Role of percutaneous drainage in management of emphysematous pyelonephritis: a changing concept

To present the outcome of percutaneous drainage in cases of emphysematous pyelonephritis [EPN] and feasibility of avoiding nephrectomy in such patients with poor general condition. EPN was diagnosed in seventeen patients by computerized tomography [CT]. All patients received intravenous fluids and antibiotics. Emergency nephrectomy was carried out in two patients. Three patients died before any surgical intervention due to cerebrovascular stroke, uremia and diabetic coma. Percutaneous drainage was carried out for the remaining 12 patients. Kidney could be saved in 3 and subsequent nephrectomy was done in 9 patients. Two patients who underwent emergency nephrectomy survived. Of the evaluable 12 patients [10 diabetic and 2 nondiabetic]; percutaneous drainage was carried out. Resolution of inflammatory process was found in 3 cases and kidney recovered and preserved. Percutaneous drainage was unsuccessful in 9 patients; thus, secondary nephrectomy was necessary but in a better general condition of the patients. The pathogenic organism was Escherichia coli in 9, klebsiella pneumoniae in 2 and proteus mirabilis in 1. Percutaneous drainage may be considered as an alternative to immediate nephrectomy in emphysematous pyelonephritis. It could be the only treatment required and the affected kidney could be preserved. On the other hand when nephrectomy is inevitable percutaneous drainage can delay it until the general condition of the patient becomes better and the technical difficulties become minimal

Radical chemoradiotherapy in the treatment of young and elderly patients of muscle invading transitional cell carcinoma of the bladder

This study which was conducted from January 1995 to December 1999 included two groups of patients, the young group [n 19] <50 Y [Range 30-50Y and Median 43Y] and the old group [n 18] >50Y [Range 52-70Y and Median 62Y]. All patients had pathologically documented muscle invasive transitional cell carcinoma of the bladder and all had a Karnofsky performance status of >70. Treatment protocol included cytoreductive transurethral resection of the tumor, 2 cycles of MVAC chemotherapy [methotrexate, vinblastine, doxorubicin and cisplatin] and radiotherapy [45 grays [GY] on pelvic volume with concurrent cisplatin [20mg/m[2] on days 1-5]. Response was determined by cytoscopic examination with tumor site biopsy and urine cytology. If there was a complete response, radiotherapy continued to a total dose of 65GY, if there was no complete response, cystectomy was performed. Of the young group [n 19] 12 patients 63% had complete response, 5 [26%] had partial response and 2 [11%] had no response. In the old group [n 18], 9 patients [50%] had complete response, 6 [33%] had partial response and 3 [17%] had no response. A significant difference in response to treatment was detected between T2 and T3a and between Bilharzial and non Bilharzial groups of patients P [0.037] and P [0.002] respectively. Overall survival for the young group was 50%, 39%, 30% in the 2[nd], 3[rd] and 5[th] years of follow up respectively, while in the old group it was 45%, 35%, and 30% for the 2[nd], 3[rd], 5[th] years of follow up respectively. Severe toxicity was uncommon. The most frequent toxicities being emesis and cystitis in both groups. The difference between both groups regarding toxicity, tolerability and response to treatment was not statistically significant. This protocol of treatment can be used for both young and elderly patients of muscle invading transitional cell carcinoma of the bladder especially in low stage non Bilharzial cancer despite a few well tolerated short term complications