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Percutaneous nephrostomy tubes

Percutaneous nephrostomy tubes
Literature review current through: Jan 2024.
This topic last updated: Feb 14, 2023.

INTRODUCTION — Percutaneous nephrostomy tube placement is a procedure that decompresses or provides access to the renal collecting system in native and transplanted kidneys [1]. The procedure involves image guidance to place a drainage catheter into the renal pelvis through the skin. As imaging technology has improved, the indications for nephrostomy tube placement have expanded to involve drainage of infected and noninfected kidneys and to provide access to the renal pelvis, ureter, or bladder to treat a variety of urologic disorders. It has been proven to be a safe and effective procedure that is minimally invasive.

The indications, contraindications, insertion techniques, maintenance (including tube exchange), outcomes, and complications of percutaneous nephrostomy are discussed here.

Other treatments for urinary obstruction and/or kidney stones are discussed elsewhere.

(See "Kidney stones in adults: Surgical management of kidney and ureteral stones".)

(See "Management of urinary tract obstruction".)

INDICATIONS — Percutaneous nephrostomy tube placement is an increasingly common procedure used as an alternative to cystoscopic or more invasive urologic procedures to treat a variety of urologic disorders across all age groups. In general, placement of percutaneous nephrostomy tubes can be divided into placement in obstructed or non-obstructed kidneys.

In obstructed kidneys, the indications are broadly related to infection/urosepsis or renal insufficiency.

The indications for placement in non-obstructed kidneys are more variable and include:

Access for percutaneous intervention on stones or tumor.

Access for ureteroplasty or ureteral stent placement.

Access for diagnostic tests such as pyelography and pressure measurement (Whitaker test).

Access for medication infusion for infection or tumor.

Access for cooling (pyeloperfusion) during percutaneous ablation of renal masses.

Urinary diversion for ureteral injury, urinary fistula, or cystitis.

Neonatal — In the neonatal population, percutaneous nephrostomy tubes are most often placed to relieve obstruction related to ureteropelvic junction (UPJ) obstruction, posterior urethral valves, or congenital megaureter [2]. Placement of percutaneous nephrostomy tubes in neonates in non-obstructed kidneys is less commonly done. In a single-center series of 31 neonates and 43 nephrostomy tubes, 24 neonates had nephrostomy tubes placed for obstruction (4 with associated infection), and 7 neonates had nephrostomy tube placement for treatment of urosepsis or pyonephrosis in a non-obstructed urinary tract [3]. Nephrostomy tube placement in neonates with systemic candidiasis with renal involvement to allow both decompression and therapeutic infusion of amphotericin B has also been described [4].

Pediatric — In children, nephrostomy tubes are placed more commonly for ureteral obstruction due to stone disease, ureteral stricture following stone disease or infection, myelomeningocele, mechanical obstruction of a transplanted kidney, or malignancy [2]. In a retrospective multicenter review of 441 pediatric patients and 675 nephrostomy procedures, the most common indication was hydronephrosis in 57 percent of patients, with 14 percent having stones and 12 percent having infection. Nephrostomy tubes were also placed for elevated creatinine in 5 percent and urinary diversion for urinary leak in 4 percent, and a combination of urinoma, urinary fistula, and vesicoureteral reflux accounted for the remaining 8 percent [5].

In the pediatric population, nephrostomy tube placement can also provide access for antegrade pyelography to help distinguish anatomy; provide access for other endoscopic or interventional procedures, including stone removal, ureteroscopy, ureteral stent placement, and ureteroplasty; or deliver antibiotics or chemotherapy into the collecting system [2]. In addition, nephrostomy tube placement in the pediatric population can also be done for urinary diversion for iatrogenic or traumatic ureteral injury or for diversion of hemorrhagic or radiation cystitis [2].

Adult — In adults, the majority of nephrostomy tubes (72 to 97 percent) are placed for noninfected obstruction [6]. Symptoms that can manifest from these noninfected obstructions include renal colic, hematuria, or azotemia, but they may also be discovered incidentally on imaging studies.

