When should a nephrostomy (percutaneous nephrostomy) tube be considered?

Indications for Nephrostomy Tube Placement

Percutaneous nephrostomy (PCN) should be considered in cases of urinary tract obstruction with evidence of declining renal function, pyonephrosis, or sepsis, as it provides rapid and effective decompression of the collecting system with technical success rates approaching 100% in dilated systems. 1

Primary Indications for Nephrostomy Tube Placement

Urgent/Emergent Indications

• