經皮腎造廔取石術作為黃色肉芽腫性腎盂腎炎的一種腎臟保留治療方式

徐任廷¹、鐘旭東¹、陳俊翔¹

¹亞東紀念醫院 外科部 泌尿科

Percutaneous nephrolithotomy serves a nephron-sparing treatment in xanthogranulomatous pyelonephritis

Jen-Ting Hsu¹ , Shiu-Dong Chung¹, Jiun-Siang Tan¹

Division of Urology¹ Department of Surgery, Far Eastern Memorial Hospital, New Taipei City

Introduction: Xanthogranulomatous pyelonephritis (XPGN) is a rare but potentially fatal disease, comprising 1% of all kidney infections but having a mortality rate of 10%. In histopathology, XPGN is characterized by recurrent chronic inflammation leading to infiltration of inflammatory cells and granulomatous tissue in the renal parenchyma. Etiology includes recurrent urinary tract infections, abnormal lipid metabolism and long-term stone obstruction. When conservative antibiotic therapy fails, more effective treatments typically involve partial or total nephrectomy. However, in our case, Through the procedure of percutaneous nephrolithotomy, we provide a nephron-sparing treatment.

Case report:  A 67-year-old female presented to our ER due to severe right flank pain for two days. She had underlying diseases of hypertension, diabetes mellitus and hyperlipidemia. Physical examination revealed right revealed costovertebral-angle knocking pain. She denied fever, chillness or gross hematuria.  Urinalysis revealed hematuria and pyuria. Biochemical tests showed an elevated white blood cell count (14.51 × 103/μL) and mildly decreased hemoglobin (9.1 g/dL). Abdomen CT showed right xanthogranulomatous pyelonephritis, with urolithiasis at right ureteropelvic junction (UPJ). Due to urosepsis, emergent PCN was inserted for drainage. URS exam with right double J stent insertion was performed after her fever subsided. After discussion with the patient, she chose PCNL as initial management of the right UPJ and renal stone.

Under ETGA with a prone position, we use echo-guided to locate the stone for puncture. The guidewire was inserted into the renal pelvis along with the puncture needle. A balloon dilator was applied to dilate the tract to Fr. 24 for Amplatz sheath placement as a tract. Thick pus continuously flowed out from the tract. During the surgical procedure, the operative field is often obscured by a large amount of pus and necrotic tissue debris. We utilize a suction tube to remove these infected and inflamed materials, allowing us to successfully locate the stone. The stone was fragmented by the lithoclast and cleared from the tract. A Nephrostomy tube was placed into the renal pelvis. No postoperative fever or septic sign was noticed. Clear and tinged red urine was drained out from the nephrostomy tube. She was discharged under relatively stable condition. Following up KUB showed no residual stone in the right renal pelvis. 

Conclusion: In summary, XPGN is a rare but potentially life-threatening disease. In patients with XPGN caused by prolonged obstruction due to kidney stones, percutaneous nephrolithotomy offers a therapeutic option to preserve the kidney, as observed in our case.