However, it is important to note that hydronephrosis alone is not an indication for nephrostomy tube placement. Hydronephrosis can be present on imaging without obstruction and can persist after nephrostomy tube placement, particularly in the older adult population and in patients with longstanding obstructions. Hydronephrosis can be physiological in cases of pregnancy, overhydration, arginine vasopressin disorders, diuretic use, and post-obstructive relief from renal venous or ureteric obstruction [7]. In addition, ureteral obstruction does not necessarily lead to severe hydronephrosis, and the clinical severity of the obstruction does not correlate with the extent of hydronephrosis seen on imaging [7].

Nephrostomies are placed for infected urinary obstruction in 3 to 19 percent of adults [6]. Urgent decompression is indicated in these cases due to the high risk of developing gram-negative sepsis. Stones are responsible for >50 percent of cases of infected obstruction; other less common etiologies include urothelial malignant obstruction, retroperitoneal fibrosis, pelvic masses such as uterine fibroids, cervical and endometrial carcinoma, prostate or bladder cancer, and lymphoma [6,7].

Nephrostomies placed to provide access for stone removal are performed more commonly at some centers than others, accounting for 3 to 50 percent of nephrostomy placements [6]. At some centers, the kidney is accessed percutaneously to allow for stone removal, but access to the kidney is removed immediately following stone removal. A meta-analysis of 26 studies on percutaneous nephrolithotomy (PCNL) procedures with and without placement of a nephrostomy tube post-stone removal reported shorter operative times, shorter hospital lengths of stay, and a lower rate of postoperative urinary fistula (relative risk 0.18, 95% CI 0.07-0.47) after the tubeless PCNL procedure compared with PCNL with nephrostomy tubes [8]. However, the routine use of nephrostomy tubes following percutaneous stone removal continues to vary with the institution and operator [8].

Nephrostomy access to allow for placement of ureteral stents is a less common indication and accounts for 2 to 3 percent of nephrostomy tube placements [6].

Nephrostomy placement for urinary diversion to treat urinary leaks, urinary fistula, or hemorrhagic or radiation cystitis accounts for 1 to 34 percent of nephrostomy tube placements [6]. The use of nephrostomy tube placement for such indications is variable. In a French retrospective review of close to 5500 women with a vesicovaginal fistula, 40 percent underwent nephrostomy tube placement or long-term bladder catheterization; the remaining patients underwent either an attempt at surgical repair (48 percent) or immediate surgical urinary diversion (12 percent) [9].

Other less common indications for nephrostomy tube placement include antegrade access for pyeloperfusion to cool the surrounding renal parenchyma during tumor ablation [10], access for therapy for urothelial carcinoma with gelatinous mitomycin C [11], and access for diagnostic pyelography and pressure measurements. The Whitaker test can be done using antegrade renal access to measure the pressure in the kidney with concurrent pressure measurement in the bladder. This is uncommonly done to evaluate for ureteral obstruction in patients with hydronephrosis to differentiate obstruction from dilation secondary to permanent changes in the musculature when other less invasive tests such as diuretic renography are equivocal [12].

CONTRAINDICATIONS — Uncorrectable severe coagulopathy and terminal illness or imminent death are the only relative contraindications to nephrostomy tube placement [6]. There are limited data to support specific parameters, but the Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions considers percutaneous nephrostomy tube placement to be a high-risk procedure and recommends that the international normalized ratio (INR) should be within the 1.5 to 1.8 range or less and transfusion should be considered for a platelet count less than 50 x 109/L [13].

INSERTION TECHNIQUES — Prior to the procedure, existing imaging should be reviewed to note any malposition or malrotation of the kidney, the presence of partial or complete duplication of the collecting system, the location of renal cysts or diverticula that can be mistaken for a dilated calyx, the presence of renal tumors, and the presence of existing renal calculi [7]. Care should also be taken to review preprocedural imaging to determine the presence of large branch renal arteries prior to nephrostomy placement to reduce the risk of arterial injury and bleeding.

