Ambulatory and Office Urology

Xanthogranulomatous Pyelonephritis:
Clinical Experience with 41 Cases
Fernando Korkes, Ricardo L. Favoretto, Marcos Bróglio, Carlos A. Silva,
Marilia G. Castro, and Marjo D. C. Perez
OBJECTIVES Xanthogranulomatous pyelonephritis (XGP) is an uncommon inflammation of the renal paren-
chyma that occurs in the presence of chronic obstruction and suppuration. In this retrospective
study, a review of the features of 41 recent cases of XGP is presented and compared with current
published data.
METHODS We retrospectively evaluated the clinical, surgical, and radiologic features of 41 cases of
XGP and compared the data of this Brazilian population with that from current published
reports.
RESULTS XGP was diagnosed in 19.2% of all nephrectomies performed for pyelonephritis during the period
analyzed. Of the 41 patients with XGP, 85.4% were women and 14.6% were men. All patients
were symptomatic, and the most common symptoms were fever, flank or abdominal pain, weight
loss, lower urinary tract symptoms, and gross hematuria. The most frequent computed tomog-
raphy findings included hydronephrosis, kidney enlargement, poor excretion of contrast medium,
and air in the urinary tract. All patients had renal calculi, 34.1% of which were staghorn calculi.
All patients underwent nephrectomy. For the few cases in which laparoscopy was performed, the
conversion rate was high.
CONCLUSIONS XGP is a common histologic variant of surgically managed pyelonephritis, corresponding to
almost 20% of such cases. As described in other series, we found a population that largely
consisted of middle-age women. The clinical presentation was characterized mainly by pain and
constitutional symptoms. The main etiologic agent isolated was Escherichia coli, and in all cases,
calculi were present. Computed tomography can be considered the best imaging study to
diagnose XGP, and in the few cases managed by laparoscopy, high conversion rates were
observed. UROLOGY 71: 178 –180, 2008. © 2008 Elsevier Inc.

X
anthogranulomatous pyelonephritis (XGP) is an
uncommon inflammation of the renal paren-
chyma that occurs in the presence of chronic
obstruction and suppuration. Schlagenhaufer1 was the
first to describe the disease. According to previously
published data, it accounts for only 0.6% of histologically
documented cases of pyelonephritis.1,2 Only a few series
of cases have been published.2– 8
The symptoms, and laboratory and imaging findings
of XGP are not always easily interpreted, and a preop-
erative diagnosis is not always feasible. In the era of
laparoscopy, however, the preoperative differential di-
agnosis of XGP is even more important, because lapa-
roscopic surgery in these cases is associated with
greater conversion and complication rates.9,10 In the
From the Division of Urology and Department of Pathology, Faculty of Medical Sciences
of Santa Casa de São Paulo, São Paulo City, São Paulo, Brazil
Reprint requests: Fernando Korkes, M.D., Division of Urology, Faculty of Medical
Sciences of Santa Casa de São Paulo, Rua Pirapora, 167, São Paulo, SP 04008-060
Brazil. E-mail: fkorkes@terra.com.br
Submitted: June 6, 2007, accepted (with revisions): September 16, 2007
present retrospective study, the characteristics of 41
cases of XGP are reviewed.
The aim of the present study was to retrospectively
evaluate the clinical, surgical, and radiologic features of
41 cases of XGP and compare these data of a recently
treated Brazilian population with the data from current
published studies.
MATERIAL AND METHODS
All records of nephrectomies performed between 1994 and
2005 at our institution were reviewed. All specimens with
histologic evidence of pyelonephritis without concurrent
malignancy or congenital dysplasia were included. During
this period, 41 patients who had undergone nephrectomy at
our institution were proven histologically to have XGP. The
retrospective data compiled from the clinical history, symp-
toms and physical examination findings, laboratory findings,
preoperative diagnosis, radiologic findings, operative find-
ings, and details of the postoperative period were analyzed.
The pathologic material was reviewed in each case to con-
firm the initial diagnosis. The diagnosis was defined as XGP
when a focal or diffuse process characterized by the presence

