169μM vs 203±91μM post-operation (P = 0.014). Five patients were lost during follow-up.CONCLUSIONThis study demonstrated an optimal approach for relieving upper urinary tract obstruction and acute infection in which percutaneous nephrostomy drainage is preferred for patients with severe pyonephrosis, large stones (>10 mm) with high-grade hydronephrosis, steinstrasse, or failure in retrograde ureteric stent placement, while retrograde ureteral catheterization using cystoscopy is suitable for patients diagnosed with small stones (≤10 mm) and low-grade hydronephrosis.

Non-traumatic spontaneous subcapsular renal hematoma, also known as Wunderlich syndrome, is a rare entity that is associated with some renal pathology, mainly tumors or cysts, anticoagulant drugs administration or unknown reasons. We present a case of an elderly patient that presented with spontaneous subcapsular renal hematoma and complete deterioration of his kidney due to severe pyonephrosis that was managed conservatively.

The diagnosis of urinary tract infection (UTI) in adults is primarily based on a typical presentation with urinalysis findings suggestive of UTI. In general, routine radiologic imaging is not required for diagnosis and treatment of uncomplicated cases in adult patients. Appropriate imaging not only defines the extent of disease but also identifies significant complications. This may help in treatment adjustment. It can also guide the interventional radiologist in planning the management of pyonephrosis and abscess.

Background Febrile urinary tract infections (UTIs) include a spectrum of pathologies from uncomplicated pyelonephritis to urosepsis, including xanthogranulomatous pyelonephritis (XGP). Most febrile UTIs are treated with antibiotics alone, but studies indicate nearly 12% of cases of presumed simple pyelonephritis require emergent urologic intervention. How to identify these individuals, while limiting unnecessary advanced imaging and delays in diagnosis, challenges all emergency providers. We review the diagnosis and management of XGP, as well as the evidence regarding the role of renal ultrasound in the identification of complicated presentations of febrile UTIs. Case Report We present a case of XGP, a complicated febrile UTI requiring immediate urologic intervention, diagnosed by point-of-care ultrasound. A 40-year-old female presented in severe sepsis and complaining of flank pain. Prompt bedside ultrasound demonstrated hydronephrosis, expediting definitive urologic treatment via percutaneous nephrostomy tube placement. Why Should an Emergency Physician Be Aware of This? With a mortality rate exceeding 40%, obstructed pyonephrosis requires prompt decompression. Given its exceptional sensitivity for identifying hydronephrosis and ability to detect abscesses and emphysematous changes, we advocate a point-of-care ultrasound–first approach to screen for cases of complicated febrile UTIs in order to expedite treatment and limit radiation in uncomplicated presentations.

Background Peritoneal fistulization of a pyonephrosis is an extremely rare event which invariably leads to generalized peritonitis. This is a very rare case report on generalized peritonitis after spontaneous rupture of pyonephrosis. Case presentation A 28-year-old male patient from the rural part of Bale zone, Ethiopia, was admitted to Goba Referral Hospital with high-grade fever, diffused abdominal pain and abdominal distension. Initially, he experienced colicky and intermittent pain that made him stay at home for 2-3 days. He then started to develop constant left flank pain which gradually got worse and was associated with urinary frequency of approximately 5–6 times/day, high-grade intermittent fever, chills, rigors and loss of appetite. With the diagnosis of generalized peritonitis, we resuscitated him with two bags of normal saline and one bag of ringer lactate intravenously. During an abdominal ultrasound examination we identified that the left kidney was replaced by an abscess containing sac, and there was a huge intraperitoneal loculated abscess with internal septation and an associated free inter-loop and pelvic echo debris abscess. When we performed an exploratory laparotomy, 1 L-thick abscess from the general peritoneum was aspirated and early fibrinous inter-loop adhesion was identified. In addition, there was a large retroperitoneal cystic abscess containing sac extended from the spleen up to the pelvic brim crossing the midline to the right side and bulged intraperitoneally. Furthermore, a 1.5 cm wide perforation that pour abscess in to peritoneal cavity was found. A total of 4 L of puss was removed from the left kidney. As treatment, since the left kidney lost all function and became a pus-contacting sac, we performed a left-sided nephrectomy and abdominal lavage. Postoperatively, the patient had an uneventful recovery and was discharged from the hospital on the eighth day. We followed him for 6 months, and kidney function tests were normal and he did not develop any complications. Conclusion This case report highlighted the importance of recognizing the possibility of underlying kidney rupture in a patient with generalized peritonitis. Uretero-pelvic junction obstruction (UPJO) might be the possible cause of pyonephrosis in our case. As a treatment, nephrectomy is a preferable option when the affected kidney is not fully functional and the contralateral kidney is normal.

Inferior vena cava (IVC) thrombosis is a rare medical condition. Suppurative thrombophlebitis of the IVC is even a more uncommon subtype of IVC thrombosis and is mostly associated with IVC filters or venous catheters. We describe a 66-year-old man with persistent fever and history of pyonephrosis secondary to transurethral lithotripsy 1 month before recent admission. Computed tomography scan of the chest and abdomen revealed a filling defect in the IVC protruding into the right atrium. Transesophageal echocardiogram (TEE) revealed a large mass at the origin of the IVC entering into the right atrium, suggestive of a clot. Diagnosis of suppurative thrombophlebitis of the IVC secondary to a retroperitoneal abscess was made, and intravenous antibiotic therapy for 6 weeks without anticoagulation conferred ample thrombus resolution. Follow-up TEE in week 16 showed no residual thrombus in the IVC.