Pemeriksaan Lain

 Renal nuclear scanning

o Renal nuclear scanning tidak begitu membantu dalam mendiagnosis secara
cepat pyonephrosis. Pada fase akut, scanning akan menunjukkan. Acutely,
scans may exhibit prolonged cortical uptake with delayed excretion of
radionuclide similar to that observed in acute obstruction. These defects
often resolve with resolution of the infection; however, persistence in
follow-up renal nuclear scans may indicate permanent damage to the renal
cortex.23
o Renal nuclear scanning may be helpful when a kidney is believed to be
nonfunctional on any imaging study during the acute phase of
pyonephrosis. If a kidney is proven to be nonfunctional after resolution of
infection and treatment of the etiology of the obstruction, then nephrectomy
may be indicated to prevent further episodes of pyonephrosis.
 Antegrade nephrostography
o This test may be extremely helpful in determining the etiology of the
obstruction associated with pyonephrosis and in planning further treatment
strategies.
o As with any invasive procedure, nephrostography should be delayed until
the patient is stable, on antibiotics, and afebrile for 1-2 weeks after
placement of a nephrostomy tube.
 Further imaging tests
o When a definitive anatomic abnormality, such as a stone or tumor, cannot
be determined, further imaging studies and tests may be needed to establish
the etiology of the pyonephrosis.
o These tests may include voiding cystourethrography to exclude
vesicoureteral reflux, multichannel urodynamics to establish a possible
neurogenic bladder with urine stasis, and serial renal ultrasonography to
document resolution of hydronephrosis after treatment.

Diagnostic Procedures

 CT- and ultrasound-guided aspiration

o Aspiration of the collecting system with CT or ultrasonographic guidance
with Gram stain and culture of the fluid provides a definitive diagnosis of
pyonephrosis.
o Sending the culture for aerobic, anaerobic, and fungal pathogens is
important.
o If clinically indicated, perform acid-fast stain and send cultures for
tuberculosis testing.

Treatment

Medical Therapy
The treatment of pyonephrosis has changed dramatically over the years. Prior to the 1980s,
emergency surgical excision with nephrectomy was the standard of care. However, this was
associated with a high morbidity and complication rate, including sepsis, wound infections, peritonitis,
and fistulas.

Initially, treat patients with appropriate intravenous antibiotics consisting of an aminoglycoside

(gentamicin) and gram-positive coverage (ampicillin) prior to instrumentation. Depending on the clinical
situation, additional anaerobic coverage with clindamycin may be needed. Be cognizant of the fact that
patients may have fungal infection or tuberculosis. The use of antifungal or antibacterial agents is
predicated on culture results. Many patients are septic and may require aggressive fluid resuscitation
with crystalloids. Pressor support (with dopamine) may be needed to maintain adequate blood
pressure and hemodynamics.

Surgical Therapy
With the advent of ultrasonography and CT scanning, percutaneous drainage has become the
mainstay of treatment.24,25 It has low morbidity and mortality rates with an excellent outcome. CT- and
ultrasound-guided drainage significantly decreases the need for nephrectomy, resulting in renal
preservation.

Retrograde decompression of pyonephrosis in patients who are severely ill is not advocated because
of the need for internal instrumentation and the possible future need for antegrade irrigation. In
selected healthy stable patients, consider retrograde decompression as an option. This avoids
placement of the percutaneous nephrostomy tube and allows internalization of the drainage catheter;
however, it does not allow for antegrade medication infusion or treatment of obstruction that is
sometimes needed with funguria and infected stones.26,27

Consider treating patients with pyonephrosis in the following 2 stages:

 Stage 1 (decompression and drainage)

o Perform retrograde stent placement.
o Use percutaneous CT- or ultrasound-guided nephrostomy.25 The posterior calyx
should be entered from an oblique posterolateral approach in the posterior axillary
line, 2-4 cm below the 12th rib. This avoids the pleura, colon, liver, and spleen and is
least likely to result in hemorrhage. Initial entry is made with a 20-gauge Chiba or 18-
gauge sheath needle. The tract is then dilated using the Seldinger technique, and an
8F-14F nephrostomy tube is placed and connected to a closed-system drainage bag.
o The infectious process often resolves within 24-48 hours following drainage, and the
patient may improve significantly once this occurs.
 Stage 2
o Eliminate the obstruction by removing the stone, fungus ball, or tumor 1-2 weeks after
percutaneous drainage or stent placement. Accomplish this with the use of
electrohydraulic lithotripsy, laser lithotripsy,28 percutaneous nephrolithotomy,
extracorporeal shockwave lithotripsy, endopyelotomy, transurethral resection, or
open surgical procedures. All of these are based on the type of obstruction and
clinical situation.
o In patients with uric acid stones and fungus balls, antegrade irrigation with alkaline
fluids and antifungals through the nephrostomy tube may be needed prior to surgical
intervention.
Complications

