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PCNL Nephrostomy Tube Insertion & Management

Author Quynh-Chi Dang covers PCNL Nephrostomy Tube Insertion & Management on BackTable Urology

Quynh-Chi Dang • Jul 7, 2021 • 123 hits

Percutaneous nephrolithotomy (PCNL), a minimally invasive alternative to open kidney stone surgery, is a surgical technique that is used to remove large or complex kidney stones. Certain PCNL patients will require a nephrostomy tube, a catheter that drains urine from the kidney to an external bag. Urologist Dr. Margaret Pearle explains when nephrostomy tube placement is appropriate and how they can stabilize post-operative bleeding.

We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• A nephrostomy tube placement may be performed pre-operatively or post-operatively to facilitate urinary flow in PCNL patients.

• As with all indwelling catheters, nephrostomy tubes increase the risk of bacterial and fungal infections. For this reason, Dr. Pearle rarely inserts a pre-operative nephrostomy tube.

• For patients who have a pre-operative nephrostomy tube, Dr. Pearle recommends administering antifungals during the procedure, even if the patient is already on pre-operative antifungals, to prevent fungal sepsis.

• Dr. Pearle usually leaves a nephrostomy tube in the PCNL patient until the CT results come back in case residual fragments are present and a second procedure is needed.

• Nephrostomy tube insertion may stabilize post-operative bleeding until the PCNL patient can be brought to Interventional Radiology for an arteriogram.

nephrostomy tube placement

Table of Contents

(1) Antifungals for Pre-Operative Nephrostomy Tubes

(2) Post-Operative Nephrostomy Tube Placement

(3) Nephrostomy Tubes and Post-Operative Bleeding

Antifungals for Pre-Operative Nephrostomy Tubes

Indwelling catheters refer to catheters that are left in place for a long period of time. A nephrostomy tube is an example of an indwelling catheter that helps drain urine from the kidney in patients who have kidney stones that obstruct urinary flow. Nephrostomy tube placement can occur before or after the PCNL procedure.

Some urologists prefer to place nephrostomy tubes pre-operatively to collect urine samples for urine culture analysis as well. However, when improperly cared for, nephrostomy tubes may become sites of fungal and bacterial infections. For this reason, Dr. Pearle takes a conservative approach to placing pre-operative nephrostomy tubes; she only places them if she suspects the patient has xanthogranulomatous pyelonephritis (XGP), a rare chronic inflammatory kidney disorder.

In patients with a pre-operative nephrostomy tube, Dr. Pearle administers antifungals intraoperatively to prevent fungal sepsis. She notes that, in some cases, even patients with a negative urine culture analysis can present with yeast intraoperatively.

[Dr. Aditya Bagrodia]
If [PCNL patients] are coming in with a preexisting nephrostomy tube or a stent, do you ever prophylactically treat them with the antifungals?

[Dr. Margaret Pearle]
Yeah, that's a really good question and comment because fungal sepsis, I think we all would agree, is really one of the probably worst forms of sepsis that we deal with and those patients get incredibly sick. So, sometimes I'll just think about it and think this patient's been on a lot of antibiotics preoperatively, let's just give a dose of an antifungal at the time of surgery, not necessarily preoperatively.

Sometimes I look in the kidney and I see something that looks a little fluffier than I like to see, and I'll start it then. But it is absolutely something to keep in mind preoperatively. And I know Dr. Nicole Miller has always been a proponent of being pretty liberal about placing nephrostomy tubes preoperatively if they don't have tubes in, but they have a high grade obstruction. She will often put in a nephrostomy tube so she can sample the urine preoperatively and know what she’s actually treating, which might reveal fungus. But certainly with tubes in place, they're at higher risk of that.

So, in patients with longer term indwelling tubes, I'm definitely thinking about antifungals. I may not do it routinely every time if cultures from the tube are negative. But sometimes the cultures are negative for yeast and yet intraoperatively, there'll be the appearance that maybe there's yeast. Then, I'll add it at the time.

[Dr. Aditya Bagrodia]
If they're coming in with a preexisting nephrostomy tube or a stent, do you ever prophylactically treat them with the antifungals?

[Dr. Margaret Pearle]
Yeah, that's a really good question and comment because fungal sepsis, I think we all would agree, is really one of the probably worst forms of sepsis that we deal with and those patients get incredibly sick. So, sometimes I'll just think about it and think this patient's been on a lot of antibiotics preoperatively, let's just give a dose of an antifungal at the time of surgery, not necessarily preoperatively.

