Renal abscess

,Xanthogranulomatous
pyelonephtitis and Renal
Tuberculosis
AUA Update series 2014 ,Volume 33 ,Lesson 36
Pais ,sharmma ,Pattison et al

Anas Hindawi PGY3 Urology Resident

Makassed General Hospital
Beirut Arab University

Introdution
Retroperitoneal abscesses may arise from pathology
originating sources most commonly the kidney
Kidney infections itself span a wide spectrum like acute
uncomplicated acute pyelonephritis
Pyonephrosis ,Emphysematous Pyelonephritis pose true
urologic emergencies

 In this update we focus on Dx and Mgt. of 3 challenging

manifestations of renal infection
Renal abscess ,Xanthogranulomatous pyelonephtitis and
Renal Tuberculosis
Symptoms ,laboratory studies and imaging findings are
non specific
Diagnostic and therapeutic arsenals reduce the associated
significant morbidity and mortality
we will discuss pathophysiology ,diagnostic capabilities
and treatment options applicable to those patients

Renal and Perinephric abscesses

Renal abscesses are collections of pus within renal
parenchyma ,further categorized by anatomical location
Perinephric abscess extend beyond capsule but contained
by Gerota fascia ,commonly caused by rupture of renal
abscess thru. Renal capsule , seeding of Perinephric
Haematoma or Urinoma
An abscess extending through Gerota classified as
Paranephric abscesses that may result from GI infectious
process

 Renal and Perinephric abscesses are reviewed

together under the designation of renal abscess
Paranephric abscesses are beyond preview in this
update

Epidemiology
Relatively uncommon (0.01% hosp. admissions)
Most often unilateral
No gender predilection
Prevalence increases with age
Etiologies include infected renal or ureteral stones ,non
calculus renal obstruction (*) ,pyelonephritis ,UTI
,previous urological surgeries ,PCKD

 Predisposing factors include : DM , steroids ,HIV ,IV drug

abuse ,prior uncomplicated UTI ,liver disease ,pregnancy
15 % of abscesses occurred in patients without known
predisposing factors
DM represents an important factor acc. To a population
based study in which hazard ratio of hospitalization of 3.81
in DM patients was seen
DM was associated with lengthened hospitalization with no
increase in mortality

Pathogenesis
The advent use of antibiotics had led to earlier control and
reduced hameatogenous spread of pyogenic G+ve
infections shifting isolates to G-ve rods
Mot common organisms cultured are : E.coli ,Klebsiella
,Proteus ,Pseudomonas and staph. Aureus
It is suspected that Uropathogenic G-ve renal abscesses
arise from ascending infection
Rarely renal abscesses reported to arise from ascending
infection tracking up fascial planes from prostate abscess
or s/p biopsy

Presentation
Classic presentation of fever and unilateral flank pain in
23%
Common symptoms : Flank or abdominal pain ,palpable
flank mass and voiding dysfunction
Insidious onset of chills ,N/V and weakness of less than
one week duration
Laboratory findings of leulocytosis 90% ,pyuria 70%

Diagnosis
Historically high degree of morbidity and mortality was
referred to difficult diagnosis and delayed targeted
treatment
Recently CT replaced x-ray and execratory urogram ,it
provides anatomical and adequate assessment of infection
Non contrast CT findings of fluid filled lesion (0-40 HU)
with or without gas ,Contrast enhanced films showed
peripheral thickening and enhancement
Perirenal fluid and inflammatory stranding with thickened
Gerota might present

 CT is diagnostic in 90%
Ultrasound is particularly useful in :children ,pregnant
,patient preference ,following known abscess
Nonetheless Ultrasound sensitivity is much lower than CT
in initial evaluation
Ultrasound
findings
are
variable
:hypoechoic
,hyperechoic , complex cystic or post. Acoustic
enhancement
Doppler distinguish abscess from neoplastic lesion

 Acute pyelonephritis is among the most common

admission misdiagnoses
Typically diagnosis is made clinically and treated non
surgically
Renal abscess distinguished from acute pyelonephritis by
2 features : 1) symptomatic > 5 days 2) fever > 5 days
Not all acute pyelonephritis pts. Needs imaging ,unless
high suspicion of obstruction or dowentrending of fever
curve does not follow conservative and IV antibiotics
management

Treatment
Empiric ABx therapy should cover the most common
uropathogen /E-coli ,klebsiella ,proteus and less
commonly haematogenous spread staph-aureus/
Culture data of abscess ,urine and blood has to be
interpreted and considered
Concordance of abscess and urine cultures may be
observed in 49%
Additional isolates might be seen in abscess but not viceversa in urine

