Xanthogranulomatous Pyelonephritis

Xanthogranulomatous pyelonephritis is an atypical form of chronic renal infection, usually associated with obstructive nephrolithiasis. Proteus and Escherichia coli are the most common organisms isolated from these kidneys. Lysis of tissue and phagocytosis of lipid material by histiocytes result in sheets of lipid-laden macrophages (xanthoma). Treatment traditionally involves open nephrectomy due to the dense fibrosis/inflam-matory process involving the affected renal unit, the surrounding perinephric structures, and occasionally the adjacent organs. Nevertheless, several cases of laparoscopic nephrectomy have been performed in such patients, e.g., nine cases (five laparoscopic, four open) reported by Bercowsky et al. Two patients, of whom one was converted open, were approached retroperitoneally, and three transperitoneally (15). Mean operative time was 360 minutes compared to 154 minutes for the open procedure, while hospital stay (6 days vs. 5.7 days) was similar. Complications occurred in three patients in the laparoscopic group, including ileus (1), ileus and a pulmonary embolism (1), and an open conversion (1). In another study of three cases of laparoscopic transperitoneal nephrectomy for xanthogranulomatous pyelonephritis, mean operative time was 213 minutes and open conversion was necessary in one patient (14).

Laparoscopic nephrectomy for xanthogranulomatous pyelonephritis is feasible. The scant available data suggest longer operative times and no clear advantage over open nephrectomy. Laparoscopic simple nephrectomy in xanthogranulomatous pyelonephritis cases should only be attempted by the very experienced laparoscopist.

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