2007 by the Societe Internationale de Chirurgie World J Surg (2007) 31: 431436

Published Online: 5 January 2007 DOI: 10.1007/s00268-006-0162-x

Renal and Perinephric Abscesses: Analysis of 65

Consecutive Cases
Rafael Ferreira Coelho, MD, Edison D. Schneider-Monteiro, MD,
Jose Lus Borges Mesquita, MD, Eduardo Mazzucchi, MD,
Antonio Marmo Lucon, MD, Miguel Srougi, MD
Department of Urology, Hospital das Clnicas, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil

Abstract
Objective: The objective was to describe the last 10 years experience of the diagnosis and
treatment of renal, perinephric, and mixed abscesses in an academic reference center.
Patients and Methods: The medical records of 65 patients with renal, perinephric, and mixed
abscesses treated at our hospital from January 1992 to December 2002 were reviewed. The data
collected included predisposing factors, symptoms, physical examination, initial diagnosis, labo-
ratory and radiologic evaluation, treatment, and clinical outcome.
Results: Perinephric abscesses were found in 33 (50.8%) patients, renal abscesses were found in
16 (24.6%), and 16 (24.6%) had mixed abscesses. Urolithiasis (28%) and diabetes mellitus (28%)
were the most common predisposing conditions. The duration of symptoms before hospital
admission ranged from 2 to 180 days (mean 20 days). Urine culture was positive in 43% of
patients and blood culture was positive in 40% of patients. Most of the perinephric abscesses
received an interventional treatment: surgical drainage (24%), percutaneous drainage (42%) or
nephrectomy (24%). Most patients were cured (73.3%) on discharge from hospital. Mixed (renal
and perinephric) abscess treatment was similar: percutaneous drainage (37.5%), surgical drain-
age (18.75%) or nephrectomy (37.5%). Most patients were cured (60%) on discharge from hos-
pital. Renal abscesses, however, were treated medically in 69% of patients and 73% were cured
on discharge from hospital.
Conclusions: Perinephric and mixed abscesses are successfully managed by interventional
treatment. Renal abscesses can be managed by medical treatment only, reserving interventional
treatment for large collections or patients with clinical impairment. Early diagnosis is an important
factor in the outcome of renal and perinephric abscesses.

P erinephric and renal abscesses are uncommon, but

potentially lethal complications of urinary tract
infection. In the early treatment experiences reported, the
mortality rates approached 39% to 50%, despite
aggressive drainage.13 The characteristically vague
symptoms and the inherent difficulty in identifying retro-
Correspondence to: Rafael Ferreira Coelho, MD, R. Cardeal
Arcoverde, No. 201 Apartment 143, 05407-000, Sao Paulo, Brazil,
e-mail: coelho85@hotmail.com
peritoneal disease by physical examination contributed to
these disappointing therapeutic outcomes in the past.4,5
During the last 20 years cross-sectional imaging stud-
ies, such as computed tomography (CT) and magnetic
resonance imaging, have become available. Additionally,
technological improvements have increased the quality of
renal ultrasound examinations.5,6 Therefore, the diag-
nostic performance improved substantially and the time
to diagnosis reduced. Moreover, percutaneous catheter
drainage of intra-abdominal and retroperitoneal
432 Coelho et al.: Renal and Perinephric Abscesses

abscesses is now feasible and commonly performed with Table 1.

minimal morbidity.6,7 The diagnostic and treatment Patients characteristics
developments are believed to have improved outcomes Characteristics Statistics
for this disease process. Mean age, years (range) 41.1 (1588)
We studied retrospectively 65 patients with renal, Gender
perinephric, and mixed abscesses treated at our hospital Male 27 (41%)
from January 1992 to December 2002, and to analyze our Female 38 (59%)
Total 65 (100%)
experience in the diagnosis and treatment of these rare
Abscess side
infections. Right 25 (38.4%)
Left 32 (49.2%)
Both 8 (12.4%)
PATIENTS AND METHODS Total 65 (100%)

