Nephrostomy Tube Placement

Nephrostomy Tube Placement

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Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.


3 main categories: relief of urinary obstruction, urinary diversion and access for endourologic procedure

[1] Urinary obstruction
• Urosepsis
• Acute renal insufficiency
• Intractable pain
[2] Urinary diversion
• Hemorrhagic cystitis
• Ureteral injury
• Urinary fistula
[3] Access for intervention
• Percutaneous nephrolithotripsy (PCNL) - most common
• Many more
[4] Diagnostic testing:
• Antegrade pyelography
• Whitaker test
• Less common with advances in noninvasive imaging

SIR periprocedural coagulation parameters:
• INR, aPTT, platelets labs recommended
• INR: correct to < 1.5
• Platelets: < 50,000/µl recommend transfusion
• aPTT: correct so that value is < 1.5 control

• No absolute contraindications
Uncorrectable coagulopathy
• Correct if possible to do in appropriate time frame
• If urosepsis is driving coagulopathy, do not delay nephrostomy tube placement for blood products
Metabolic/electrolyte disorder
• Example: hyperkalemia with EKG changes. Safer to dialyze first then place nephrostomy tube

Preprocedural evaluation
• H&P
• Understand indication for placement
• Hydronephrosis is not an indication for nephrostomy tube. Need to uncover underlying etiology and timeframe of hydronephrosis
• BMP helpful for baseline GFR
• Also will depend on clinical scenario
• Take advantage of all prior imaging including US, CT and renal scintigraphy
• Assess patient body habitus and degree of hydronephrosis
• Evaluate renal anatomy and relevant surround structures - evaluate location of pleura, diaphragm, colon, spleen and liver

• Orientation, size and degree of hydronephrosis
• Avascular plane of Brodel: relatively hypovascular segment of kidney typically oriented 20-30° posteriorly from the body's sagittal plane. Plane is located between anterior and posterior divisions of renal artery
• Calyces typically oriented in anterior and posterior columns. Anterior calyces tend to project laterally in coronal plane and posterior calyces tend to project end-on
• Upper pole: more medial and posterior
• Evaluate for cysts, stones, tumors
• Cysts can be used as landmarks and are also commonly mistaken for calyces under ultrasound
• Stones are helpful fluoroscopic landmarks and will drive renal access site in cases performed for subsequent intervention

Diaphragm and pleura more commonly injured than colon, liver or spleen
• Posteriorly, pleura extends further inferior when moving from lateral to medial
• Pleura extends to approximately 9th rib at mid axillary line, 11th rib at scapular line and 12th rib at paravertebral line
• Can visualize diaphragm and potential interposed lung with ultrasound during procedure


• 1-2 g ceftriaxone (Rocephin) IV
• Vancomycin or clindamycin-gentamicin for PCN allergy
Other regimens
• 1.5–3 g ampicillin/sulbactam (Unasyn) IV
• 1 g cefotetan IV plus 4 g mezlocillin IV
• 2 g ampicillin IV plus 1.5 mg/kg gentamicin IV


• Patient prone
• May be helpful to oblique/elevate ipsilateral side 20-30° for more ergonomic position for operator
• Roll beneath upper abdomen can be helpful to reduce lordotic curvature which may help with sonographic visualization of kidney

• Planning access site is more important step. Optimal access site selection with facilitate smooth nephrostomy tube placement and reduce risk of complications
• Some operators say, "Do more looking than sticking" referring to access site planning
• Can access with 18 to 22-gauge needle
• Operator preference for ultrasound vs fluoroscopic guidance
• Consider echogenic needle tip for US access in obese patients
• Good dermatomy with 11 blade can facilitate access set and tract dilation

Image after needle placement
• May not get urine return particularly in urosepsis patients with small gauge needles
• If there is urine return, save for cultures
• Inject small volume of contrast to opacify renal collecting system
• Over injecting will obscure kidney both with fluoroscopy and ultrasound
• Evaluate appropriate access site
• If undesirably access site, leave needle in place. Additional air/CO2 or contrast injection may facilitate double-stick technique

Advance 0.018" wire into renal pelvis or preferably into ureteral
Use 6 or 8-Fr access set to transition to 0.035" or 0.038" wire
• Remove of wire and inner stiffeners
• Gentle injection of contrast to opacify renal collection system
• If system is markedly dilated and contrast too diluted, inject 5 mL of contrast, then aspirate and re-inject multiple times. Will help opacify renal collecting system without over distending the system

Advance 0.035-0.038" wire into renal pelvis or ureter
• May need to use catheter
• Reasonable to place sheath and use safety wire for tenuous or difficult access
• Serially dilate tract

Place nephrostomy tube
• Advance nephrostomy tube into renal pelvis
• Form and lock pigtail catheter
• If have not already obtained urine, collect for cultures
• Confirm placement with contrast injection
• Flush and secure to skin
• Dress catheter to prevent kinking at skin entry site
• Connect to gravity


Postprocedural care:
• For appropriate patients, can be done as outpatient procedure
• Recover patient for 4 hours with vital signs Q15-30 minutes until discharge
• Confirm catheter is draining appropriately
• Record drainage output
• Educate patient on drain care and signs to report to IR clinic or emergency room
For patient's with urosepsis
• Depending on patient's scenario, consider overnight ICU admission
• Continue antibiotics and IV hydration
• Follow-up on urinalysis from nephrostomy tube placement to direct antibiotic therapy

Drain care:
• Flush drains twice daily
• Record output
• Nephrostomy tube exchange every 2-3 months

Success rate for percutaneous nephrostomy tube placement
• Obstructed dilated system with or without stones: 96-100%
• Obstructed system in renal transplant: 98-100%
• Nondilated system: 82-96%
• Complex stone disease: 82-85%

• Septic shock: 1-10%
• Septic shock in setting of pyonephrosis: 7-9%
• Hemorrhage requiring transfusion without PCNL: 1-4%
• Vascular injury requiring embolization or surgery: 0.1-1%
• Bowel transgression: 0.2 - 0.5%
• Pleural complication (pneumothorax, empyema, hydrothorax, hemothorax) without PCNL: 0.1 - 0.6%

Complication rates increased for hemorrhage and pleural injuries with PCNL
Risks of complications higher for upper pole access with regards to bleeding and pleural injury

Related Procedures

No related procedures.



[1] Young M, Leslie SW. Percutaneous Nephrostomy. [Updated 2020 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
[2] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[3] Macchi V, Picardi E, Inferrera A, et al. Anatomic and Radiologic Study of Renal Avascular Plane (Brödel's Line) and Its Potential Relevance on Percutaneous and Surgical Approaches to the Kidney. J Endourol. 2018;32(2):154-159. doi:10.1089/end.2017.068
[4] Pabon-Ramos WM, Dariushnia SR, Walker TG, et al. Quality Improvement Guidelines for Percutaneous Nephrostomy. J Vasc Interv Radiol. 2016;27(3):410-414. doi:10.1016/j.jvir.2015.11.045
[5] Wang CJ, Hsu CS, Chen HW, Chang CH, Tsai PC. Percutaneous nephrostomy versus ureteroscopic management of sepsis associated with ureteral stone impaction: a randomized controlled trial. Urolithiasis. 2016;44(5):415-419. doi:10.1007/s00240-015-0852-7
[6] Dagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011;28(4):424-437. doi:10.1055/s-0031-1296085
[7] Mariappan P, Smith G, Bariol SV, Moussa SA, Tolley DA. Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study. J. Urol. 2005 May;173(5):1610-4

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