178 © 2008 Elsevier Inc. 0090-4295/08/$34.00

All Rights Reserved doi:10.1016/j.urology.2007.09.026

Figure 1. Distribution of presenting symptoms and physi-
cal findings of 41 patients with XGP.
of foam laden macrophages within a chronic inflammatory
background were found.
RESULTS
XGP was diagnosed in 41 (19.2%) of the 214 nephrec-
tomies performed for pyelonephritis during the period
analyzed. Of the 41 patients with XGP, 35 were women
(85.4%) and 6 were men (14.6%). Their mean age was
47 ⫾ 17 years (range 9 to 84).
All patients were symptomatic and the most common
symptoms were fever, flank or abdominal pain, anorexia,
weight loss, lower urinary tract symptoms, and gross he-
maturia. In general, patients had more than one symptom
(Fig. 1).
The hematologic evaluation showed leukocytosis
(41%) and anemia (63%), and urinalysis revealed pyuria
in most cases (57%). The mean initial hemoglobin in all
cases was 10.4 mL/dL (range 7.5 to 14.2). The mean
initial white blood count was 12.3 ⫻ 106/mL (range 3.5
to 22.5).
Urine culture of a voided urine sample was available
for 17 cases. Escherichia coliand Proteus mirabilis were
detected in the urine culture (35.3% and 17.6%, respec-
tively), but 35% of patients had a sterile urine culture. A
mixed infection was detected in 1 patient and Candida
spp. in 1 patient (5.9%).
XGP was suggested preoperatively as a possible diag-
nosis in only 22.0% of the cases (Table 1). Pyonephrosis
and nephrolithiasis were the most common preoperative
diagnoses (31.7% and 31.7%, respectively), although re-
nal tumor (4.9%) and perinephric abscess (4.9%) were
also suspected. The computed tomography (CT) findings
included hydronephrosis (36.6%), kidney enlargement
(36.6%), poor or absent excretion of contrast medium
(41.5%), low-density fluid-filled areas representing di-
lated calices filled with pus and debris (9.8%), and the
spread of the disease beyond the kidney (22.0%) and to
the psoas muscle (17.1%; Fig. 2). In 9.8% of the cases, air
UROLOGY 71 (2), 2008
Table 1. Diagnosis suspected preoperatively for 41
patients with Xanthogranulomatous pyelonephritis
Diagnosis % (n)
Nephrolithiasis 31.7 (13)
Pyonephrosis 31.7 (13)
Xanthogranulomatous pyelonephritis 22.0 (9)
Perinephric abscess 4.9 (2)
Renal tumor 4.9 (2)
Figure 2. Contrast-enhanced CT scan of 56-year-old woman
with diffuse XGP demonstrating multiple fluid-filled cavi-
ties, enlarged kidney with staghorn calculus, thickening of
Gerota’s fascia, and stranding of perinephric fat, as well as
to psoas muscle, indicating extension of inflammation.
was also reported as a radiologic finding. All patients had
renal calculi, of which 34.1% were staghorn calculi. Also,
17% of the patients had contralateral nephrolithiasis.
All patients underwent nephrectomy, and a standard
flank incision was used in 81.3% of the cases. In 15.6% of
the cases, laparotomy was performed, generally using a
subcostal incision. In 2 cases, laparoscopy was used, 1
requiring conversion.
Three patients had intestinal lesions and were easily
diagnosed and managed. Two had cava vein lesions. Two
required a second operation because of evisceration, and
two died in the immediate early postoperative period of
septic shock (3 and 11 days postoperatively). Hospital-
ization ranged from 3 to 14 days (average 5.9).
Late postoperative complications included 3 cases of in-
cision hernia. The overall complication rate was 21.9%.
COMMENT
XGP is commonly misdiagnosed preoperatively, because
it mimics other pathologic conditions such as pyelone-
phritis, tuberculosis, perinephric abscess, and renal cell
carcinoma. Although the pathogenesis of the disease is
still obscure, urinary tract infection and obstruction are
considered predisposing factors.
Our rate of XGP in 19.2% of the nephrectomies for
pyelonephritis was much greater than previously re-
ported,2 although other investigators have previously
179
noted a similar high prevalence.11 If all patients who
underwent renal biopsies during the period analyzed were
considered, XGP was observed in 6% of the total. There-
fore, because of its relatively common frequency, XPG
should be considered in the differential diagnosis before
nephrectomy is undertaken for end-stage pyelonephritis.
The laboratory findings were nonspecific and similar to
those previously reported.4,12 Pyuria was observed in only
58.5% of the patients, and 35.3% of patients had a sterile
urine culture. This could be attributed to either urinary
tract obstruction preventing contaminated urine from
reaching the bladder or to the antibiotic treatment given
before the patient’s admission.
The radiologic findings included an enlarged kidney
