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Nephrostomy Tube Placement

Nephrostomy tube placement is a common non-vascular interventional radiology procedure that can be accomplished with multiple techniques. Commonly, a combination of ultrasound and fluoroscopy are used for percutaneous renal access. Common nephrostomy tube indications include drainage of a sterile or infected renal collecting system, access for further urologic interventional such as percutaneous nephrolithotomy (PCNL) and urinary diversion. Regardless of the indication, nephrostomy tube can be safe and effective procedure for access into the renal collecting system using basic interventional radiology skill sets. Understanding patient factors will help decide how to pursue a nephrostomy tube placement procedure that is typically straightforward, but potentially difficult and/or frustrating.

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Ep 253 How I Place Nephrostomy Tubes with Dr. Aaron Fritts

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Pre-Procedure Prep

SIR Periprocedural Coagulation Parameters

• INR, aPTT, platelets labs recommended
• INR: correct to < 1.9
• Platelets: < 50,000/µl recommend transfusion
• aPTT: correct so that value is < 1.5 control

Suggested laboratory parameters for patients with chronic liver disease
• INR < 2.5
• Platelets: > 30,000
• Consider fibrinogen level

Contraindications

• 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

Pre-Procedural Evaluation

• H&P
• Understand indication for placement
• Hydronephrosis is not an indication for nephrostomy tube. Need to uncover underlying etiology and timeframe of hydronephrosis

Labs
• CBC, INR
• BMP helpful for baseline GFR

Imaging
• 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

Anatomy

Kidney
• 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

Nephrostomy Tube Placement Podcasts

Listen to leading physicians discuss nephrostomy tube placement on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #253

How I Place Nephrostomy Tubes

In this back to the basics episode, Dr. Christopher Beck interviews Dr. Aaron Fritts about his standard procedure for nephrostomy tube placement, preferred tools, and troubleshooting tips.

Episode #97

Nephrostomy Tube Placement: Basic to Advanced

Dr. David Field from MedStar Georgetown University Hospital walks us through indications and technique for placement of Nephrostomy tubes, as well as some advanced tricks for the non-distended collecting system.

Episode #43

Managing Urosepsis

Urologist Dr. Arthur Caire and IR Dr. Shelby Bennett return to the BackTable Podcast to discuss their approaches to urosepsis, stent vs. nephrostomy for a variety of presentations, and the middle-of-the-night patient.

Nephrostomy Tube Insertion Procedure

Antibiotic

• 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

Positioning

• 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

Access

• 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
• 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 Ureter

• 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
• 4 Fr angled tapered glide catheter will advance through the outer sheath of an Accustick sheath

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

Percutaneous Nephrostomy Tube Placement

• 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

Nephrostomy Tube Placement Articles

Read our exclusive BackTable VI Articles for quick insights on nephrostomy tube placement, provided by physicians for physicians.

Percutaneous Nephrostomy for a Non-Dilated Collecting System

Non-distended collecting system nephrostomy tube placement can often be challenging, requiring more advanced techniques. Interventional radiologist Dr. David Field discusses common indications, procedural steps using the Philips XperGuide CT software (and without it).

Percutaneous Nephrostomy for a Dilated Collecting System

A percutaneous nephrostomy is a surgical procedure to drain urine from a kidney. Indications for nephrostomy tube placement include urinary diversion and access for further urologic interventions such as percutaneous nephrolithotomy. Learn more about indications, procedure prep, and complications.

Post-Procedure

Post-Procedural 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%

Nephrostomy Tube Complications

• 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%

Nephrostomy tube 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

Nephrostomy Tube Placement Demos

Watch video walkthroughs of nephrostomy tube placement on the BackTable VI expanded content network.

Trans-Nephrostomy Ureteral Stent placement under fluoroscopy guidance: procedure and technique

References

[1] Young M, Leslie SW. Percutaneous Nephrostomy. [Updated 2020 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493205/
[2] Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions-Part II: Recommendations: Endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. J Vasc Interv Radiol. 2019;30(8):1168-1184.e1. doi:10.1016/j.jvir.2019.04.017
[3] 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
[4] 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
[5] 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
[6] 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
[7] Dagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011;28(4):424-437. doi:10.1055/s-0031-1296085
[8] 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
[9] E Radecka, A Magnusson, Complications associated with percutaneous nephrostomies. A retrospective study., Acta radiologica, 45 (2), 04-01-2004; 184-8

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