Background A pyonephrosis caused by an obstructing calculus is typically accompanied by fever, loin pain, and other signs of urinary tract infection. Occasionally, severe thinning of the renal parenchyma in pyonephrosis allows direct forniceal rupture into the retroperitoneum and very rarely into the anterior abdominal wall, misconstruing it as an isolated abdominal wall abscess. Case presentation Diabetes-related 55-year-old diabetic male presented with abscess in his periumbilical region extending into right lumbar region. He did not exhibit any urinary symptoms, and contrast enhanced computed tomography [CECT] abdominal and pelvic examinations revealed right pelvic calculus with pyonephrosis. There is a 7.5 mm defect in the lower pole of the right kidney with 171 cc of collection adjacent to the kidney communicating with 150 cc of superficial abdominal wall collection through a 15 mm defect. Incision and drainage of abdominal and retroperitoneal abscesses were done at first. Right DJ stenting was performed. Right lateral decubitus was placed for dependent drainage. Resolution of residual collections was confirmed by subsequent ultrasonography KUB, and drain was then removed. Right DJ stenting done, and patient was discharged. Two months later, DTPA scan done and revealed GFR of 30 ml/min of right kidney. Patient underwent right percutaneous nephrolithotomy. Conclusion The sudden rupture of pyonephrosis is a rare event. Even rarer is the presentation of pyonephrosis as an abscess on the anterior abdominal wall. The correct diagnosis and search for the source of the abscess must be undertaken before intervention. An aggressive and prompt management is needed to prevent further complications from occurring. This case is being presented to add to the literature with regard to abnormal presentations of ruptured pyonephrosis and its management.

Introduction: It is a common practice to perform detailed bladder evaluation(DBE) in patients awaiting transplant surgery, with previous research by some noted authors Yang(1994), Peter(2004), Antoniewicz(2015) supporting this. ESRD patients on maintenance haemodialysis for more than a year eventually become anuric. For their bladder evaluation, it becomes imperative to catheterize and fill the bladder retrogradely. Catheterization thus may need to be done as high as three times, for ultrasonography (USG), micturating cystourethrogram (MCU) and uroflowmetry (UFR). This leads to bacterial colonization in bladder and results in colonisation of the lower tract and a nidus for repeated reinfection. Aim of our study is thus to find out the necessity for detailed bladder evaluation in all patients & how low-capacity poor flow bladders fare post-operatively. Methods: We studied 80 patients retrospectively for detailed reports on bladder evaluation and their follow up till one year post transplant. Results: A very high incidence of pyelonephritis (70%) in our post-transplant patients who has undergone DBE. Additionally, some patients are still advised bladder cycling. 85%(68) of patients even with no prior history of lower urinary tract dysfunction (LUTD) or Genitourinary Tuberculosis(GUTB) had a small capacity bladder on USG and/or poor flow pre-operatively. However, in majority (90%) of them, bladder capacity and urine flow normalize as soon as urine production starts. Only a few (7 out of 68) having healthy but low capacity bladder with poor flow required some form of intervention. Conclusions: Patients who have healthy bladders prior to progressing to ESRD and becoming anuric fare well in post-transplant period as soon as urine production starts even if they are found to have small capacity, low flow in pre-transplant period. DBE in such patients can not only lead to overtreatment, waste resources but also increases infectious complications. Thus, we can omit MCU& UFR in pre transplant evaluation. Only baseline USG to measure bladder capacity and thickness is all that is required. Detailed evaluation reserved only for patients having past-history of LUTD, GUTB, or bladder dysfunction like posterior urethral valves. Thus, by carefully selecting the patient, we minimized the post-transplant pyelonephritis infectious complications to 29%.