We recommend antibiotic prophylaxis prior to all new percutaneous nephrostomy tube placement. A single dose of antibiotics is sufficient unless the patient is found to have active infection at the time of tube placement. The agents used are comparable to the ones used perioperatively in other urologic procedures (table 1) and guided by preprocedure urine cultures when results are available. Once the tube has been inserted, there is no further role for routine antibiotics.

The placement of percutaneous nephrostomy tubes requires image guidance, typically with ultrasound and fluoroscopy. Nephrostomy tube placement was originally described using fluoroscopy alone, but with the availability of ultrasound, most centers are using ultrasound during placement (image 1). The placement of nephrostomy tubes can be done using computed tomography (CT) guidance if necessary and depending on operator preference.

Fluoroscopic guided – When fluoroscopic access alone is performed, a two-needle puncture is often required, with the first puncture placed directly into the renal pelvis using bony landmarks as a guide, with the renal pelvis located typically 2 to 3 cm lateral to the L2 vertebral body. When access is gained into the renal pelvis, this needle is used to infuse contrast into the collecting system to allow placement of a second needle into a more peripheral calyx to allow for safe placement of a larger tube. If the patient’s kidney is functioning and they can tolerate intravenous iodinated contrast, this can be given to opacify the renal collecting system and allow fluoroscopic placement through a single needle puncture.

Ultrasound guided – Ultrasound-guided nephrostomy tube placement typically allows for placement with a single needle puncture using ultrasound to place the needle directly into a posterior calyx. Once the needle is placed into a peripheral calyx, a wire is placed through the needle into the renal pelvis or ureter, and the needle is then exchanged for the nephrostomy tube over the wire, typically using fluoroscopic guidance. Fluoroscopic guidance is required for patients with non-dilated collecting systems and is recommended in those with higher body mass index. Nephrostomy tube placement can be performed with ultrasound guidance alone in pregnant and pediatric patients.

CT guided – CT guidance is used less commonly for nephrostomy tube placement but is sometimes necessary for challenging placements in kidneys that are in malposition or malrotation or when the traditional transretroperitoneal or transparaspinal access routes are not possible and further image guidance into the abdomen is required [14].

A systematic review and meta-analysis of eight trials compared percutaneous nephrolithotomy (PCNL) under fluoroscopy versus ultrasound guidance [15]. Ultrasound guidance was associated with a comparable stone-free rate but a lower complication rate compared with fluoroscopy guidance. However, the reduced complication rate was only observed in one of the eight studies, and most of the complications were minor.

When placement of the nephrostomy is for obstruction related to stone disease or for access to facilitate stone removal, care should be taken to access the calyx with the stone, when possible, to facilitate endoscopic removal.

To reduce the risk of bleeding, nephrostomy tubes should be placed through the avascular plane between the major ventral and dorsal branches of the renal artery, known as the Brodel bloodless line of incision. This line typically lies in the posterolateral region of the kidney between the anterior two thirds and the posterior one third of the kidney. The posterior calices are typically located with their long axis pointing toward this avascular plane, making them a good target for nephrostomy placement when possible [16]. However, newer anatomic studies have shown variability in the location of the avascular plane and that 20 percent of cadaveric kidneys analyzed demonstrate absence of an avascular plane at the level of the inferior segment of the kidney [17].

The placement of nephrostomy tubes in the neonatal patient has unique challenges due to the small size of the kidney and the mobility of the kidney [3]. In addition, in the neonatal patient, care must be taken to monitor and control the patient's body temperature during placement [2].

MAINTENANCE

Routine tube maintenance — Nephrostomy tubes are fixated to the skin using sutures or adhesives according to local practice. They should remain connected to a closed drainage system that is positioned lower than the kidney.