The medical records of 70 patients treated for renal,

perinephric, and mixed abscesses at our hospital from Table 2.
Factors associated with development of renal and perinephric
January 1992 to December 2002 were reviewed. Five abscesses
cases were excluded from analysis because the diagnos-
tics and treatment were influenced largely by other factors Factor Statistics
(2 patients had an abscess after open renal surgery, 2 had Diabetes mellitus 18 (28%)
a perinephric abscess resulting from pancreatitis, and 1 Lithiasis 18 (28%)
Ureteral obstruction 7 (10.5%)
had an abscess after penetrating abdominal trauma). Immunosuppression 3 (4.6%)
Renal abscesses were confined to the renal paren- Chronic urinary retention 4 (6%)
chyma. Perirenal abscesses extended outside the renal Pregnancy 1 (1.5%)
capsule into Gerotas fascia, and mixed abscesses Ureterosigmoidostomy 1 (1.5%)
affected both the renal parenchyma and Gerotas fascia. Renal biopsy 1 (1.5%)
None 12 (18.4%)
The data collected from medical records included pre-
disposing factors, symptoms, physical examination, initial
diagnosis, laboratory and radiologic evaluation, treat- The clinical outcome was classified as cure, clinical
ment, and clinical outcomes. Associating factors included improvement or death. Patients were cured when clinical
diabetes mellitus, urolithiasis, ureteral obstruction, and laboratory parameters normalized at discharge from
immunosuppression, chronic urinary retention, preg- hospital. When the clinical status improved, but antibiotic
nancy, ureterosigmoidostomy, renal biopsy, and others. therapy was still required and laboratory parameters were
The symptoms and physical examination were related to not normalized by the time of discharge from hospital the
infection, like fever, lumbar pain, lethargy, dysuria, chills, outcome was classified as clinical improvement.
painful percussion of the costovertebral angle, and
abdominal or flank mass. Laboratory and radiological
evaluation included leukocyte count, urinalysis, urine and RESULTS
blood culture, sonogram, and CT, when available.
Treatment modalities were specified in 4 categories:
Patient Characteristics
medical treatment only, percutaneous drainage, surgical
drainage (open surgery), and nephrectomy. Perinephric The characteristics of the 65 patients are shown in
abscesses were usually elected to surgical intervention Table 1.
unless they were smaller than 3 cm and the patient was in Perinephric abscesses were found in 33 (50.8%) pa-
good clinical condition. Percutaneous drainage was indi- tients, renal abscesses were found in 16 (24.6%), and 16
cated when no septation or multiloculation were identified (24.6%) had mixed abscesses.
in imaging studies. In these situations, surgical drainage Urolithiasis (28%) and diabetes mellitus (28%) were the
was elected. Renal abscesses were elected to undergo most common associating factors. Of the 18 (28%) dia-
interventional treatment when unfavorable clinical condi- betic patients, 5 had additional coexisting disorders (renal
tions were presented and abscess diameter was greater calculus in 4 and neurogenic bladder in 1; Table 2).
than 45 cm.46,8 Nephrectomy was reserved for non- Three patients were immunosuppressed: 2 were under
functioning kidneys, usually secondary to nephrolithiasis. corticotherapy for treatment of an autoimmune disease
Coelho et al.: Renal and Perinephric Abscesses 433

