Somani BK et al. (2008) Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol 179: 1844–1849

Patients with emphysematous pyelonephritis (EPN) are usually treated with antibiotic therapy, emergency nephrectomy and/or open surgical drainage; however, these conventional treatments have a high mortality rate (∼40–50%). Although percutaneous drainage, a nephron-sparing procedure that preserves renal function, is increasingly being used to treat these patients, the optimum management approach remains controversial. Somani and colleagues performed a systematic review of the current treatment strategies for EPN.

The analysis included 10 retrospective studies performed between 1966 and 2006, with data from a total of 210 patients with EPN (mean age 57 years, 79.5% female). Diabetes mellitus and urinary-tract obstruction was present in 96% and 29% of patients, respectively. Of the 208 treated patients, 24 (11.5%) received medical management only, 64 (30.8%) underwent emergency nephrectomy, 118 (56.7%) underwent percutaneous drainage, and 2 (0.9%) underwent open surgical drainage.

The mortality rate associated with percutaneous drainage (13.5%) was significantly lower than the mortality rates associated with medical management only (50.0%, P <0.001) and emergency nephrectomy (25.0%, P <0.001). Of 118 patients who underwent percutaneous drainage, 15 subsequently had an elective nephrectomy; only 1 (6.6%) of these patients died. In addition, renal function was normal or near normal in 32 (70%) of the 46 patients who underwent percutaneous drainage and for whom data were available.

The authors conclude that the management of patients with EPN should include aggressive antibiotic therapy and early percutaneous drainage; elective nephrectomy might also be required.