Perinephric abscess drainage : percutaneous or open? Review of 63 cases reported in the last five years

Objective

Suppurative infections of the kidney and perinephric space are uncommon, but in recent years we are witnessing a gradual increase, perhaps due to lower efficiency and reduced availability of new antibiotics. Furthermore, the diagnosis is not always timely and the diagnostic delay may increase morbidity and mortality. Since the introduction of CT and MRI in the diagnostic perinephric abscesses mortality was reduced by 12% (Meng 2002). The classical treatment of abscesses involved the surgical exploration, drainage and / or nephrectomy. From the late 90s has spread the minimally invasive treatment already reported in the 70s. The authors perform a review of their cases in the last five years.

Methods and results

63 patients who underwent drainage for perinephric abscesses from January 2009 through December 2013 were evaluated. Have not been evaluated small abscesses (<3 cm) treated only with antibiotics. Suspected patients were clinically evaluated and investigated using ultrasound of the abdomen. When the findings were suggestive of renal and perinephric space infection, TC of the abdomen was done to confirm the diagnosis and grade the abscess. The study included 35 males and 28 females with ranging in age from 47 to 81 years. Complex kidney stones, diabetes mellitus, urinary diversion obstructed (Bricker, Ureterocutanoeostomy, Ureterosigmoidostomy), policistic kidney (1 case) were the predisposing causes. Abscess preferably unilocular and the possibility of direct access without having to pass vessels or bowel loops were indications that the percutaneous treatment that was performed in 48 cases. A pigtail catheter of 10 or 12F was percutaneously inserted into the abscess cavity . It was performed under local anesthesia using ultrasound or TC guidance.
Multilocular abscesses or with particularly complex development (expansion to other districts) were indications for open treatment that was made in 15 cases (4 associated with nephrectomy). Open drainage was performed under general anesthesia through a flank incision. All patients received a broad-spectrum of intravenous antibiotics, then percutaneous or open drainage was considered. In 14 patients with hydronephro¬sis due to obstructing stones, urinary drainage with double J stent in 1 case and percutaneous nephrostomy in 13 cases was also contemporaneously performed. Inadequate drainage was found in 5 cases of percutaneous drainage; in 3 cases it was repositioned the pigtail or inserted a second pigtail, and in 2 cases it was practiced an open-drain. In 1 case of massive perinephric abscess with spreading to the ipsilateral thigh (containing about 2 liters of pus) underwent open drainage there was an immediate septic shock with DIC (intravascular disseminated coagulation) and death of the patient. Drainage catheters remained in place until the output was minimal and resolution was confirmed with abdominal ultrasound or TC.

Discussion

Perinephric abscess continues to be a serious urological problem with high mortality rate, especially after open surgical intervention. A high index of suspicion, prompt diagnosis, appropriate antibiotics and surgical intervention may be effective in reducing mortality.
A drainage procedure should be considered when there is a large abscess and no clinical improvement occurs after 48 to72 hours of appropriate antibiotic therapy . The choice of the type of drainage must be made on the basis of some elements: 1. Unilocular (percutaneous) or multilocular abscess (open) 2. Diffusion of the abscess in other districts (open) 3. Partial spontaneous cutaneous opening (open) 4. Clinical conditions of the patient (Percutaneous drainage must be chosen for severely ill patients who could not withstand general anesthesia). If obstructive uropathy is present, prompt drainage by percutaneous nephrostomy should be performed.

References

1.Coelho RF, Schneider-Monteiro ED, Mesquita JL, Mazzucchi E, Marmo Lucon A, Srougi M: Renal and perinephric abscesses:analysis of 65 consecutive cases. World J Surg 2007; 31:431-6.
2.Meng MV, Mario LA, McAninch JW: Current treat¬ment and outcomes of perinephric abscesses. J Urol. 2002; 168: 1337-40.
3.EL-Nahas A.R., Faisal R., Mohsen T., AL-Marhoon M.S., Abol-Enein H. What is the Best Drainage Method for a Perinephric Abscess? International Braz J UrolVol. 36 (1): 29-37, 2010
4. Lee S. H., Jung H. J., Mah S. Y., Chung B. H. Renal Abscesses Measuring 5 cm or Less: Outcome of Medical Treatment without Therapeutic Drainage Yonsei Med J 51(4):569-573, 2010
5. Lt Col RS Rai*, Col SC Karan+, Brig A Kayastha, SM# Renal and Perinephric Abscesses Revisited MJAFI 2007; 63 : 223-225
6. Rubilotta E, Balzarro M, Lacola V, Sarti A, Porcaro AB, Artibani W Current cilinical management of renal and perinephric abscesses: a literature review Urologia. 2013 Nov 28;0(0):1-5.
7.Siegel JF, Smith A, Moldwin R. Minimally invasive treatment of renal abscess. J Urol 1996;155:52-5.