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© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Xanthogranulomatous pyelonephritis (XGP) is a rare 
but severe form of inflammatory renal disease associated 
with renal stones and results in granulomatous tissue 
invading and destroying normal parenchyma. A serious 
complication of XGP is fistulization to surrounding 
structures. We present a case of XGP with pyeloduodenal 
fistula (PDF) in a 48-year-old female with a history of 
hypertension and recurrent urinary infections but no 
previous stones.

The patient initially presented to the emergency room 
in March 2020 with f lank pain, nausea, hematuria, 
and weight loss. Abdominal CT revealed right-sided 4 
cm partial staghorn and 2.7 cm ureteropelvic junction 
stones. There was no abscess and there were no signs 
of XGP. The patient was referred to our center in April 
and booked for percutaneous nephrolithotomy (PCNL). 
Her procedure was delayed because of the COVID-19 
pandemic. On May 15,  she developed Proteus mirabilis 
urosepsis and new renal abscesses. She was admitted to 
a peripheral hospital and underwent ureteroscopy and 
ureteric stent insertion for purulent drainage.

On May 27, she presented for PCNL, and the 
retrograde pyelogram showed communication of the 
kidney with the duodenum (Figure 1A). The procedure 
was aborted, and an urgent esophagoduodenoscopy 
confirmed the diagnosis of PDF. The patient underwent 
a n open si mple neph rec tomy a nd Rou x-en-Y 
duodenojejunostomy with loop gastrojejunostomy 
and pyloric exclusion. The PDF was identified with a 
traversing ureteric stent intraoperatively (Figure 1B).  
T he rema i nder of her cou rse i n hospita l was 
unremarkable and there have been no further urinary 
infections or stones after one year follow-up.

Final patholog y revealed diffuse xanthogranu-
lomatous inflammation of the kidney invading through 
the duodenum. XGP is challenging to diagnose and 
PDFs are exceedingly rare. Only a handful of cases 
have been reported[1–3]. This case was remarkable for 
the rapid progression from staghorn renal calculus to 
fistulizing XGP over a matter of months. 

Pyeloduodenal Fistula  
in Xanthogranulomatous  
Pyelonephritis
Ryan Yan, Mark T. Dawidek, Drew Phillips, Ben H. Chew

Department of Urologic Sciences, University of British Columbia, Vancouver, Canada

This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

FIGURE 1A. 

Retrograde pyelogram with ureteral catheter in right 
renal pelvis and contrast collecting in duodenum and 
stomach

Key Words Competing Interests Article Information

Xanthogranulomatous pyelonephritis, 
staghorn calculus, pyeloduodenal fistula, 
proteus mirabilis, XGP

None declared.

Patient Consent: Obtained.

Received on June 3, 2021 
Accepted on June 5, 2021

Soc Int Urol J.2021;2(4):265–266 
DOI: 10.48083/NSLU7720

265SIUJ.ORG SIUJ  •  Volume 2, Number 4  •  July 2021

CLINICAL PICTURE

mailto:ben.chew%40ubc.ca?subject=SIUJ.org
http://SIUJ.org


References
1. Cheatle T R, Waldron RP, A rkell DG. X anthogranulomatous 

pyelonephritis associated with pyeloduodenal fistula. Br J Surg.1985 
Sep;72(9):764. doi: 10.1002/bjs.1800720934.

2. Sallami S, Rhouma S Ben, Kchir N, Dagudagui N, Nouira Y, 
Horchani A. Spontaneous pyeloduodenal fistula complicating a 
xanthogranulomatous pyelonephritis: a case report. UroToday Int 
J.2010 Apr;3(2). doi:10.3834/uij.1944-5784.2010.04.09

3. Laberge M, Kulkarni GS, Sreeharsha B. P yeloduodenal fistula 
complicating xanthogranulomatous pyelonephritis. Int Urol 
Nephrol.2018;50(6):1071–3. doi.org/10.1007/s11255-018-1886-x

FIGURE 1B. 

Intraoperative photograph after transecting the fistula tract revealing a ureteral double-J stent traversing  
from the right renal pelvis to the duodenum

266 SIUJ  •  Volume 2, Number 4  •  July 2021 SIUJ.ORG

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