 Small renal abscesses treated by IV ABx has to be

observed for clinical improvement and changing of the
course based on culture data
Selection of initial treatment modality depends on : size
,location of abscess ,overall clinical status
Efficacy of ABx therapy has been observed in smaller
abscesses in immunocompetent patients
Reports/siegel et al ,dall palma et al ,comploj et al / of
abscesses resolution smaller than 5 cm , solitary or
multiple using broad spectrum ABx over 6 weeks in some
of the reports

 Patients with no clinical improvement should be offered a

drainage procedure
ABx without drainage is not recommended in gravely ill
immunocompromised pts
Abscesses > 3cm in immunocompromised pts regardless
the size not responding to ABx alone require drainage in
combination with culture directed ABx
Ultrasound and CT guided drainage allow excellent
targeting and confirmation of appropriate drain placement

 Yen et al reported 76% resolution rate of

intrarenal/perinephric abscesses treated by percutaneous
drainage with no description of the size
Siegel et al reported 92% resolution rate for 3-5 cm
intrarenal/perinephric abscesses with percutaneous
drainage
This approach proved to be useful even in >10 cm
abscesses
Meng et al reported successful approach in 7/11 abscesses
with average size 11 cm ,all >5 cm

 Patients had longer hospitalization ,multiple drain

manipulations ,prolonged catheter placement
Siegel et al reports a high failure rate of larger abscesses
Loculations do not appear to be a contraindication
Open surgical approach may be considered in suspected
GI involvement ,large complex or multiloculated
collections ,non functioning kidney
Nephrostomy tube or uretral stent should be performed in
the setting of obstruction and infection

Follow up
Progress should be monitored to confirm clinical
improvement
Imagings /CT ,ultrasound/ are recommended to confirm
resolution of abscesses
There are no evidence based protocols to direct a course
of follow up imaging

Xanthogranulomatous
pyelonephritis
XGP is a chronic inflammatory condition of the kidney
distinguised by replacement of the renal parenchyma with
granulomatous collections of lipid laden histocytes
XGP is associated with chronic infection and obstruction
leading to enlarged poorly or non functioning kidney
Might mimic any other urological condition
CT & MRI might show neoplastic process changes

Epidemiology
XGP is identified in 8.2-19% of biopsies
nephrectomies performed for chronic pyelonephritis
Annual incidence not sufficiently reported 1.4/100.000
5th to 6th decades age average ,3/1 female to male
Predisposition factors : UTI ,nephrolithiasis
Diabetes as frequent co morbidity

or

Pathophysiology
XGP most commonly encountered with chronic renal
infection ,nephrolithiasis and obstruction
Definitive correlation is poor for renal ischaemia
,lymphatic and venous obstruction ,impaired immune
response and altered lipid metabolism a causative factor
Concomitant infection with obstruction reported in
significant numbers
Nephrolithiasis is present in 82%

 Urine cultures reveal G-ve uropathogens ,indicating

ascending infection
Proteus and E-coli are the most common offending agents
Pseudomonas ,staphylococcus ,klebsiella , candida and
anaerobs are reported
In light of frequently associated upper tract obstruction
,urine cultures can be negative in up to 40% and when
positive discordant

Presentation
Several months symptoms are common
Constitutional symptoms of weight loss ,malaise ,fever
Examination may reveal tender palpable mass ,unilateral
CVA tenderness 72%
Findings indicating fistulization or local spread such as a
draining flank sinus or empyema
Leukocytosis ,elev. ESR and anemia ,liver dysfunction
might present and reolve by Tx

Diagnosis
Clinically ,radiologically and histologically non specific
features confused with renal cell carcinoma ,malacoplakia
,renal TB ,renal infarction ,pyonephrosis and wilms tumor
Radiographic findings of classic non functioning enlarged
kidney ,nephrolithiasis in up to 80%
CT is the optimal modality for imaging and diagnosing
XGP
CT findings suggests presence of diffuse XGP are : poorly
defined renal pelvis ,diminished renal pelvis fat
,hypoechoic non enhancing spherical nodules ,rim like
enhancement around the mass ,air in urinary tract 9.8%
with no typical emphysematous pyelitis/pyelonephritis

 US may reveal hydronephrosis , stone ,pyenephrosis

evidenced by internal ehoes from pus or debris in renal
pelvis
Focal form most commonly confused with tumors and
abscesses ,with no reliable findings to differentiate
MRI offers no data above CT ,not routinely performed
The gold standard of XGP diagnosis is still pathological
examination s/p nephrectomy
Gross examination reveal indurated adherent perinephric
fat ,parenchymal and peripelvic fibrosis ,pus filled calyces
or renal pelvis
Microscopic evaluation shows replacement of normal
renal parenchyma by sheets of lipid laden macrophages
/xanthoma cells/

Treatment
Surgical excision remains the treatment of choice
Appropriate timed surgical excision avoid extrarenal
spread and potential of more complicated and morbid
procedures
In diffuse XGP ,there is no functional parenchyma radical
nephrectomy is the preferred treatment /open nehrectomy/
The benefits of laparoscopy do not extend to XGP

