Introduction: Xanthogranulomatous pyelonephritis (XGPN) is a destructive form of chronic pyelonephritis with frequent involvement of adjacent organs (with abscesses and fistulas). We present a video comparison of the laparoscopic nephrectomy of two XGPN cases.
Methods: In this video we present two cases of laparoscopic nephrectomy of XGPN cases – a simpler case (patient 1) and a more complex one with the intraoperative diagnosis and repair of a pyeloduodenal fistula (patient 2). Both patients were middle-aged females with a history of urolithiasis, who presented to the emergency department (ER) with similar symptoms: flank pain and weight loss in the previous month. The computed tomography scans showed typical signs of XGPN of right kidney: an enlarged kidney with important dilation and densification of the collecting system, caused by urinary stones. The patients were admitted to the urology ward and started on intravenous (IV) antibiotics. Patient 1 was submitted to ultrasound-guided percutaneous nephrostomy and psoas drain placement and was discharged after 9 days, with both catheters and oral antibiotics. She was readmitted after 3 months for the elective right nephrectomy. Patient 2’s also had a percutaneous nephrostomy placed by the Urology team and a hepatic drain in an abscess placed by the Radiology team. The patient stayed in the hospital for 2 weeks and was discharged after drains removal. Her right nephrectomy was scheduled for 1.5 months after. The definitive treatment of this condition is surgical with nephrectomy, drainage of concomitant abscesses and removal of the involved tissues. Our video presents and compares these patients’ laparoscopic surgeries.
Results: The surgical time was 2 hours in patient 1 and 4 hours in patient 2, with no intraoperative complications. Patient 1 recovered quickly and was discharged after 3 days. Patient 2 was required to stay on bowel rest with a nasogastric tube placed for 3 days. She started solid food ingestion on day 5 with great tolerance and was discharged on post-operative day 8. No post-operative complications were observed. The pathology report was similar for both patients: terminal kidney with XGPN.
Conclusions: Laparoscopic management of xanthogranulomatous pyelonephritis is challenging due to the loss of anatomical planes and inflamed tissues, so a systematic approach is advisable. The management of pyeloduodenal fistulas can also be made by laparoscopy, as demonstrated in our video, the first reported case of laparoscopic treatment of this kind of fistula.