There is little evidence to guide the skin care of nephrostomy tubes once placed. Some authors suggest weekly dressing changes and use of an anchoring adhesive dressing to reduce the risk of tube displacement [18]. At our institution, we recommend weekly dressing changes done either by the patient or a visiting nurse, but we do not routinely use specialized adhesive dressings to anchor the tubes to the skin, due to the expense related to these dressings and concern that use of anchoring dressings increases the risk of tube dislodgement during dressing changes. Antibiotic ointment is not routinely used around the nephrostomy tube site.

Nephrostomy tubes are susceptible to dislodgement or occlusion related to catheter kinking or encrustation. In a retrospective review of 475 patients with nephrostomy tube placement after percutaneous nephrolithotomy, 24 (5.5 percent) experienced tube dislodgement [19].

The type and size of tube placed was not found to impact tube dislodgement rate, but the patient's body mass index (BMI) was found to be an independent risk factor for tube dislodgement, with a 6 percent increase in tube dislodgement for every unit of increases in BMI [19].

Pregnancy also predisposes to tube malfunction. In a series of eight pregnant patients with nephrostomy tubes, three of eight (37.5 percent) developed tube occlusion post-placement that required flushing [20]. In a review of 10 publications on pregnancy and nephrostomy tube placement, 13 of 29 patients (45 percent) required some form of tube manipulation to address tube occlusion or dislodgement [20]. (See "Kidney stones in adults: Kidney stones during pregnancy", section on 'Elective surgery'.)

To reduce the rate of tube malfunction and associated infectious complications, some institutions routinely flush nephrostomy tubes with sterile saline once or twice a day, but there is little evidence to support this practice, and it is not universally done.

Tube exchange — Preventative maintenance tube exchanges are typically scheduled every two to three months, but there is no standard exchange interval, and this interval is often influenced by local practice. A retrospective review of 57 patients and 87 exchanges determined that exchanges every 60 days were the most cost effective [21]. To ensure proper replacement of the tube and its locking pigtail in the renal pelvis, nephrostomy tubes are routinely exchanged under fluoroscopic guidance.

In the adult population, the risk of bacteremia with tube exchanges has been reported at 11 percent [22], and the use of prophylactic antibiotics is often suggested, but there are little data to support the effectiveness of this practice. In a prospective study of urinary interventions including nephrostomy and ureteral stent placement, 122 patients had exchanges performed without periprocedural antibiotics, and 23 patients were treated with antibiotics. No difference in infection rate or symptoms was identified between the two groups [23].

At our institution, all patients who present for nephrostomy tube exchanges due to tube malfunction or malposition receive prophylactic periprocedural antibiotics. The use of prophylactic periprocedural antibiotics in asymptomatic patients undergoing preventative maintenance nephrostomy tube exchanges varies by operator.

OUTCOMES

Success rates — Percutaneous nephrostomy tube placement is a safe and effective treatment of kidney stone disease in all age groups.

In the neonatal group, the technical success rate has been reported at 97.7 percent [3]

In the pediatric population, the reported technical success rate is 95 percent and is not correlated with patient age, degree of hydronephrosis, or presence of renal calculi [2].

In the adult population, the reported technical success rates range from 84 to 99 percent [6].

For obstructed dilated collecting systems, the reported success rate is 96 to 100 percent.

The reported technical success rates are lower in nondilated collecting systems (82 to 96 percent) and in complex stone disease cases (82 to 85 percent) [6].

Factors such as operator experience and patient body mass index may also affect technical success rates regardless of the etiology of obstruction. The success of stone removal depends on factors other than the placement of the percutaneous nephrostomy access, such as stone composition, stone burden, patient anatomy, number of access tracts required, use of flexible or rigid instruments, and performance of other adjunctive procedures [6]. (See "Kidney stones in adults: Surgical management of kidney and ureteral stones", section on 'Percutaneous nephrolithotomy'.)

Nephrostomy tube placement for urinary diversion to treat intractable hemorrhagic cystitis is an effective minimally invasive treatment that has been reported to reduce or eliminate symptoms in 5 of 6 patients in one series [24] and in 10 of 11 patients in another [25]. (See "Chemotherapy and radiation-related hemorrhagic cystitis in cancer patients", section on 'Urinary diversion'.)