with poor or absent function and with simple or staghorn
calculi. These findings were observed in the vast majority
of our patients but emphasis should be given to the high
incidence of air inside the urinary tract (9.8%) at CT,
usually related to severe forms of pyelonephritis. None of
these patients, however, had clinical symptoms sugges-
tive of emphysematous pyelonephritis.
Although most of our cases were managed through
open surgery, for the few cases in which the laparoscopic
approach was attempted, we had a high conversion rate,
similar to that of other investigators.9,10 In recent series,
nephrectomies for benign conditions have been fre-
quently done using the laparoscopic approach. For XGP
and other inflammatory conditions, however, surgery can
become challenging, and high complication and conver-
sion rates have been observed.9,10 XGP should, therefore,
be included in the differential diagnosis in this situation.
It is important to diagnose or mainly suspect the disease
preoperatively, because the inflammatory process could
be extensive and could significantly increase the inci-
dence of intraoperative hazards and postoperative com-
plications. A preoperative diagnosis of XGP allows ap-
propriate patient preparation and operation planning.
However, a preoperative diagnosis is not always easy. In
the present series, only 22.0% of the patients had the
correct diagnosis. If we retrospectively analyzed our cases,
2 patients had partial XGP and, therefore, could have
been treated with partial nephrectomy. One had recur-
rent nephrocutaneous fistula, and total nephrectomy was
performed with the correct preoperative diagnosis of par-
tial XGP; the other had had a preoperative diagnosis of a
5.4-cm renal cell carcinoma.
Of our patients, only CT provided a preoperative
diagnosis of XGP (22.0%). For patients assessed by
other imaging modalities (eg, ultrasonography, renog-
raphy, radionuclide renography, and intravenous urog-
180
raphy), XGP was not diagnosed or suspected preoper-
atively.
CONCLUSIONS
XGP is a common histologic variant of surgically man-
aged pyelonephritis, corresponding to almost 20% of such
cases, and only a few large series have been reported. As
described in other series, we found a population that
consisted largely of middle-aged women. The clinical
presentation was characterized mainly by pain and con-
stitutional symptoms. The main etiologic agent isolated
was E. coli, but other bacterial, or even fungal, agents
were also isolated. In all cases, calculi were present,
reinforcing the theory of obstruction before infection.
CT should be considered the best imaging method to
diagnose XGP. In the few cases managed through lapa-
roscopy, high conversion rates were observed.
References
1. Schlagenhaufer F: Uber eigentumliche Staphylmykosen der Nieven
und der pararenalen Bindegewebes. Frankfurt Z Pathol: 139 –148,
1916.
2. Malek RS, and Elder JS: Xanthogranulomatous pyelonephritis: a
critical analysis of 26 cases and of the literature. J Urol 119:
589 –593, 1978.
3. Rosi P, Selli C, Carini M, et al: Xanthogranulomatous pyelone-
phritis: clinical experience with 62 cases. Eur Urol 12: 96 –100,
1986.
4. Proca E, Lucan M, and Alexianu M: [Xanthogranulomatous pye-
lonephritis: comments apropos 145 clinical cases.] Rev Chir Oncol
Radiol ORL Oftalmol Stomatol Chir 37: 451– 466, 1988.
5. Mhiri MN, Sellami F, Njeh M, et al: [Xanthogranulomatous pye-
lonephritis: apropos of 42 cases.] Ann Urol (Paris) 25: 113–117,
1991.
6. Chuang CK, Lai MK, Chang PL, et al: Xanthogranulomatous
pyelonephritis: experience in 36 cases. J Urol 147: 333–336, 1992.
7. Bazeed MA, Nabeeh A, and Atwan N: Xanthogranulomatous
pyelonephritis in bilharzial patients: a report of 25 cases. J Urol
141: 261–264, 1989.
8. Ballesteros Sampol JJ: [Up-date on renal xanthogranulomatosis:
comparison of personal experience in 66 cases and the 720 cases
from the literature.] Actas Urol Esp 13: 10 –18, 1989.
9. Tobias-Machado M, Lasmar MT, Batista LT, et al: Laparoscopic
nephrectomy in inflammatory renal disease: proposal for a staged
approach. Int Braz J Urol 31: 22–28, 2005.
10. Rassweiler J, Fornara P, Weber M, et al: Laparoscopic nephrectomy:
the experience of the laparoscopy working group of the German
Urologic Association. J Urol 160: 18 –21, 1998.
11. Matthews GJ, McLorie GA, Churchill BA, et al: Xanthogranulo-
matous pyelonephritis in pediatric patients. J Urol 153: 1958 –
1959, 1995.
12. Zorzos I, Moutzouris V, Korakianitis G, et al: Analysis of 39 cases of
xanthogranulomatous pyelonephritis with emphasis on CT find-
ings. Scand J Urol Nephrol 37: 342–347, 2003.
UROLOGY 71 (2), 2008