The prognosis of pyonephrosis is good in most patients who receive prompt diagnosis and treatment.

Sepsis is the most common complication in the perioperative period when treatment is delayed.

Generalized peritonitis can result from a rupture of the pyonephrotic kidney. In 1996, Hendaoui et al
reported the first case of a splenic abscess that developed from a ruptured pyonephrosis after the
development of generalized peritonitis.6 This occurrence was again reported by Sugiura et al in 2004,
making it possibly much more common than originally thought.14

Fistulas may develop and can be associated with peritonitis.29 Renocolonic, renoduodenal,30 and
renocutaneous fistulas are the most common; therefore, suspect these in patients with continued
electrolyte disorders, diarrhea, and recurrent urinary tract infections after resolution of pyonephrosis.

Other rare complications include pneumoperitoneum from lithogenic pyonephrosis, nephrobronchial

fistula, renal vein thrombosis, psoas abscess and/or perinephric abscess, and rhabdomyolysis.

Delay in diagnosis and treatment may result in a loss of renal function from parenchymal damage.

Perinephric hematomas, blood transfusions, and the need for nephrostomy tube revision are also
complications of percutaneous drainage. If a nephrectomy must be performed in the future, long-term
nephrostomy tubes are reported to increase the risk of a postoperative wound infection. 31

Outcome and Prognosis

Most infectious processes resolve within 24-48 hours and significantly improve after either
nephrostomy or retrograde stent drainage of the infection. If pyonephrosis is recognized and treated
promptly, recovery of the affected renal unit is rapid. Long-term complications are rare when managed
promptly; however, injury to the functional renal unit, abscesses, fistulas, and scarring may occur when
definitive therapy is delayed.

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also,
see eMedicine's patient education article Urinary Tract Infections.

Future and Controversies

Treatment of infections occurring from pyelonephritis and pyonephrosis are changing rapidly and
dramatically. The persistent use of broad-spectrum antibiotics, an increase in the population of
immunocompromised patients (eg, patients with AIDS, patients undergoing chemotherapy), and the
evolution of multiple drug–resistant bacteria complicate the picture.

Rare organisms, multiple organism infections, and Candida species are now commonly associated
with infected calculi. Antegrade percutaneous nephrostomy placement allows both drainage of
purulent material and the antegrade infusion of antifungal medication and antibiotics to adequately
treat these infections. Retrograde stent placement does not allow this form of therapy; therefore, many
experts stress the importance of nephrostomy drainage rather than retrograde transurethral drainage
for pyonephrosis. The authors currently prefer retrograde stent drainage after loading the patient with
broad-spectrum antibiotics, saving antegrade drainage for patients who may require further
intervention, as discussed above.

The need for nephrectomy after percutaneous nephrostomy drainage and antibiotic treatment is
debated. Some advocate the need for removal if the source of obstruction is not clearly identified. This
can help exclude the presence of a malignant etiology for the obstruction, such as transitional cell
carcinoma of the renal pelvis. Nonresponsiveness to therapy and progression of disease after
percutaneous drainage are additional indications for nephrectomy; however, current technology
reflects that preserving the maximal number of renal units is prudent.

Multimedia

Media file 1: Sonogram of the kidney showing hydronephrosis

with the presence of debris and layering of low-level echogenic
foci consistent with pyonephrosis.

(Enlarge Image)

Media file 2: Computed tomography scan with images through

the kidneys showing dilation of the collecting system,
increased renal pelvic wall thickness, and the presence of
renal pelvic debris.

(Enlarge Image)

References
1. St Lezin M, Hofmann R, Stoller ML. Pyonephrosis: diagnosis and treatment. Br J
Urol. Oct 1992;70(4):360-3. [Medline].
 2. Perimenis P. Pyonephrosis and renal abscess associated with kidney tumours. Br J
Urol. Nov 1991;68(5):463-5. [Medline].

3. Wah TM, Weston MJ, Irving HC. Lower moiety pelvic-ureteric junction obstruction (PUJO) of
the duplex kidney presenting with pyonephrosis in adults. Br J Radiol. Dec 2003;76(912):909-
12. [Medline].

4. Roberts JA. Pyelonephritis, cortical abscess, and perinephric abscess. Urol Clin North
Am. Nov 1986;13(4):637-45. [Medline].

5. Sugiura S, Ishioka J, Chiba K, et al. [A case report of splenic abscesses due to

pyonephrosis]. Hinyokika Kiyo. Apr 2004;50(4):265-7. [Medline].

6. Hendaoui MS, Abed A, M'Saad W, et al. [A rare complication of renal lithiasis: peritonitis and
splenic abscess caused by rupture of pyonephrosis]. J Urol (Paris). 1996;102(3):130-
3. [Medline].

7. Sharma S, Mohta A, Sharma P. Neonatal pyonephrosis--a case report. Int Urol

Nephrol. 2004;36(3):313-5. [Medline].

8. Wu TT, Lee YH, Tzeng WS, et al. The role of C-reactive protein and erythrocyte
sedimentation rate in the diagnosis of infected hydronephrosis and pyonephrosis. J
Urol. Jul 1994;152(1):26-8. [Medline].

9. Baumgarten DA, Baumgartner BR. Imaging and radiologic management of upper urinary tract
infections. Urol Clin North Am. Aug 1997;24(3):545-69. [Medline].

10. Author: Andrew C Peterson, MD, FACS, Assistant Professor of Surgery,

Uniformed Services University; Chief, Reconstructive Urology, Female Urology
and Urodynamics, Residency Program Director, Department of Surgery, Section
of Urology, Madigan Army Medical Center
Contributor Information and Disclosures

Upper Tract
Ureter
Pada stadium awal obstruksi, tekanan intravesical masih normal sewaktu vesicaurina terisi
dan hanya meningkat saat berkemih. Tekanan yang terjadi tidak sampai ke ureter dan pelvis
renal karena adanya katup ureterovesical. Akan tetapi akibat hipertrofi dari trigonum dan
adanya peningkatan resultante dari tahanan aliran urine pada ureter terminal, timbul
penekanan balik ke arah ureter dan ginjal, menyebabkan dilatasi ureter dan hydronephrosis.
Adanya dekompensasi dari komplex uretrotrigonal, mekanisme katup menjadi terganggu
dan terjadi reflux vesicoureteral, sehingga peningkatan tekanan intravesical ditransmisikan
langsung ke pelvis renal, memperparah derajat hydroureteronephrosis.
Sekunder dari tekanan balik akibat reflux atau obstruksi karena trigonum yang terarik dan
mengalami hipertrofi atau karena batu ureteral, otot-otot daripada ureter menebal sebagai
usahanya untuk mendorong urine ke arah bawah dengan cara meningkatkan peristaltik
(stadium kompensasi). Hal ini mengakibatkan pemanjangan dan perputaran dari ureter.
Pada saat kontraksi, ureter akan semakin tertekuk, menyebabkan obstruksi ureter sekunder.
Dalam kondisi ini pengangkatan sumber obstruksi tidak akan menyebabkan ginjal
terhindar dari proses obstruktif progrseif yang terjadi sekunder daripada obstruksi ureter.
Pada akhirnya akibat tekanan yang terus meningkat, dinding ureter menjadi semakin tipis
dan kehilangan kekuatan kontraksinya (stadium dekompensasi). Dilatasi yang terjadi
sangat ekstrim sehingga ureter membentuk lengkungan menyerupai usus.