For patients with vesicovaginal, vesicorectal, or vesicocutaneous fistula, the success of percutaneous nephrostomy tube placement alone is more variable, and it is now often used as a temporizing method prior to definitive surgery [26,27]. For patients with malignant fistula or patients not felt to be candidates for surgical repair, nephrostomy tube placement with ureteral embolization to ensure complete urinary diversion can be performed. Ureteral embolization using butyl-2-cyanoacrylate glue was first described in 1979 in three patients with vesicovaginal or vesicosacral fistula with a 100 percent technical success rate [28]. Since that time, multiple different embolic agents, including vascular plugs, coils, Gelfoam, and liquid ethylene vinyl alcohol, have been used to achieve a safe and durable result. The reported primary success rates were 40 to 100 percent, and the reported recanalization rates were up to 67 percent [29]. A 2022 series of 12 patients with vesicovaginal fistula and cervical cancer treated with bilateral nephrostomy tube placement and ureteral stent occlusion reported a 100 percent technical success rate [30].

Ureteral strictures that are not amenable to cystoscopic treatment (eg, after kidney transplantation) may be treated with balloon ureteroplasty via percutaneous nephrostomy access. In a series of 75 renal transplant patients, 44 percent were treated with ureteroplasty alone; the remaining 56 percent of patients were treated with surgical revision, long-term nephrostomy tube placement, or ureteral stent [31]. The use of a cutting balloon has been suggested to increase the technical success of percutaneous treatment of ureteral strictures in a series of four patients with an initial 100 percent technical success [32].

Efficacy compared with ureteral stenting — For patients with urinary obstruction with or without infection, whether to place a nephrostomy tube or a ureteral stent varies with institution and operator preference. (See "Management of urinary tract obstruction".)

Although some providers prefer nephrostomy tubes for infected systems or patients with severe renal insufficiency because of the belief that the nephrostomy tube provides more definitive drainage, such practice is not supported by data.

In a randomized trial of 90 pediatric patients with renal failure and renal calculi randomly assigned to either nephrostomy tube or ureteral stent, no difference in return to normal renal function was seen [33]. A stone size greater than 2 cm was found to increase the failure rate and mucosal injury rate in the ureteral stent group.

In a randomized trial of 143 adult patients with renal insufficiency and renal calculi randomly assigned to either nephrostomy or ureteral stent placement, no difference in the time to return to normal renal function was noted, but a higher rate of positive urine culture was seen in the ureteral stent group (55 versus 37 percent) [34].

For patients with infected obstructed kidneys, the type of drainage was also not found to correlate with the risk of sepsis.

In an observational study, 62 patients with acute obstructive pyelonephritis underwent either ureteral stent placement or nephrostomy tube placement. In univariate analysis, older age, high neutrophil count, increased serum creatine, higher Charlson comorbidity index score, diabetes mellitus, longer operation time, and multiresistant bacteria stains were risk factors for sepsis but not the type of drainage [35].

A meta-analysis of nine studies (three randomized) that included a total of 396,887 patients who underwent either ureteral stent or percutaneous nephrostomy tube placement showed a higher rate of sepsis, longer hospital stay, and higher cost for percutaneous nephrostomy patients, but this could be related to patient selection given that a small number of the included studies were randomized and one retrospective study included 396,385 patients [36].

Therefore, the choice to place a nephrostomy tube over ureteral stent is generally left to the local experts within each institution. One consideration is that ureteral stent placement via cystoscopy usually requires general anesthesia, whereas a nephrostomy tube is placed under local anesthesia with or without sedation; thus, critically ill patients, such as those who are septic, may be better candidates for nephrostomy tube drainage. Additionally, patients with ureteral stents have been found to have a lower health-related quality of life than the nephrostomy tube group given the lower urinary symptoms following ureteral stent placement [36,37]. (See "Placement and management of indwelling ureteral stents", section on 'Pain management'.)

