Contemporary Mortality and Comparative Outcomes of Nephrectomy Versus Non-nephrectomy Management in Emphysematous Pyelonephritis: A Systematic Review and Meta-Analysis.

Emphysematous pyelonephritis is a life-threatening necrotizing infection of the renal parenchyma characterized by gas formation and systemic toxicity. Although advances in imaging and minimally invasive techniques have altered treatment patterns, reported mortality rates and optimal management strategies remain variable across institutions. This systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines to evaluate contemporary mortality and compare outcomes between non-nephrectomy management and nephrectomy. Peer-reviewed studies published between 2010 and 2025 reporting mortality in adult patients were identified through structured database searches. Quantitative synthesis was performed using R software. Mortality proportions were pooled using random-effects modeling, and ORs were calculated to compare management approaches. In total, 26 studies met the inclusion criteria for qualitative synthesis, and 11 studies comprising 523 patients were eligible for meta-analysis. The pooled mortality was 7.6% (95% CI, 5.4-10.5) under the fixed-effects model and 7.7% (95% CI, 4.4-13.3) under the random-effects model, with moderate between-study heterogeneity. Comparative analysis demonstrated significantly lower odds of mortality in patients managed without nephrectomy. These findings indicate that contemporary mortality is lower than previously reported and support a selective, stepwise management approach.