From the Guidelines
Management of a psoas abscess with fistula to the kidney requires a multidisciplinary approach involving both drainage procedures and antimicrobial therapy, with the most recent guidelines suggesting percutaneous drainage and nephrostomy tube placement as initial management, followed by broad-spectrum antibiotics and possible surgical intervention if necessary, as recommended by the 2023 WSES guidelines 1.
Initial Management
Initial management should include percutaneous drainage of the abscess guided by CT or ultrasound, followed by placement of a nephrostomy tube to divert urine away from the fistula tract.
- Broad-spectrum antibiotics should be started empirically, typically with a combination of piperacillin-tazobactam 4.5g IV every 6 hours or meropenem 1g IV every 8 hours, plus vancomycin 15-20mg/kg IV every 8-12 hours (adjusted based on levels) 1.
- This regimen should be narrowed once culture results are available, and continued for 4-6 weeks.
Surgical Intervention
Surgical intervention may be necessary if percutaneous drainage fails or if there is significant tissue destruction.
- This would involve surgical debridement of the abscess, repair of the renal fistula, and possibly nephrectomy in severe cases with extensive renal involvement.
- The underlying cause of the fistula, such as urinary tract obstruction, renal calculi, or malignancy, must be addressed to prevent recurrence.
Monitoring and Follow-up
Close monitoring with serial imaging (CT or ultrasound) every 1-2 weeks during treatment is essential to assess response.
- The fistula typically closes spontaneously once the infection is controlled and proper urinary drainage is established.
- This condition requires careful management as it can lead to sepsis, renal dysfunction, and significant morbidity if not treated appropriately, as highlighted in the ACR appropriateness criteria for radiologic management of infected fluid collections 1.
From the Research
Management of Psoas Abscess with Fistula to the Kidney
- The management of psoas abscess with fistula to the kidney is a complex condition that requires a comprehensive approach, as seen in studies 2, 3, 4, 5, 6.
- The current first-line treatment for psoas abscess is percutaneous catheter drainage (PCD) under imaging guidance, combined with broad-spectrum antibiotics, as stated in 2.
- Surgical drainage should be considered if PCD fails or is impossible, and laparoscopic drainage is a good treatment option when PCD fails, affording all the advantages of open surgery, as mentioned in 2.
- Retroperitoneoscopic drainage represents a minimally invasive and potentially definitive therapeutic option for psoas abscess, with a low recurrence rate and no major complications, as reported in 3.
- The treatment of psoas abscess with fistula to the kidney may involve a combination of antimicrobial therapy, CT-guided percutaneous drainage, and laparoscopic or open drainage, as discussed in 6.
- Robotically assisted laparoscopic drainage is a promising approach for the management of refractory psoas abscesses, offering complete drainage and irrigation, and maximizing source control of infection, as presented in 6.
- The choice of treatment depends on the size and location of the abscess, as well as the patient's overall health and medical history, as noted in 4, 5.
- In general, small abscesses may be treated with antibiotics alone, while larger abscesses may require drainage, either percutaneously or surgically, as stated in 5.