COMPLICATIONS — The overall rate of complications for percutaneous nephrostomy tube placement varies by patient selection and operator experience. When major and minor complications are considered together, the approximate complication rate for both adult and pediatric patients is 10 percent [2,6].

Major complications — The major complications of percutaneous nephrostomy include sepsis, bleeding requiring transfusion, vascular or bowel injury, and pleural complications with intercostal puncture.

In pediatric patients, the reported range of complications for major complications is 0.8 to 3 percent for sepsis, 0.8 to 3 percent for hemorrhage requiring treatment, and 0.2 percent for vascular or bowel injury [2].

For adults, the reported rate of major complications includes 1 to 10 percent for sepsis, with a higher average rate of 7 to 9 percent reported in patients with nephrostomy tube placement for pyelonephrosis [6]. The risk of hemorrhage requiring transfusion is 1 to 4 percent for percutaneous nephrostomy tube alone but is as high as 12 to 14 percent in adult patients with nephrostomy tubes placed for percutaneous nephrolithotomy [6]. The risk of vascular injury requiring embolization or nephrectomy is reported as 0.1 to 1 percent, and the risk of bowel injury is 0.2 to 0.5 percent [6]. The risk of pleural complications, including pneumothorax, empyema, hydrothorax, or hemothorax, is 0.1 to 0.6 percent for nephrostomy alone but is higher, at 8.7 to 12 percent, for nephrostomy tubes placed during percutaneous nephrolithotomy due to the potential need to use an intercostal puncture to access the upper pole of the kidney [6].

Minor complications — In addition to major periprocedural complications, more minor complications have been reported, including tube infection both within the kidney and at the skin entry site, tube dislodgement, hematuria, urinary leak, and tube occlusion.

In a series of 43 neonates with nephrostomy tube placement, 2 (4.6 percent) were reported to have self-limiting bleeding around the tube, 5 (11 percent) chronic microhematuria, 5 (11 percent) cellulitis at the entry site, 5 (11 percent) clinical urinary tract infection, 4 (9.3 percent) nephrostomy tube dislodgement, and 5 (11 percent) urinary leak [3].

In the pediatric age group, reported minor complications include urinary tract infection (4 to 17 percent), skin site infection (1.8 percent), tube dislodgement or occlusion (3 to 17 percent), oozing from insertion site (1.8 percent), and urine leak (2 to 10 percent) [2].

As mentioned previously, the risk of tube dislodgement has been reported to be 5.5 percent in the adult population, and the risk is higher in patients with higher body mass index [19]. (See 'Maintenance' above.)

Bacteriuria — The optimal use of antibiotics and tube exchanges in the setting of bacteriuria remains controversial.

Tube check or exchange — When a patient with a nephrostomy tube is found to have bacteriuria, it is important to confirm the nephrostomy tube is draining adequately. This can often be done by confirming adequate amounts of drainage from the tube and/or by flushing the tube with 5 to 10 mL of normal saline to ascertain that the tube flushes with low resistance and that there is no pain or leaking around the tube. If the tube is not draining or flushing well, it should be exchanged.

If there is a question about the location of the tube, an abdominal radiograph can be obtained to compare the internal position of the nephrostomy tube with that of the initial placement or exchange. If the plain abdominal radiograph is equivocal, further evaluation with renal ultrasound or cross-sectional imaging can be obtained. A malpositioned tube should be exchanged.

We do not exchange well-positioned and functioning nephrostomy tubes for symptomatic bacteriuria, as nephrostomy tube exchange is unlikely to sterilize the urine but could risk sepsis in those with urinary tract infection.

Nephrostomy tube exchange for symptomatic bacteriuria due to multidrug-resistant bacteria that are challenging to treat with antibiotics is considered on a case-by-case basis after discussion with our infectious disease specialists as part of a broader antibiotic treatment plan for the patient.

