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Emphysematous pyelonephritis (EPN) is an acute necrotizing and suppurative infection of the kidney parenchyma. It is defined by the presence of gas within the kidney parenchyma and surrounding tissues. This rare condition is usually seen in diabetic or immunocompromised adults. In this paper, we report four cases of emphysematous pyelonephritis (including two diabetic patients) managed by broad spectrum antibiotics and drainage. These patients were in different clinical stages of the disease (1, 2, 3a, and 4). All of them were discharged after a mean hospital stay of two to three weeks without needing a major surgery. Patients with kidney stone were referred to an endo-urologist for percutaneous nephrolitotomy after hospital discharge. We managed our four cases conservatively with an aggressive medical treatment including rapid control of dehydration, high blood glucose level (for diabetic cases), hypoxia, sepsis and kidney failure. The results were promising. Thus, we believe that in EPN patients, nephrectomy can be replaced by conservative therapy.