XANTHOGRANULOMATOUS PYELONEPHRITIS

1. XANTHOGRANULOMATOUS
PYELONEPHRITIS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
◼ Prof. Dr. G. Sivasankar, M.S., M.Ch.,
◼ Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
◼ Dr. J. Sivabalan, M.S., M.Ch.,
◼ Dr. R. Bhargavi, M.S., M.Ch.,
◼ Dr. S. Raju, M.S., M.Ch.,
◼ Dr. K. Muthurathinam, M.S., M.Ch.,
◼ Dr. D. Tamilselvan, M.S., M.Ch.,
◼ Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. Xanthogranulomatous pyelonephritis is rare,
severe chronic renal infection typically
results in diffuse renal scarring
*most cases are unilateral
*nonfunctioning, enlarged kidney associated
with obstructive uropathy
*secondary to nephrolithiasis
*characterized by accumulation of lipid
laden foamy macrophages
*Begins with the pelvis & calyces and
extends into& destroys renal
parenchyma and adjacent tissues 3
Dept of Urology, GRH and KMC, Chennai.

4. ETIOLOGY
◼ Unknown
◼ Following nephrolithiasis (stag horn)
83%
◼ Increased risk in diabetics
◼ Following recurrent UTIs
◼ Urological instrumentation
◼ Common in 5th-7th decade
◼ Common in women
4
Dept of Urology, GRH and KMC, Chennai.

5. PATHOGENESIS
Nephrolithiasis (stag horn)
I
obstruction
I
stasis
I
infection
I
tissue destruction
I
collection of lipid material by macrophages
I
lipid laden macrophages (xanthoma cell) are
distributed around parenchymal abscess
intermixed with lymphocytes ,giant cells &plasma
cells
5
Dept of Urology, GRH and KMC, Chennai.

6. 6
Dept of Urology, GRH and KMC, Chennai.

7. Bacteria : low virulence
septicemia uncommon
Interrelated factors:
1.venous occlusion &hemorrhage
2.abnormal lipid metabolism
3.lymphatic blockage
4.failure of antibiotics in UTI
5.altered immunological competence
6.renal ischemia 7
Dept of Urology, GRH and KMC, Chennai.

8. PATHOLOGY
The kidney is massively enlarged
normal contour
Two types
Diffuse : 80% entire kidney is
involved
Segmental :20% only the
parenchyma surrounding one or more
calyces or one pole of a duplicated
collecting system
8
Dept of Urology, GRH and KMC, Chennai.

9. On section: Macroscopically:
Kidney demonstrate:
Nephrolithiasis
peripelvic fibrosis
calyceal dilatation filled with pus
papillary necrosis
multiple parenchymal abscess
(advanced disease) with yellowish tissue
&pus
cortex is thin often replace by
Xantho granulomatous tissue
capsule is thickened
inflammatory extension into
peripelvic & parapelvic space is common
9
Dept of Urology, GRH and KMC, Chennai.

10. 10
Dept of Urology, GRH and KMC, Chennai.

11. MICROSCOPIC EXAMINATION:
*yellowish nodules line the calyces
and surrounds parenchymal abscesses
*contain dark sheets of lipid laden
macrophages (foamy histiocytes with
small dark nucleus & clear cytoplasm)
*Intermixed lymphocytes, giant
cells and plasma cells
11
Dept of Urology, GRH and KMC, Chennai.

12. 12
Dept of Urology, GRH and KMC, Chennai.

13. CLINICAL PRESENTATION
*Flank pain (69%)
*Fever & chills (69%)
*Persistent bacteriuria(46%)
*Flank mass(62%)
*calculi(35%)
Less commonly
*Hypertension
*Hematuria
*Hepatomegaly
*Vague symptoms like malaise
13
Dept of Urology, GRH and KMC, Chennai.

14. BACTERIOLOGY & LAB DIAGNOSIS
*Proteus (most common organism involved)
*Ecoli(also common)
*Anaerobes
*10%(mixed infections)
URINE ANALYSIS
Shows pus &protein
BLOOD TESTS
*Anemia
*hepatic dysfunction(50%)
*Azotemia or frank renal failure
uncommon 14
Dept of Urology, GRH and KMC, Chennai.

15. RADIOLOGICAL FINDINGS
*50-80% show classic triad
-unilateral renal enlargement
-little or no function
-large calculus in renal pelvis
EXCRETORY UROGRAPHY:
-delayed function
-Hydronephrosis (massive)
-smaller calcification with in
the mass
15
Dept of Urology, GRH and KMC, Chennai.

16. RETROGRADE PYELOGRAPHY:
*point of obstruction
*dilatation of pelvis &calyces
*ulcerated pyelocalyceal system with
multiple irregular filling defect
(if extensive parenchymal damage)
USG:
*demonstrate global enlargement of the
kidney
*normal architecture is replaced by multiple
hypoechoic fluid filled masses correspond
to debris filled ,dilated calyces or foci of
parenchymal destruction 16
Dept of Urology, GRH and KMC, Chennai.

17. CT SCAN :
*most useful
*large reniform mass with renal pelvis
tightly surrounding a central calcification
without pelvic dilatation
*Renal parenchyma is replaced by multiple
water density masses representing dilated
calyces &abscess cavity
*on enhancement the walls of the cavity
demonstrate a prominent blush
*cavity fail to enhance whereas tumor
enhance
*CT is useful to know the extent of renal
involvement &also adjacent organ or 17
Dept of Urology, GRH and KMC, Chennai.

18. 18
Dept of Urology, GRH and KMC, Chennai.

19. RADIONUCLIDE RENAL SCANNING:
*99mTC-DMSA is used
*confirm differential lack of function in the
involved kidney
MRI :
* not yet super seeded to CT
*advantage is in delineating extrarenal
extension of inflammation
*T1 weighted image : appear as cystic foci of
intermediate intensity signal
*T2 weighted image : hyperintensity signal
ARTERIOGRAPHY: shows hypervascular areas.
-- All radiological studies although distinctive
often cannot differentiate between XGPN
&Renal cell ca 19
Dept of Urology, GRH and KMC, Chennai.

20. DIFFERENTIAL DIAGNOSIS
1. Renal cell carcinoma:
-indistinguishable by radiological examination
- CT- contrast enhancement of RCC
differentiating
-Lipid laden macrophages closely resembles
clear cell Adencarcinoma
-so difficult to differentiate on frozen section
2.Pyoneprosis;
massive pelvic dilatation cannot be
distinguished
20
Dept of Urology, GRH and KMC, Chennai.

21. 3.Malacoplakia:
-Renal enlargement, multiple
inflammatory process seen
-Calculus are not present in
malacoplakia
4.Renal lymphoma:
-multiple hypoechoic masses
surrounding contracted nondilated
pelvis
-renal involvement is bilateral-
differentiating
21
Dept of Urology, GRH and KMC, Chennai.

22. MANAGEMENT
*Primary obstacle to correct treatment is
incorrect diagnosis
*with CT scan preoperative diagnosis is
90%
Antimicrobial therapy
*To stabilise the patient preoperatively
*occasionally with initial stages long
term
antimicrobial therapy will eradicate
infection& restore renal function
Percutaneous drainage
-not curative 22
Dept of Urology, GRH and KMC, Chennai.

23. NEPHRECTOMY
*If diagnosed preoperatively
for diffuse type nephrectomy is
the treatment of choice
*For segmental involvement partial
nephrectomy is considered
LAPROSCOPIC NEPHRECTOMY
-reasonable
-recent approach
23
Dept of Urology, GRH and KMC, Chennai.

24. THANK YOU
24
Dept of Urology, GRH and KMC, Chennai.