Predictors of Complications and Surgical Approach in Xanthogranulomatous Pyelonephritis: A 10-Year Cohort Study

Background 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 identify predictors of postoperative complications and compare laparoscopic versus open approaches. Methods We retrospectively analyzed 42 XGP nephrectomies performed between 2014 and 2024 at a tertiary referral center. Demographics, imaging features, intraoperative findings, and 30-day outcomes were collected. Complications were graded by Clavien–Dindo, and comparative analyses used nonparametric and exact tests with risk estimates expressed as confidence intervals. Results Median age was 47 years, and 79% were women. Laparoscopy was attempted in 32 cases, with 5 conversions (15.6%). Overall, 29 patients (69%) developed complications, including 21 (50%) with major events. Despite this morbidity, only 2 patients (4.8%) required ICU admission and no deaths occurred. Compared with open surgery (n = 10), laparoscopy showed lower transfusion requirements (34% vs 60%) and less blood loss, while overall and major complication rates were similar. Hydronephrosis and perinephric/psoas abscesses were associated with higher morbidity, whereas the duration or number of preoperative antibiotic regimens showed no association with outcomes. Conclusions Nephrectomy for XGP carries high morbidity but low mortality in experienced centers. Laparoscopy offers hemostatic benefits but requires readiness for conversion. Imaging markers may guide risk stratification, and the lack of benefit from prolonged antibiotics underscores the need for stewardship. Prospective multicenter studies are warranted to validate predictive factors and refine surgical selection.