Nephrostomy

Dr Christopher Watts

Consultant Radiologist

Salisbury District Hospital

Talk Overview

Indications & Contraindications

Patient preparation

Consent

Kit

Techniques – dilated and non dilated kidney

Complications

Indications Relief of Urinary Obstruction

Urosepsis or possible infection

Acute Renal failure

Urinary Diversion

Haemorrhagic cystitis

Trauma or iatrogenic ureteral injury

Inflammatory or malignant urinary fistula

Access for endourological procedure

Dilating or stenting ureteral stricture

Biopsy or treatment of urothelial lesions

Foreign body retrieval

QuickTime™ and aJVT/AVC Coding decompressorare needed to see this picture.

ContraindicationsAbsolute

? None…

RelativeDying patient

Uncorrectable severe coagulopathy / bleeding diathesis

Severe hyperkalaemia and/or metabolic acidosis

Pregnancy

Who should do it?

When should it be done?

IR or Urologists?

Part of RCR specialty IR training

Not just a drainage….

During the day

Possibly during the night Single kidney Sepsis

The referral

Speak to your urologist

Get a detailed overview of the problem and the patient’s current state of health

Discuss the urgency of the case

Review relevant imaging

Is there another way?

Patient Preparation

Bloods…..

Bleeding Risk Assessment

Evidence of coagulopathy

Is the patient on warfarin

FBC – plts >50 x 109

INR - <1.5

Hyperkalaemia

K >6.5 – call your medic / anesthetist. Can the patient be dialysed?

Patient Preparation Sedation

I like it BUT the patient may become agitated.

If giving conscious sedation the patient needs to be appropriately starved

6 hours solids

2 hours clear fluids

Combination of an opiate and benzodiazepine

E.g. morphine & Midazolam

Check local policy or guidelines

Monitoring and Oxygen

Patient Preparation

Antibiotics – evidence is weak

Potentially infected, obstructed system

Very easy to make the patient worse when trying to make them better

Septicaemia

Antibiotics to consider

Gentamycin 160-240mg IV

Cefuroxime 1.5gm iv

CHECK HOSPITAL GUIDELINES

Consent and Complications

Major (<5%)Septic Shock

1-3% ( <10% if

pyonephrosis)

Haemorrhage 1-4%

Bowel Transgression <1%

Pleural Complications <1%

SIR classification

MINOR

A no therapy or consequence

B nominal therapy, no consequence, overnight admission for observation only

MAJOR

C therapy , minor hospitalisation <48 hrs

D major therapy, increased care, prolonged hospitalisation >48hours

E permanent adverse sequelae

F death

Success RatesObstructed Dilated system without stones 95-98%

Non-dilated collecting system 80-85%

Where to Puncture?

Considerations:

•Anatomy – Where am I least likely to cause significant complications

•Bleeding

•Perforation

•Pneumothorax

•Next intervention

•Simple nephrostomy

•Ureteral intervention

•Patient comfort

Bleeding Renal artery divides into

anterior an posterior branches

Posterior branch supplies 30% of the kidney

Brodel’s Line divides the area between the anterior and posterior division

RELATIVELY AVASCULAR

Other anatomical considerations

BOWEL

LUNG

Upper pole Puncture

May be easier for stenting but risks pleural transgression

Interpolar region

Reasonably safe, good for antegrade ureteric work

Lower pole

Safe. Simple for nephrostomy, may be harder for ureteric access

The Procedure

For dilated collecting systems

US puncture

For Non Dilated collecting systems

Not straightforward.

‘Hybrid IVU’

Frusemide

CT

Kit

Angiocath 16gu

Kellet Needle -19gu

Access Kits

Access Kits

KIT 18 needle

Some sort of micropuncture kit

Eg Neff Set

22gu access needle

Platinum tipped 018 wire

4Fr catheter and metal stiffener

Outer 7Fr catheter

Ultrasound probe cover

Local – 1% lignocaine

Iodinated contrast and extension tube

Metal wire e.g. amplatz super stiff, J or Bentson

Dilate to 1Fr > than intended nephrostomy drain

6-8Fr.

Drainage bag

Single Stick Technique

The Procedure

Performed Prone

Check with US access is suitable

TIPS

Pillow under the abdomen

Semi prone – kidney to puncture uppermost

QuickTime™ and a decompressor

are needed to see this picture.

QuickTime™ and aH.264 decompressor

are needed to see this picture.

QuickTime™ and aJVT/AVC Coding decompressorare needed to see this picture.

Post Procedural Care

Bed Rest for 4hours

Obs – Bp/Pulse 30min for 4 hrs

Temperature

The Non Dilated System

Single stick v Double Stick

Non Dilated US guided

22gu needle better for single stick

If good views may be successful

Small volumes of contrast

Consider frusemide to plump up the calyces

Eg 40mg IV -

Fluoro IVU

US FIRST to ensure a safe passage

22Gu spinal needle

50 ml contrast >300mg/dl

5 mins

CENTRED AP

PELVIS PUNCTURE

Aspirate – contrast – air

Opposite 20° AO

CT guided

Complications

References Hausegger Percutaneous nephrostomy and antegrade

ureteral stenting: technique— indications—complications.. Eur Radiol (2006) 16: 2016–2030

Patel & Hussain Percutaneous Nephrostomy of non-dilated renal collecting systems with fluoroscopic guidance: Techniques and Results.. Radiology 2004; 233:226-233

Barbaric et al. Percutaneous nephrostomy: placement under CT and fluoroscopic guidance. AJR 1997; 169(1):151-5

Gupta et al Ultrasound-guided percutaneous nephrostomy in non-dilated pelvicaliceal system. J Clin Ultrasound. 1998 Mar-Apr;26(3):177-9.

Quality Improvement Guidelines for Percutaneous Nephrostomy J Vasc Interv Radiol 2003; 14:S277–S281 (SIR website)