Ginjal
Tekanan pada pelvis renal normalnya mendekati nol. Pada saat tekanan meningkat
akibat obstruksi atau reflux, pelvis renal dan kaliks ginjal berdilatasi. Derajat
hydronephrosis tergantung dari lama, derajat, dan letak dari obstruksi. Semakin tinggi letak
obstruksi, pengaruh terhadap ginjal semakin besar.
Pada stadium awal, muskulatur dari pelvis mengalami hipertrofi sebagai
kompensasi akibat usahanya untuk mendorong urine melewati obstruksi. Selanjutnya, otot
menjadi tertarik dan atonic
Perkembangan dari Hydronephrotic atrophy adalah sebagai berikut:
Perubahan awal dari terjadinya hydronephrosis tampak pada kalises. Bagian akhir
dari kaliks normal berbentuk konkaf karena adanya papilla; dengan peningkatan tekanan
intrapelvik, fornises manjadi tumpul dan membulat. Peningkatan tekanan intrapelvik yang
persisten mengakibatkan papilla menjadi datar dan konveks (clubbed) sebagai hasil
kompresi dari iskemik atrofi.
Parenkim diantara kalises mengalami perubahan yang diakibatkan oleh (1)
kompresi atrofi akibat peningkatan tekanan intrapelvis dan (2) iskemik atrofi dari
perubahan hemodinamik, biasanya terjadi pada pembuluh darah arcuata yang berada di
dasar pyramid dan paralel dengan bagian terluar ginjal sehingga lebih rentan mengalami
kompresi diantara kapsula renalis dan tekanan dari intraplevis.
Atrofi disebabkan oleh bentuk aliran darah pada ginjal, arteriol ginjal merupakan
”end arteries”, oleh karena itu sering terjadi iskemia pada area distal dari arteri
interlobularis. Peningkatan tekanan aliran balik memperparah hydronephrosis.
Peningkatan tekanan ini ditransmisikan ke tubulus sehingga tubulus berdilatasi dan sel-
selnya menjadi atrofi karena iskemik. Perlu dicatat dilatasi daripada pelvis renal dan kalises
tidak hanya disebabkan oleh obstruksi tetapi dapat juga disebabkan oleh kelainan
kongenital yang membentuk rongga ginjal dan akhirnya menyebabkan hydronephrosis.
Pada umumnya hydronephrosis yang terjadi pada anak-anak disebabkan oleh reflux
vesicoureter. Derajat dari hydronpehrosis mungkin akan menetap bila fungsi katup sudah
membaik sehingga dokter mencurigai adanya obstuksi yang tidak memerlukan tindakan
operasi. Isotop renogram atau Whitacre test dapat menunjukkan adanya obstruki organik.
Hanya pada hydronephrosis unilateral dapat terlihat hydronephrosis atrofi tahap
lanjut. Seringkali ginjal menjadi hancur seluruhnya dan tampak kantung berdinding tipis
yang diisi oleh cairan jernih. Jika obstruksi unilateral, peningkatan tekanan intrarenal
menyebabkan penurunan fungsi ginjal pada sisi yang bersangkutan. Semakin tekanan
intrapelvis mendekati tekanan filtrasi glomerulus (6-12 mmHg) maka produksi urine juga
berkurang. Laju filtrasi glomerulus dan laju plasma ginjal, tenaga konsentrasi berkurang
secara bertahap dan rasio konsentrai ureum-kratinin urin dari ginjal yang mengalami
hydronephrosis lebih rendah daripada ginjal normal.
Atrofi hydronephrosis merupakan tipe kelainan patologis yang tidak umum. Organ
sekretorik misalnya kelenjar submaksila akan berhenti berekskresi bila salurannya
terobstruksi, hal ini merupakan atrofi primer. Pada ginjal yang mengalami obstruksi
komplit urine akan tetap disekresikan (hydronephrosis tidak akan terjadi selama ada
peningkatan tekanan intrarenal).

Komplikasi
Stagnasi urine akan menyebabkan infeksi yang kemudian akan menyebar ke
seluruh sistem urinarius. Pengobatan infeksi tersebut sulit dilakukan walaupun penyebab
obstruksinya telah dihilangkan.
 Organisme invasif seperti urea-splitting organism seringkali menyebabkan urine
menjadi alkali. Garam kalsium mudah mengalami presipitasi dan membentuk batu ginjal
atau Vesica urinaria pada urine yang bersifat alkalis.
Apabila kedua ginjal terkena dapat mengakibatkan insufisiensi renal. Infeksi
sekunder dapat meningkatkan kerusakan ginjal.
Pyonephrosis merupakan stadium akhir dari ginjal yang mengalami obstruksi dan
terinfeksi. Ginjal sama sekali tidak berfungsi dan berisi pus yang kental. Foto polos
abdomen menunjukkan adanya udara urogram yang disebabkan oleh gas yang dilepaskan
oleh organisme yang menginfeksi.