Table 3. Table 4.
Clinical presentation of renal and perinephric abscesses Laboratory results in patients with renal/perinephric abscesses
Clinical presentation Statistics Serum leukocyte counts (leucocytes/mm3)
Less than 8,000 4 (6.5%)
Symptoms 8,00016,900 36 (59%)
Fever 55 (84%) 17,00024,999 14 (23%)
Lumbar pain 42 (64.5%) 25,000 or more 7 (11.5%)
Lethargy 21 (32%) Total 61 (100%)
Nausea and vomiting 20 (30%) Serum creatinine (mg/dl)
Abdominal pain 17 (26%) 1.2 or less 30 (49%)
Weight loss 10 (15.4%) 1.34.0 29 (47.5%)
Dysuria 8 (12%) More than 4.0 2 (3.5%)
Chills 6 (9%) Total 61 (100%)
Anorexia 4 (6%) Urinalysis (leucocytes/high power field)
Duration of symptoms (days) 10 or less 8 (15%)
2 or less 1 (1.5%) More than 10 46 (85%)
39 22 (34%) Total 54 (100%)
1013 4 (6%) Urine culture
>14 37 (57%) Positive 22 (43%)
Physical findings Negative 29 (57%)
Fever 32 (49%) Total 51 (100%)
Painful percussion of the costovertebral angle 34 (52%)
Abdominal mass 18 (27.8%)
Flank mass 7 (10.7%)
Bloomberg sign 2 (3%)
were not available. The mean serum creatinine level was
1.7 mg/dl (range 0.24.3).
In 13 cases the results of urinalysis were not available.
and 1 had AIDS. Twelve patients (18.4%) had no identi- Of the remaining 51 patients, 46 (85%) had pyuria (greater
fiable systemic or urologic disorder that might have pre- than 10 leukocytes per high power field; Table 4.)
disposed to abscess formation.
Urine, Blood, and Abscess Cultures
Clinical Presentation The results of urine culture and blood culture were
Symptoms suggestive of upper urinary tract infection available in 51 and 30 patients respectively. Urine culture
(fever, lumbar pain, lethargy, chills) were reported by all was positive in 22 (43%) patients and blood culture was
patients. However, 6 (9.2%) patients had only one positive in 12 (40%).
symptom. Abscess cultures were obtained during surgery or
The duration of symptoms before hospital admission percutaneous drainage and results were available in 43
ranged from 2 to 180 days (mean 20 days) and 37 (57%) (66%) patients. Of the 43 abscess cultures, 1 organism
patients had symptoms for at least 14 days. Abnormal was isolated in 32 cultures (74.4%), 2 organisms were
physical findings (fever, painful percussion of the cost- recovered from 5 cultures (11.6%), and 6 cultures were
overtebral angle, flank mass) consistent with renal ab- sterile (14%).
scess were identified in 54 cases (83%; Table 3). The organisms found in abscess cultures (or in urine
culture if the abscess was not cultured) are listed in Ta-
ble 5. Among the 9 patients with abscesses caused by
Laboratory Findings on Admission Staphylococcus aureus 3 were immunosuppressed (1
with AIDS and 2 had had chronic corticotherapy), 1 had
The mean blood leukocyte count was 16,100/mm3
cutaneous lesions, 3 had renal calculus, 2 were diabetic,
(range 1,90035,400/mm3). Leukocytosis (leukocyte
and 1 had no predisposing factor.
count more than 8,000/mm3) was present in 57 patients
(93%). In 4 cases the results of the leukocyte count were Imaging Studies
not available.
In 3 cases the serum creatinine level was excluded Renal ultrasonography results were recovered in 44
from analysis because of known dialytic chronic renal cases. In 31 (70%) patients, the study revealed a cystic
insufficiency. In 2 cases the results of serum creatinine image suggestive of a renal or perinephric abscess. In 6
434
Table 5.
Organisms causing renal/perinephric abscesses
Organism Statistics
Escherichia coli 13 (26.5%)
Klebsiella pneumoniae 11 (22.4%)
Staphylococcus aureus 9 (18.3%)
Proteus mirabilis 9 (18.3%)
Streptococcus viridans 3 (6%)
Morganela morgani 2 (4%)
Enterococcus sp. 1 (2%)
Providencia sp. 1 (2%)
Total 49
patients, the examination suggested an abscess and
nephrolithiasis (13.6%), in 4 patients (9%) renal echo-
genic alteration, in 2 (4.6%) only hydronephrosis, and in 1
patient (2.3%) the examination was normal. CT was
performed in 28 patients: in 27 cases (96.4%) a cystic
mass suggestive of an abscess was identified.
Treatment
Treatment outcome was analyzed in different groups,