[Dr. Aditya Bagrodia]
...Before we jump into some of those considerations, I want to ask you a quick question. Patients coming in with partial stags or full stags, positive UTIs, not clinically sick, are those patients routinely getting decompressed? Or do you think it's safe to manage them with antibiotics, try to sterilize them and then treat them as you typically would down the way?

[Dr. Margaret Pearle]
Yeah, I don't typically decompress them. Patients will often come to me with a standard nephrostomy tube in place. But if I encounter them, if they're referred to me and they don't have drainage or I'm seeing for the first time and they don't have drainage, I don't routinely place a drainage tube--unless sometimes they'll have sort of the appearance of an XGP type kidney. That might worry me more that I might want to sample that urine and save a trip to the operating room. Because if you get in there and you find pus, then you're going to put a nephrostomy tube in and get out. But I don't typically.

Now, there are times I've been burned by that and found pus at the time of obtaining access. But more often than not, I'd say usually I don't. And again, this is where Dr. Nicole Miller probably is more aggressive about putting tubes in and sampling the urine. I just obtain my routine urine cultures and treat appropriately and aggressively with antibiotics preoperatively and intraoperatively. But I don't necessarily prophylactically place nephrostomy tubes, even in a patient with a staghorn stone and a hydronephrosis.

[Dr. Jose Silva]
...And in those cases, you will leave like a big Foley instead of just an 18 French or a smaller caliber nephrostomy tube?

[Dr. Margaret Pearle]
Yeah, and I don't know if that's really necessary or not. But generally, if I've been in there and I went ahead and dilated the track to 24 French or 30 French, I may leave a 16 or 18 French tube in place that is going to achieve good drainage and also leave a way for me to come back the second time. And I don't go through that procedure with the intent of finishing it. I go through with the intent of getting enough stone out to achieve better drainage.

Listen to the Full Podcast

Tips & Tricks for Percutaneous Nephrolithotomy (PCNL) with Dr. Margaret Pearle and Dr. Aditya Bagrodia on the BackTable Urology Podcast)
Ep 9 Tips & Tricks for Percutaneous Nephrolithotomy (PCNL) with Dr. Margaret Pearle and Dr. Aditya Bagrodia
00:00 / 01:04

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Post-Operative Nephrostomy Tube Placement

To ensure that no residual stone fragments are left behind in the kidney, a flexible nephroscopy is performed at the end of every PCNL procedure. However, it is possible that the nephroscope is not able to visualize certain residual fragments. Dr. Pearle emphasizes the importance of ordering a post-operative CT scan to ensure that patients are stone-free.

Dr. Pearle normally inserts a post-operative nephrostomy tube in all her stone patients, just in case residual fragments show up on the CT scan later. The nephrostomy tube allows her to go back into the kidney to perform a second procedure within 48 hours to extract the residual fragments. She notes that nephrostomy tube placement after the first procedure greatly increases the probability of patients returning for the second procedure. If a second procedure is necessary, she removes the nephrostomy tube intraoperatively. In this manner, her patients are able to go home stone-free and tube-free.

[Dr. Aditya Bagrodia]
Could you talk a little bit about when you're inclined to leave stents or tubes in place? And which types of tubes, or even tubeless?

[Dr. Margaret Pearle]
Yeah, so there's definitely a trend toward more tubeless procedures, I'd say. More and more urologists are doing tubeless procedures. And we certainly know that we can do that safely and compared to standard PCNL, with nephrostomy tubes in place, the risk of bleeding or needing transfusion is really pretty comparable. So, I think we can do it safely.

In my mind, the issue has always been the residual fragments. And almost 100% of the time when I finish a PCNL, I think that my patients are stone-free. I do thorough flexible nephroscopy at the end of every case, multiple trips around the kidney with a flexible nephroscope, imaging and looking at every calyx. And I'm wrong, at least 30% of the time, probably more like 60% of the time.

You do CTs postoperatively and patients have residual stones, and I think it just depends on your philosophy about residual fragments. And Aditya, you did seminal work in this area. But my feeling is that if you're going to make a hole in someone's kidney, you've got an obligation to get them stone free. You can put a nephrostomy tube and you can come back and you can get those residual fragments out. So, until we have a better way of assuring that we have gotten every fragment out, I don't want to burn a bridge.

