Emergency nephrectomy in surgical pyelonephritis: outcomes and predictors of conservative management failure.

Background: Surgical pyelonephritis (SP) encompasses severe upper urinary tract infections, including pyonephrosis, renal and perinephric abscesses, and emphysematous pyelonephritis. The 2024 EAU Guidelines classify these as complicated UTIs requiring early antibiotic therapy, hemodynamic stabilization, and prompt source control. This study aimed to reassess the role of emergency nephrectomy (EN) in SP management and to identify predictors of conservative management (CM) failure.

Methods: We conducted a retrospective, single-center study including patients treated for SP at Caen University Hospital, France, between January 2011 and December 2022.

Results: Eighty-eight patients were included: 10 underwent primary EN, and 78 received CM, of whom 9 (11.5%) later required secondary nephrectomy (SN) due to CM failure. Renal abscesses (RA) were the most frequent indication for EN, followed by emphysematous pyelonephritis. Diabetes was significantly more prevalent in EN patients (p < 0.001). Urinary tract obstruction was observed in 30.0% of EN patients versus 82.1% of those initially treated conservatively (p = 0.001). Initial EN patients had higher severe morbidity rates than CM patients (50.0% vs. 29.5%, p = 0.04), although similar to SN patients (66.7% vs. 50.0%, p = 0.07). A high ASA score, chronic kidney disease (CKD), and smoking were associated with an increased risk of CM failure.

Conclusions: Surgical pyelonephritis should be managed stepwise, favoring conservative approaches when possible. Early identification of patients at risk of failure is crucial, and timely escalation to nephrectomy may improve outcomes. Biomarkers and standardized reassessment protocols may support better risk stratification.