according to abscess location. Of the 16 patients with
renal abscesses, 5 (31.2%) were subjected to an inter-
ventional procedure. Three (60%) of these 5 patients
were considered cured on discharge from hospital and 2
(40%) showed clinical improvement. Of the 11 patients
subjected to medical treatment, 8 (73%) were cured by
the time of hospital discharge and 1 (9%) died.
Of the 33 patients with perinephric abscesses, 30
(91%) were subjected to an interventional procedure.
Twenty-two (73.3%) of these 30 patients were considered
cured on discharge from hospital. Of the 3 patients sub-
jected to medical treatment, just 1 (33.3%) was cured by
the time of hospital discharge and 1 (33.3%) died.
Of the 16 patients with mixed abscess (renal and peri-
nephric), 15 (93.7%) were subjected to an interventional
procedure. Nine (60%) of these 15 patients were consid-
ered cured on discharge from hospital and 6 (40%) showed
clinical improvement. The patient subjected to medical
treatment died. These results are summarized in Table 6.
DISCUSSION
The difficulty in diagnosing renal and perinephric ab-
scesses has been well documented in previous ser-
ies.2,3 The patients often had vague symptoms with long
duration and the physical findings did not always reflect
Coelho et al.: Renal and Perinephric Abscesses
the severity of the infection. The spectrum of clinical
signs and symptoms remains essentially unchanged,
with fever (84%), pain (64.5%), abdominal complaints
(26%), and leucocytosis (93.5%) being the most com-
mon findings. In our study, most patients had symptoms
with a mean duration longer than 14 days (57%)
reflecting a significant delay in the recognition of renal
abscesses. Thorley et al.1 and Salvatierra et al.2 noted
similar rates of misdiagnosis.
There was a remarkable similarity among patients
characteristics, predisposing conditions, and abscess
localization in our series and in previous reports.1,2,4,9,10
Almost 30% of the patients had diabetes mellitus and
another 30% had urological disorders (nephrolithiasis).
Perinephric localization was the most common in our
study.
Our results demonstrate that organisms isolated from
the urine culture usually parallel the bacteriology of the
abscess (different only in 6.6%). All organisms isolated in
blood culture were isolated from abscess cultures too.
These results have practical implications, as the micro-
biology of urine and blood culture can reliably guide the
selection of antimicrobial therapy before the surgical
procedure. However, urine and blood cultures are posi-
tive in less than half of patients.
The bacteriology of the abscess in our patients parallels
that of all other reported experience in the post-antibiotic
era.1,2,4,5,911 Staphylococcus aureus, the most common
cause of renal abscess in the pre-antibiotic era, was
responsible for only 18.3% of the infections. At present,
aerobic gram-negative bacilli have become the most
frequent isolated microorganisms, particularly Proteus
spp. and Escherichia coli.1,4,5 Among our patients, E. coli
(26.5%) and Klebsiella pneumoniae (22.4%) caused most
of the abscesses. Abscesses due S. aureus are generally
believed to result from bacteremia produced by infection
at another site or from immunosuppression.1,5 In our
series, 3 of the 9 patients with abscesses caused by S.
aureus abscesses were immunosuppressed (AIDS and
corticotherapy) and 1 had cutaneous lesions.
The improvement and widespread availability of imag-
ing studies of the retroperitoneum (CT and US) in recent
decades improved the diagnosis and treatment of renal
abscesses.6 The abscesses were identified in 93% of our
patients investigated with ultrasonography and in 96%
studied with CT, similar to other reports.4 Ultrasonogra-
phy has the advantage of being an accessible and non-
invasive technique, although this technique has some
pitfalls, including the possibility of confusing retroperito-
neal masses with hematomas, urinomas and the impos-
sibility of diagnosing abscesses smaller than 23 cm.5 CT
Coelho et al.: Renal and Perinephric Abscesses 435

