Left-Sided Percutaneous Nephrostomy Placement Technique
Percutaneous nephrostomy (PCN) should be performed using image-guided Seldinger needle-wire technique with ultrasound for initial access followed by fluoroscopy for catheter placement, achieving technical success rates approaching 100% in dilated systems. 1
Patient Positioning
Position the patient in the prone position as the standard approach, though a supine anterolateral position is an acceptable alternative, particularly for obese patients or those with respiratory compromise 2. For the supine approach:
- Place towels under the ipsilateral (left) shoulder and gluteus to elevate the flank approximately 30 degrees
- Position the left arm over the thorax
- Flex the ipsilateral leg slightly
- In supine position, the colon falls anteromedially away from puncture paths, whereas in prone position it is pushed against the lateral kidney surface
Imaging Guidance Protocol
Use ultrasound for initial renal access, then switch to fluoroscopy for wire and catheter placement 1. This dual-modality approach is the current standard:
- Ultrasound identifies the collecting system and guides needle puncture
- Fluoroscopy confirms wire position and facilitates catheter advancement
- CT or MRI guidance may be used in special circumstances
Access Technique
Target a posterior lower-pole or mid-pole calyx to minimize vascular injury and facilitate subsequent procedures 1. The Seldinger technique is preferred:
- Puncture the collecting system under ultrasound guidance
- Advance a guidewire through the needle into the renal pelvis (confirmed fluoroscopically)
- Dilate the tract over the wire
- Place the drainage catheter (typically 8-12 French)
Critical Technical Points
- Avoid upper-pole calyceal puncture when possible - this increases pneumothorax risk from 1% to higher rates due to intercostal approach 1
- Access nondilated systems has 80-90% technical success versus >95% for dilated systems 1
- The procedure can be performed under local anesthesia without general anesthesia 3, 4
Expected Outcomes
Technical success rates approach 100% in dilated collecting systems per large UK registry data of over 3,000 procedures 1. Society of Interventional Radiology quality improvement thresholds:
- 95% success for urinary obstruction without stones
- 80% success for nondilated collecting systems
- 85% success for complex stone disease 1
Complication Monitoring
Overall complication rates are low at 6.3-10%, with most being minor 1. Watch for:
- Bleeding: Mild hematuria occurs in ~50% (expected and benign); clinically significant bleeding requiring transfusion should remain <4% 1
- Sepsis: Risk is 4% overall, 10% in pyonephrosis 1
- Vascular injury requiring embolization: <1% 1
- Pneumothorax: 1% overall, higher with intercostal approaches 1
- Bowel injury: <1% 1
Key Risk Factors
Thrombocytopenia increases bleeding risk; diabetes and renal calculi are associated with sepsis but not predictive 1
Post-Placement Options
The catheter permits either:
- External drainage (standard PCN)
- Internal/external drainage (percutaneous nephroureteral catheter - PCNU) with longer catheter extending through ureter 1
Most patients can subsequently undergo ureteral stent placement via the nephrostomy tract if needed 1