Robotic nephrectomy in pediatric xanthogranulomatous pyelonephritis: technical challenges and considerations

Xanthogranulomatous pyelonephritis (XGP) is a rare and severe form of renal infection that can present significant challenges in diagnosis and management, particularly in pediatric patients. Experience regarding this condition is limited in pediatric surgical literature, since only around 300 pediatric cases have been reported till date. This report details the case of a 10-year-old boy with XGP, presenting with symptoms of abdominal pain, low-grade fever, and a history of recurrent urinary tract infections and nephrolithiasis. Diagnostic imaging revealed multiple renal calculi, a non-functioning right kidney, and extensive perinephric inflammation. The patient underwent a robot-assisted nephrectomy, which presented us with substantial technical difficulties due to dense adhesions, extensive peri-renal inflammation, and a loss of clear tissue planes. Despite initial dissection via a minimally invasive approach, the complexity of the dissection necessitated conversion to an open procedure to safely manage the renal hilum and to extract the kidney. Histopathological examination confirmed the diagnosis of XGP, showing extensive inflammatory infiltrate, lipid-laden macrophages, and abscess formation. This case underscores the challenges of managing XGP in children, particularly with minimally invasive techniques. With this report, we have attempted to highlight the technical difficulties in managing these children via a minimally invasive approach while highlighting the pre-operative imaging findings to identify those candidates who might not be very suitable for minimally invasive surgery. It highlights the importance of thorough pre-operative imaging to assess the extent of disease and the potential need for open surgery.