Table 6.
Renal, perinephric and mixed abscesses treatment
Abscess localization Treatment n Cured Clinical improvement Death
n (%) n (%) n (%)
Renal Antibiotic Therapy only 11 (69%) 8 (73) 2 (18) 1 (9)
Percut. Drainage 3 (18.8%) 3 (100) 0 0
Surgical Drainage 1 (6.1%) 0 1 (100) 0
Nephrectomy 1 (6.1%) 0 1 (100) 0
Perinephr Antibiotic Therapy only 3 (10%) 1 (33.3) 1 (33.3) 1 (33.3)
Percut. Drainage 14 (42%) 12 (86) 2 (14) 0
Surgical Drainage 8 (24%) 4 (50) 3 (37.5) 1 (12.5)
Nephrectomy 8 (24%) 6 (75) 2 (25) 0
Mixed Antibiotic Therapy only 1 (6.3%) 0 0 1 (100)
Percut. Drainage 6 (37.5%) 4 (66.7) 2 (33.3) 0
Surgical Drainage 3 (18.7%) 3 (100) 0 0
Nephrectomy 6 (37.5%) 2 (33.3) 4 (66.7) 0

is a more sensitive and specific technique for detecting
renal abscesses in all the series reviewed, with diagnostic
performance within the range of 90%100%.4,5,7 CT de-
fines the abscess contents, provides information about
the renal capsule and Gerotas fascia and allows precise
delineation of small collections [12 cm]).4,5,7
The treatment employed in our study was analyzed
according to abscess localization. Most of the perinephric
abscesses received an interventional treatment: surgical
drainage (24%), percutaneous drainage (42%) or
nephrectomy (24%). Most were cured (73.3%) on dis-
charge from hospital. In 4 of the 14 patients (28.5%)
subjected to percutaneous drainage the abscesses
resolved, although a second-stage nephrectomy was
ultimately required to address nephrolithiasis in a non-
functioning kidney. Percutaneous drainage guided by CT
or ultrasonography has proved to be an effective thera-
peutic tool that reduces the need for surgery in some
patients.17 In patients with a surgical indication, it also
helps to delay surgery, thus improving the patients con-
dition.4 Contraindications for percutaneous abscess
puncture are the presence of coagulation disorders and
calcified masses.5 Septation or multiloculation are not
absolute contraindications for percutaneous drainage
because these conditions can be resolved by inserting
several catheters or by septal perforation.515 However,
surgical drainage allows anatomic examination, a more
exact delineation of the extension of the process, and
simpler and safer drainage of septated abscesses.5
Therefore, in multiloculated or septated abscesses we
prefer surgical to percutaneous drainage. Nephrectomy
was reserved for non-functioning kidneys, usually sec-
ondary to nephrolithiasis.
Only 9% of the patients with perinephric abscesses
were treated with antibiotics alone, with a mortality rate of
33%. These data corroborate the low effectivity of medi-
cal treatment alone for perinephric abscesses.13 As
reported by Siegel et al.14 only selected small perinephric
abscesses may resolve with antibiotics alone. They
reported a cure in all patients with lesions smaller than
3 cm. In our series, the 2 patients successfully treated
with antibiotics alone were generally in good condition
and had an abscess size of less than 3 cm. The
deceased patient in the medical treatment group was
initially diagnosed as having a pulmonary infection. When
the perinephric abscess was identified the patient had
already presented with septic shock and acute respiratory
distress syndrome. The collection was greater than 3 cm
and if the diagnosis had been made early the patient
could not have been elected to undergo clinical treatment
only. This reinforces the importance of early identification
and prompt drainage of large abscesses and the signifi-
cant mortality in untreated patients. The decision to treat
this entity using antibiotics alone requires consideration of
other associated medical conditions and accurate staging
of the abscess.15,16,17 Broad-spectrum coverage of gram-
positive and gram-negative organisms is required.
Treatment for mixed abscesses was similar to that for
perinephric abscesses. Most of the mixed abscesses in
our study received an interventional treatment: surgical
drainage (18.7%), percutaneous drainage (37.5%) or
nephrectomy (37.5%). Only 1 (6.25%) of the patients was
treated with antibiotics alone. This patient had a delayed
diagnosis (23 days) and died before surgical intervention.
Most of the renal abscesses, however, were treated
medically only, with good results. Sixty-nine percent were
treated with antibiotics without surgery, and 73% of these
were cured by the time of discharge from hospital. One
patient under medical treatment died, and the diagnosis
of the infectious site was made only at the autopsy. Other
436
reports present good results with medical treatment for
renal abscesses, mainly in cases of early diagnosis,
favorable clinical conditions, and abscess diameter under
5 cm.8,18,19,20
In the literature there was a substantial difference in
survival between patients in series predating 1970 and
later series. Earlier diagnosis thanks to the information
obtained from ultrasonography and CT seems to be the
most important factor in improving survival. Other factors,
such as improved antimicrobial treatment and support
care, are important but hard to quantify.4,5 In our study,
the general mortality was 6% (4/65), substantially lower
than the 40%50% reported three decades ago. In
the most recent series the mortality rate varied from
1.515%.13,6,17
CONCLUSION
Our experience demonstrates that perinephric and
mixed abscesses are successfully managed by interven-
tional treatment. Renal abscesses, however, can be
managed by medical treatment only, reserving interven-
tional treatment for large collections or patients with clini-
cal impairment. Early and correct diagnosis is an important
factor in the outcome of renal and perinephric abscesses.
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