Multiple pyonephrotic compartments with different microorganisms and an infected “calcium milk” in a patient with bilateral obstructive uropathy: A challenging case

If the surgeon encounters frank pus, he is advised to limit the procedure to efficient drainage of the infected compartment of the urinary tract either by double J stent insertion or percutaneous nephrostomy and abort and postpone the definitive stone treatment until the infection is treated. We present a highly complex case of an elderly female with multiple obstructing stones in the left kidney and ureter, with complete staghorn stones in the right kidney. While this scenario was already complex by virtue of the stone burden alone, which demands the combination of multiple stone treatment techniques, it was further complicated by compartmental infections in various parts of the kidneys with different microbes necessitating repeated abortion of procedures. As often in elderly patients, there was no rise of inflammatory markers, and bladder urine cultures were repeatedly negative. Moreover, a rare form of infection was encountered, namely “calcium milk” in the form of a radio-opaque lower pole abscess on the right. We discuss the etiology, treatment, and management of pyonephrosis and remind the need to always take it into account and react accurately when encountering infected space behind obstruction during minimally invasive surgeries in urolithiasis. Hidden microorganisms with different entities should be considered during surgical management of urinary stones. Complete drainage and appropriate antibiotic therapy are the cornerstones of treating this condition. •Hidden microorganisms with various entities should be considered for urinary stones.•Obstructed parts of the urinary tract can form infected compartments in isolation.•Complete drainage and antibiotic therapy are needed for treating pyonephrosis.•It is important to stop the procedure and only apply drainage for purulent fluids.