A 58-year-old diabetic woman presents with high fever, flank pain and confusion. CT shows a swollen left kidney with streaks of gas in the renal parenchyma and collecting system. She remains septic despite intravenous antibiotics and resuscitation. What is the definitive next step?

• A Continue broad-spectrum antibiotics and tight glycaemic control alone
• B Percutaneous drainage or nephrectomy along with continued antibiotics ✓
• C Double-J stent insertion
• D Radical nephrectomy with regional lymphadenectomy

Explanation

Emphysematous pyelonephritis is a necrotising infection by gas-forming organisms, typically in diabetics, and carries high mortality. Antibiotics and glycaemic control alone suffice only in selected stable patients with limited disease; a persistently septic patient requires source control by percutaneous drainage or nephrectomy. A double-J stent does not drain infected parenchyma. Lymphadenectomy is an oncological procedure and has no role here, and radical nephrectomy is reserved for suspected malignancy, not infection.

Reference: Campbell-Walsh Urology, 12th ed.

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