And so, I like to leave a nephrostomy tube in place. I get a CT scan on postoperative day one. And if they have residual fragments, they come back for a planned second look procedure 48 hours later. Some urologists don't have the luxury of being able to schedule two procedures 48 hours apart, but just because of operating room time. We established that practice a long time ago, and we have the luxury of being able to do that. If patients are stone free, we cancel the second look. But we always have that time available to look back. So, in my mind, I just don't want to burn the bridge.

I also find that patients hate stents. They hate stents. When they go home, they want to go home with no tubes. And by leaving a tube in place postoperatively, imaging with a CT on postoperative day one, I can take out their nephrostomy tube and postoperative day one, if they're stone free and send them home with no tubes and with an assurance that they have no residual fragments.

If I have to look back in the kidney a second time, I have the ability to do that, I leave the nephrostomy tube out after the second procedure. And again, they go home free, go home stone free and with no nephrostomy tube.

Those who perform tubeless will state that they'll do imaging maybe or maybe not with a CT, I'd say most often not. And if there are residual fragments, they'll bring them back and do ureteroscopy in a couple weeks.

I would argue, this is just my guess, is that most of the time, those patients aren't brought back for a second procedure. So, just a whole lot less push for you to go back a second time once they leave the hospital. They don't want to go back for another procedure. Once they leave the hospital, they want to be done. And I just think that we have a much lower or much higher threshold for going back for residual stones once they leave the hospital with a stent in place.

So, at least in my mind, I think if it was me, I'd rather go home with no tubes and know that it's over and that all my stones are out. But I would have to say, I'm probably the minority in that. I think there's more and more tubeless PCNL that's being done because they are less invasive and everybody pretty much goes home on post op day one and they're left with no nephrostomy tube, so there's certainly less pain and that's definitely been shown in randomized trials to be the case.

Nephrostomy Tubes and Post-Operative Bleeding

Post-operative bleeding is a possible PCNL complication. Oftentimes, nephrostomy tube insertion can stop the bleeding until the patient is stabilized enough to transport to Interventional Radiology for an arteriogram. However, if the first arteriogram does not show a bleed, nephrostomy tube removal or readjustment may be necessary to visualize a pseudoaneurysm.

[Dr. Aditya Bagrodia]
Okay, okay. So, hopefully, as to be the case, stone free, tubes coming out, tube comes out and you encounter bleeding. Can you walk us through kind of the management of your preferred way to deal with an early or even a delayed post-operative bleed?

[Dr. Margaret Pearle]
So, outside the operating room, typically, if we have, for instance, a council catheter in the kidney, which we advance over like a 5 French angiographic catheter into the bladder, we typically remove the council catheter first, leaving the angiographic catheter in place. So, if there's bleeding encountered immediately, you can just slip the council catheter back over the angiographic catheter into the collecting system. And that will almost always stop the bleeding until you can get interventional radiology.

So, we sort of give it just a little time before burning that angiographic catheter. In rare cases, and I've certainly had them through my career, we had to take them straight to interventional radiology because of a significant bleed. We've done so. But we've almost always been able to get a tube back in. So, we've had very few real sort of dire emergency, big bleeds that were critical in terms of wheeling pretty much down to IR right away.

But if you can get a nephrostomy tube back in, it'll generally stop and then we would subsequently take them to interventional radiology. And I think the key, in terms of arteriograms, is that you sometimes have to deflate the balloon to find the bleeder or find the pseudoaneurysm, or you have to back the nephrostomy tube out. So, again, we'll put a wire down our angiographic catheter.

And then if they do an arteriogram on a first run and don't see a bleed, then we deflate the balloon and then we back the nephrostomy tube out. And sometimes, there's significant bleeding as you back it out, but you're not going to be able to find the pseudoaneurysm sometimes until you get the tube out of the way. So, we're always kind of prepared to do that. And our interventional radiologists are aware that they may need to contact us to come and move the tube if need be.

Podcast Contributors

Dr. Margaret Pearle discusses Tips & Tricks for Percutaneous Nephrolithotomy (PCNL) on the BackTable 9 Podcast

Dr. Margaret Pearle

Dr. Margaret Pearl is a Professor and Vice Chair of Urology at UT Southwestern Medical Center in Dallas, TX.

Dr. Aditya Bagrodia discusses Tips & Tricks for Percutaneous Nephrolithotomy (PCNL) on the BackTable 9 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Dr. Jose Silva discusses Tips & Tricks for Percutaneous Nephrolithotomy (PCNL) on the BackTable 9 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2021, June 16). Ep. 9 – Tips & Tricks for Percutaneous Nephrolithotomy (PCNL) [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com 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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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