An 81-year-old female patient presented to the emergency department with asthenia, anorexia and right lumbar pain of 2 weeks' duration. Haemodynamically stable, and with fever (38.5 degrees) for 3 days.

With a history of heart failure associated with atrial fibrillation, with no history of urological diseases.

Physical examination revealed pain on deep palpation located in the right hemiabdomen, with no signs of peritoneal irritation, with the presence of a palpable mass and positive renal Murphy on the right.

Analyses showed leukocytosis (22,390 with left shift), normochromic normocytic anaemia, with renal function within normal parameters, leukocyturia and microscopic haematuria.

Reno-vesical radiography showed multiple radiopaque stones located in the right kidney.

Abdominal-pelvic computed axial tomography with intravenous contrast injection showed an enlarged right kidney, with cortico-medullary disorganisation and the presence of multiple large lithiasic formations located in the renal pelvis.

With the diagnosis of pyonephrosis and to stabilise the general deterioration, we decided to perform a pecutaneous nephrostomy at first. We witnessed abundant purulent fluid coming out of the nephrostomy, the culture of which revealed polymicrobial flora. Intravenous broad-spectrum antibiotic therapy was started. After four days and as the surgical conditions were more suitable, we decided to perform a right nephrectomy by lombotomy.

The description of the surgical specimen is as follows:

Kidney (13x8.5x5 cm) sent with ureteral segment 10 cm long and with presence of perirenal adipose tissue. There is dilatation of the pyelocaliceal tree and marked atrophy of the renal parenchyma. Inside the pyelic tree there is purulent content and stones are identified, the largest of which is 4.5 cm. There are foci of suppuration with abcedification of the renal parenchyma and perirenal adipose tissue. In the pelvis and adjacent calyxes there is white tissue with a soft consistency measuring 6x5 cm, 10 cm away from the ureteral surgical top.

Histological examination showed adenocarcinoma with predominant areas of tubular pattern and focal areas of tubulovillous pattern.

The neoplasm presents characteristics of intestinal type adenocarcinoma, being possible to identify intestinal type Goblet cells characterised by the presence of apical intracytoplasmic mucus vacuoles.... The nuclei in some areas are uniform and monotonous and in other areas are more aggressive, irregular, of different sizes and with frequent mitotic activity. The neoplasm invades the subepithelial connective tissue. Glandular metaplasia of the urothelial epithelium is identified in the lining of the pyelocaliceal tree.

Six months after surgery the patient died.