GIANT PYOHYDRONEPHROSIS: REPORT OF A CASE

A 44-year-old man visited a hospital with complaints of frequency and residual sensation. The excretory urography disclosed the non-visualizing left kidney. The left retrograde pyelography suggested huge hydronephrosis but no adequate visualization was obtained. Two or three days after this procedure, spiking fever and a tender mass in the left flank developed. Despite vigorous antibiotic therapy he showed no improvement and his temperature continued to be elevated and left flank mass grew gradually day by day. So, he was transferred to our hospital for further treatments. He was well nourished but in acute distress. Plain film showed no calculus shadow. An excretory urogram demonstrated a normal right kidney and non-visualizing left kidney. The bladder appeared normal. Urinalysis showed 5 white and a few red blood cells under microscopic examination. There was an elevation of left diaphragm due to left flank mass on a chest X-ray. Abdominal aortography showed the main abdominal branches except left renal artery were displaced to the right side. Left renal arteriography showed separation and stretching of the renal vessels with loss of the terminal branches and no nephrogram effect. Moreover, these films disclosed that there was a giant left renal mass extending to the right side of the abdomen across the midline. From the septic clinical course and the arteriographic appearance of hydronephrosis, the preoperative diagnosis was made as giant pyohydronephrosis. On the next day of angiography, percutaneous left nephrostomy was performed. The left kidney contained 6, 300cc of purulent material. Pseudomonas cepacia was isolated in this viscous pus. He showed prompt clinical improvement and his temperature dropped to normal levels within 48 hours. On the 17th day since nephrostomy, left antegrade pyelography obtained through the already present nephrostomy tube showed hydronephrotic kidney with U-P junction stenosis. Left nephrectomy was performed. Kidney was firmly adherent to the surrounding tissues. The empty hydronephrotic sac weighed 440 g. Histology confirmed preoperative diagnosis. Postoperative course was uneventful with primary wound healing. In recent clinical follow up of 9 months from the operation, the patient doing well except neuralgia-like pain around the incision. From this clinical course and other reported cases, we concluded that excretory urography, retro- grade pyelography or even antegrade pyelography might be inadequate for making a definite diagnosis of giant pyohydronephrosis because of incomplete filling of the collecting system. In these instances, renal angiography should provide the information necessary for an evaluation. Temporary urinary tract drainage by means of percutaneous nephrostomy is, in our opinion, the method of the first choice for treatment of giant pyohydronephrosis. This procedure may contribute to significant decrease of the later surgical morbidity and mortality