Role of Minimally Invasive Urological Intervention in Acute Pyelonephritis - A Prospective Study

  • Shivraj Bharath Kumar Assistant Professor, Department of Urology
  • Velmurugan Palaniyandi Assistant Professor, Department of Urology
  • Sriram Krishnamoorthy Professor, Department of Urology
  • Venkat Ramanan Professor, Department of Urology
  • Natarajan Kumaresan Professor, Department of Urology
Keywords: Cystitis, Hydroureteronephrosis, Thrombocytopenia, Ureteric stent, Serum Creatinine


Introduction: Acute Pyelonephritis (APN) is an acute bacterial infection of the renal pelvis and parenchyma. The clinical spectrum ranges from mild cystitis to severe Emphysematous Pyelonephritis where there is destruction of the parenchyma with gas formation.
Aim: To analyze factors determining need for Double J stenting in patients with Acute Pyelonephritis and also to study the clinical profile and predisposing factors associated with Acute Pyelonephritis.
Materials and Methods: A prospective study was conducted on 100 patients with pyelonephritis. These patients were subdivided into Group 1 (n=52, who had DJ stenting done) and Group 2 (n=48, who were conservatively managed).
Statistical Analysis: Descriptive statistics frequency analysis and percentage analysis were used for categorical variables and the mean and S.D. was used for continuous variables. To find the significance in categorical data Chi-square test and Fisher’s exact test were used.
Results: Presence of turbid urine is one of the symptoms that needed DJ stenting. Patients with emphysematous pyelonephritis more often needed DJ stenting. Serum creatinine was initially high at presentation in most patients in both groups. However, in Group 2, all patients reached normal nadir levels with conservative management. In group 1, none of them had normal levels reached with conservative measures.
Conclusions: Factors that decided the final outcome included gross pyuria, significant fever spikes despite medication, persistent loin tenderness, persistently high total count despite medication, persistently high serum creatinine, thrombocytopenia, positive blood or urine culture and HbA1c > 9.2%. The presence of 2 or more of the above factors in a patient indicates need for stenting in APN cases.

Author Biographies

Shivraj Bharath Kumar, Assistant Professor, Department of Urology

Chettinad Medical College and Research Institute, Chennai, Tamil Nadu, India

Velmurugan Palaniyandi, Assistant Professor, Department of Urology

Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Sriram Krishnamoorthy, Professor, Department of Urology

Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Venkat Ramanan, Professor, Department of Urology

Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Natarajan Kumaresan, Professor, Department of Urology

Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India


1. Majd M, Nussbaum Blask AR, Markle BM, Shalaby-Rana E, Pohl HG,
Park JS, et al. Acute pyelonephritis: Comparison of diagnosis with 99mTc-
DMSA, SPECT, spiral CT, MR imaging, and power doppler US in an
experimental pig model. Radiology 2001;218:101-8.
2. Najar MS, Saldanha CL, Banday KA. Approach to urinary tract infections.
Indian J Nephrol 2009;19:129-39.
3. Kumar S, Ramachandran R, Mete U, Mittal T, Dutta P, Kumar V, et al.
Acute pyelonephritis in diabetes mellitus: Single center experience. Indian
J Nephrol 2014;24:367-71.
4. Misgar RA, Mubarik I, Wani AI, Bashir MI, Ramzan M, Laway BA, et al.
Emphysematous pyelonephritis: A 10-year experience with 26 cases. Indian
J Endocrinol Metab 2016;20:475-80.
5. Kalra OP, Raizada A. Approach to a patient with urosepsis. J Glob Infect
Dis 2009;1:57-63.
6. Das D, Pal DK. Double J stenting: A rewarding option in the management
of emphysematous pyelonephritis. Urol Ann 2016;8:261-4.
7. Boyarsky S, Labay P, Teague N. Aperistaltic ureter in upper urinary tract
infection – cause or effect? Urology 1978;12:134-8.
8. Bach PH, Nguyen TK. Renal papillary necrosis-40 years on. Toxicol Pathol
9. Scholes D, Hooton TM, Roberts PL, Gupta K, Stapleton AE, Stamm WE,
et al. Risk factors associated with acute pyelonephritis in healthy women.
Ann Intern Med 2005;142:20-7.
10. Manges AR, Johnson JR, Foxman B, O’Bryan TT, Fullerton KE,
Riley LW, et al. Widespread distribution of urinary tract infections caused
by a multidrug-resistant Escherichia coli clonal group. N Engl J Med
11. Johnson JR, Manges AR, O’Bryan TT, Riley LW. A disseminated multidrugresistant
clonal group of uropathogenic Escherichia coli in pyelonephritis.
Lancet 2002;359:2249-51.
12. Ramchandani M, Manges AR, DebRoy C, Smith SP, Johnson JR, Riley LW,
et al. Possible animal origin of human-associated, multidrug-resistant,
uropathogenic Escherichia coli. Clin Infect Dis 2005;40:251-7.
13. Ramakrishnan K, Scheid DC. Diagnosis and management of acute
pyelonephritis in adults. Am Fam Physician 2005;71:933-42.
14. Chen CY, Chen YH, Lu PL, Lin WR, Chen TC, Lin CY, et al. Proteus
mirabilis urinary tract infection and bacteremia: Risk factors, clinical
presentation, and outcomes. J Microbiol Immunol Infect 2012;45:228-36.
15. Matthews SJ, Lancaster JW. Urinary tract infections in the elderly
population. Am J Geriatr Pharmacother 2011;9:286-309.
16. Geerlings SE, Meiland R, van Lith EC, Brouwer EC, Gaastra W,
Hoepelman AI, et al. Adherence of type 1-fimbriated Escherichia coli
to uroepithelial cells: More in diabetic women than in control subjects.
Diabetes Care 2002;25:1405-9.
17. Chung VY, Tai CK, Fan CW, Tang CN. Severe acute pyelonephritis:
A review of clinical outcome and risk factors for mortality. Hong Kong
Med J 2014;20:285-9.
18. Wie SH, Ki M, Kim J, Cho YK, Lim SK, Lee JS, et al. Clinical characteristics
predicting early clinical failure after 72 h of antibiotic treatment in women
with community-onset acute pyelonephritis: A prospective multicentre
study. Clin Microbiol Infect 2014;20:O721-9.
19. Efstathiou SP, Pefanis AV, Tsioulos DI, Zacharos ID, Tsiakou AG,
Mitromaras AG, et al. Acute pyelonephritis in adults: Prediction of
mortality and failure of treatment. Arch Intern Med 2003;163:1206-12.
20. Guyer DM, Kao JS, Mobley HL. Genomic analysis of a pathogenicity island
in uropathogenic Escherichia coli CFT073: Distribution of homologous
sequences among isolates from patients with pyelonephritis, cystitis, and
catheter-associated bacteriuria and from fecal samples. Infect Immun
21. Hacker J, Blum-Oehler G, Hochhut B, Dobrindt U. The molecular basis
of infectious diseases: Pathogenicity islands and other mobile genetic
elements. A review. Acta Microbiol Immunol Hung 2003;50:321-30.
22. Fairley KF, Carson NE, Gutch RC, Leighton P, Grounds AD, Laird EC,
et al. Site of infection in acute urinary-tract infection in general practice.
Lancet 1971;2:615-8.
23. Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. Fever in the clinical
diagnosis of acute pyelonephritis. Am J Emerg Med 1997;15:148-51.
24. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based
epidemiologic analysis of acute pyelonephritis. Clin Infect Dis
25. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al.
International clinical practice guidelines for the treatment of acute
uncomplicated cystitis and pyelonephritis in women: A 2010 update by
the infectious diseases society of America and the European society for
microbiology and infectious diseases. Clin Infect Dis 2011;52:e103-20.
26. Fukami H, Takeuchi Y, Kagaya S, Ojima Y, Saito A, Sato H, et al. Perirenal
fat stranding is not a powerful diagnostic tool for acute pyelonephritis. Int J
Gen Med 2017;10:137-44.
27. Osman F, Romics I, Nyírády P, Monos E, Nádasy GL. Ureteral motility.
Acta Physiol Hung 2009;96:407-26.
28. Lang RJ, Davidson ME, Exintaris B. Pyeloureteral motility and ureteral
peristalsis: Essential role of sensory nerves and endogenous prostaglandins.
Exp Physiol 2002;87:129-46.