 Partial nephrectomy of focal XGP is considered

Nephron sparing approach is feasible with no
recurrence rate even in bilateral focal XGP
Non operative management may be an appropriate
consideration for children

Renal tuberculosis
Caused by haematogenous seeding of mycobacterium TB
from pulmonary focus
Seeding occurs at the level of glomerular capillaries
,grow insidiously years after initial infection
Caseating granulomas occur within kidneys and spread
distally through the urinary system

Epidemiology
Incidence in U.S of 3.2/100,000 ,decline in last 20 ys
Renal TB decline in association with pulmonary TB
decline
Genitournary TB represents 6.5% of extrapulmonary TB
Higher infection and high reactivation populations are at
risk of renal TB
Higher infection in : foreign born ,homelss ,resident and
workers at health care facilities
Higher reactivation in : HIV ,drug abusers ,DM ,low body
weight ,immunocompromised ,chronic inflammatory
dis.and transplants

Presentation
Non specific intermittent chronic urinary symptoms and
some asymptomatic
Most common symp. Of renal TB is : frequency then
dysuria and flank pain
Often have chronic sterile pyuria with/out microscopic
haematuria
Typical symptoms of TB are rare

 Renal TB often presents with late stage complications

such as hydronephrosis/pyonephrosis or obstructive
uropathy
Renal function rarely affected even in advanced stages
Late stage complications include formation of a sinus
tract ,complicated renal cysts ,thight abscesses ,perirenal
haemorrhage and auto-nephrectomy

Diagnosis
No testing method has adequate sensitivity/specificity to
diagnose renal TB
Should be suspected with persistent sterile pyuria despite
standard Tx
Combination of microscopic haematuria and sterile pyuria
can be suggestive of renal TB with other reisk factors or
+ve tuberculin test
Serial cultures yield variable sensitivity /80%/ after 6
weeks growth
High cost culture techniques emerged with limited data

 Single step PCR provides rapid method of detection with

higher specificity 95-100% , sensitivity 25-95%
Clinical usefulness is limited by commercial availability
of detection kits

 Imaging is faster method than culture ,more available than

PCR
1/3 of renal TB have a +ve chest x-ray findings
Execratory urography when CT unavailable or radiation
exposure is a concern
Early changes of blunting or minor calyces ,late changes
are calcifications and lost calyx due to infundibular
stenosis
Common findings include hydrocalycosis ,hydronephrosis
and hydroureter due to uretral strictures

 Retrograde pyelogram can delineate pelvicalyceal

abnormalities that can be seen either unilateral or bilateral
CT provides information abt pulmonary and extrapulmonary involvement
Better than plain films in detecting renal parenchyma
masses , scarring ,thick urinary tract wall ,non uniform
calicectasis and dense calcifications
MRI is a good option in renal insufficiency ,contrast
allergy and radiation concerns

Medical treatment
Randomized control trials are performed on the medical
management of genitourinary TB ,consensus exist on the
efficacy of 6 months antituberculosis chemotherapy
Goals of Tx are cure , spreading control and prevent
further drug resistant
Standard six months chemotherapy with multi drugs
/isoniazid ,rifampin ,pyrizinamide and ethambutol/
1st two months with all 4 drugs ,last four months with 2
drugs

Surgical treatment
Medical treatment is adequate in uncomplicated renal TB
Surgical management is indicated for : hydronephrosis
,abscess drainage ,infected non functioning kidney
removal ,urinary tract reconstruction for strictures
Stenting success rate 40-60%
Partial nephrectomy indicated in calcified lesions non
responding to chemotherapy or growing in sizetotal
nephrectomy is indicated in :non functioning kidney ,diffuse
pattern ,UPJ obstruction and HTN and coexisting RCC

 Reconstruction is indicated for complex stricture like long

segments ,extensive bilateral involvement and impassable
strictures
Simple strictures ,short segments that are passable in
setting of salvageable renal function can be managed
endoscopically

Controversies
There is debate among researchers abt. :
Use of corticosteroids in distal ureteral strictures
management
Antituberculosis chemotherapy duration /4 vs 6 mths./
Need for safe sex practice
Timeline for invasive procedures in relation to
chemotherapy
Usefulness of total nephrectomy for asymptomatic
tuberculous kidney

Follow up
The AUA recommends follow up schedule at 3 ,6 and 12
months , some suggest longer follow up surveillance
The EAU advocates weekly IV pyelogram to monitor for
distal uretral obstruction while on chemmotherapy /due to
oedema/
Recent german review suggests follow up of 5 ys after
antituberculosis Tx
Corticosetroids can be used f no improvement after 3 weeks
Fibrosis can occur after completion of therapy