產氣性腎盂腎炎的保腎治療：以內視鏡引流取代緊急腎切除術

黃國倫¹、黃維倫^1、2

¹義大醫療財團法人義大醫院 泌尿科；

²義守大學 醫學系

Nephron-Sparing Management of Emphysematous Pyelonephritis: Endoscopic Drainage as an Alternative to Emergency Nephrectomy
Guo-Lun Huang¹, Wei-Lun Huang^1,2

¹Department of Urology, E-Da Hospital, Kaohsiung, Taiwan;

²School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan

Introduction: Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the kidney caused by gas-forming bacteria, most commonly seen in diabetic patients. Traditionally treated with emergency nephrectomy, EPN management has shifted toward conservative approaches such as percutaneous drainage and endoscopic debridement. We report a case of Class II right EPN which was initially considered for nephrectomy but was successfully treated with endoscopic drainage, achieving complete infection control and renal preservation.

Case report: A 64-year-old woman with a history of diabetes mellitus (HbA1c 15.5%) and hypertension presented to the emergency department with high fever and dysuria for one week. On arrival, she was in septic shock. Laboratory evaluation demonstrated leukocytosis (white blood cell count, 22,950/μL), elevated serum creatinine (1.5 mg/dL) consistent with acute kidney injury, and markedly increased C-reactive protein (250 mg/L), indicative of severe systemic inflammation. Owing to profound septic shock and respiratory failure, she required endotracheal intubation and inotropic support. Computed tomography (CT) of the abdomen demonstrated mottled gas within the right renal parenchyma confined to Gerota’s fascia, consistent with Class II emphysematous pyelonephritis (Fig. 1A). A right percutaneous nephrostomy (PCN) was performed for decompression and drainage. Cultures from both blood and urine yielded Klebsiella pneumoniae. Due to persistent purulent drainage from the nephrostomy, nephroscopic exploration and debridement were performed through the existing tract. The access was serially dilated to 28 French, and necrotic debris was removed under direct visualization (Fig. 1B). A second session of nephroscopic debridement was subsequently undertaken, achieving complete clearance of the residual necrotic tissue. The patient’s clinical condition gradually improved following staged endoscopic management. She was discharged on hospital day 31 with the PCN left in situ, and was prescribed oral cefixime for continuation therapy. Serial follow-up imaging revealed progressive recovery of right renal parenchymal morphology, and the PCN was successfully removed approximately eight weeks postoperatively. A contrast-enhanced CT performed three months after discharge demonstrated right renal atrophy without residual abscess or intraparenchymal gas formation (Fig. 1C).

Conclusion: This case highlights that even in severe emphysematous pyelonephritis initially considered for nephrectomy, renal preservation can be achieved through timely percutaneous drainage and nephroscopic debridement. With careful patient selection and close monitoring, minimally invasive endoscopic management represents an effective, nephron-sparing alternative to emergency nephrectomy.