Antibiotics — If the nephrostomy tube is functioning well and in good position and the patient is asymptomatic, we typically do not recommend antibiotic treatment for bacteriuria.

If the tube is functioning well and in good position in a patient with symptomatic bacteriuria, we recommend treatment with antibiotics for cystitis or pyelonephritis, depending on the clinical symptoms. (See "Acute simple cystitis in adult and adolescent females" and "Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents".)

The use of antibiotics in patients with nephrostomy tubes and bacteriuria is controversial. Long-term Foley catheters in the bladder are known to form biofilm [38], but the significance of biofilm on nephrostomy tubes is not well understood. In previously sterile urinary systems that have nephrostomy tubes placed, 22 of the 27 urinary systems were found to be colonized within two to nine weeks of tube placement [39]. In a retrospective review of 571 patients with nephrostomy tubes, 81 patients (14 percent) were found to have an initial urinary tract infection, and 10 (21 percent) of the 47 patients followed over 30 days were found to have a recurrent symptomatic urinary tract infection. Multivariate logistic regression analysis found that concordant antibiotic use and nephrostomy catheter exchange within four days of infection reduced the rate of recurrent infections [40], although the retrospective nature of the study and small number of patients followed long term have limited the routine adoption of these recommendation into clinical practice.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Kidney stones" and "Society guideline links: Urinary tract infections in adults".)

SUMMARY AND RECOMMENDATIONS

Indications – Percutaneous nephrostomy tubes are generally placed for the following indications (see 'Indications' above):

In obstructed kidneys – Infection/urosepsis or renal insufficiency.

In non-obstructed kidneys:

-Access for percutaneous intervention for stones or tumor, ureteroplasty or ureteral stent placement, diagnostic tests such as pyelography and pressure measurement (Whitaker test), medication infusion for infection or tumor, and cooling (pyeloperfusion) during percutaneous ablation of renal masses.

-Urinary diversion for ureteral injury, urinary fistula, or cystitis.

Contraindication – Uncorrectable severe coagulopathy. The international normalized ratio (INR) should be within the 1.5 to 1.8 range or less, and transfusion should be considered for platelet count less than 50 x 109/L. (See 'Contraindications' above.)

Insertion techniques – Percutaneous nephrostomy tubes are placed under image guidance, typically with ultrasound and fluoroscopy. They can also be placed with fluoroscopy or ultrasound alone or under CT guidance if necessary. We recommend prophylactic antibiotics prior to all new percutaneous nephrostomy tube placement (Grade 1B). (See 'Insertion techniques' above.)

Maintenance – Nephrostomy tubes are fixated to the skin using sutures or adhesives according to local practice. They should remain connected to a closed drainage system that is positioned lower than the kidney. Some centers flush the tube with saline once or twice a day to prevent occlusion. (See 'Routine tube maintenance' above.)

Preventative maintenance tube exchanges are typically scheduled every two to three months. Prophylactic antibiotics are usually given prior to exchanging malpositioned or malfunctioning tubes. (See 'Tube exchange' above.)

Complications – The overall complication rate of percutaneous nephrostomy is about 10 percent. Major complications include sepsis, bleeding requiring transfusion, vascular or bowel injury, and pleural complications with intercostal puncture. (See 'Complications' above.)

Bacteriuria is common in patients with an indwelling nephrostomy tube, which requires a tube check and possible exchange if malfunctioning or malpositioned. Only symptomatic bacteriuria requires antibiotic therapy. (See 'Bacteriuria' above.)

Comparison with ureteral stent – In patients with severe sepsis or complicated stone disease, percutaneous nephrostomy tubes are traditionally used more often than ureteral stents because nephrostomy tubes can be inserted without general anesthesia. Data show similar time to renal function recovery and similar rate of sepsis between the two techniques. Therefore, the choice is generally left to local experts within each institution. Patients with ureteral stents do have more lower urinary symptoms than patients with nephrostomy tubes. (See 'Efficacy compared with ureteral stenting' above.)

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Topic 139781 Version 2.0

References

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