Disease complexity, not surgical approach, predicts outcomes in xanthogranulomatous pyelonephritis

Xanthogranulomatous pyelonephritis (XGP) is a destructive renal infection typically requiring nephrectomy. Although laparoscopy is increasingly feasible, morbidity remains high and predictors of adverse outcomes are not well defined. We aimed to explore predictors of postoperative complications and compare laparoscopic versus open approaches.

We retrospectively analyzed 42 XGP nephrectomies (2014-2024) at a tertiary referral center. Demographics, imaging features, intraoperative findings, and 30-day outcomes were collected. Complications were graded by Clavien-Dindo, defining major complications as grade ≥III. Comparative analyses used nonparametric and exact tests; exploratory regression identified pre- and intraoperative predictors.

Median age was 47.0 years; 78.6% were females. Laparoscopy was attempted in 32 cases, with 5 conversions (15.6%). Overall, 69.0% experienced complications and 50.0% major events, but no deaths occurred. Compared with open surgery (n=10), laparoscopy showed lower transfusion requirements (34.4% vs. 60.0%) and less blood loss, while overall complication rates were similar. Hydronephrosis, perinephric/psoas abscesses, and higher blood loss were associated with increased morbidity.

XGP nephrectomy remains a high-morbidity operation. Laparoscopy appears feasible and safe in selected cases, with trends toward reduced transfusion and blood loss. Disease complexity-rather than surgical approach-primarily drives outcomes. These exploratory findings warrant validation in multicenter studies.