Emphysematous pyelonephritis (EPN) is a severe, necrotizing infection of the kidney caused by gas-forming bacteria. Historically, emergent nephrectomy has been considered the definitive treatment for EPN, but recent evidence suggests that conservative approaches may be viable alternatives. This study aims to evaluate the outcomes of non-surgical management in patients with EPN and determine its efficacy compared to nephrectomy.

A retrospective analysis was conducted on 51 patients diagnosed with EPN between 2014-2024 by utilizing electronic medical record. Diagnosis was confirmed via computed tomography (CT), and patients were classified using the Huang and Tseng grading system. Management strategies included broad-spectrum antibiotics, percutaneous catheter drainage (PCD), ureteric stenting and nephrectomy when conservative measures failed.

Of the 51 patients, more than 90% of the patients were successfully managed conservatively with antibiotics, ureteric stenting and PCD. Nephrectomy was required in less than 10% due to failure of conservative therapy. Patients managed conservatively showed significant improvement in renal function, inflammatory markers post-treatment. Factors associated with successful conservative management included lower Huang-Tseng grades (I-II), absence of septic shock, and timely intervention. Majority of our patients were known to have diabetes prior to admission that might be a factor that leads to EPN

Conservative management, including antibiotics, ureteric stenting and PCD is a viable alternative to nephrectomy for select patients with EPN, particularly those with lower grades and stable hemodynamics. This approach preserves renal function and avoids surgical risks, emphasizing the need for individualized treatment strategies in EPN management.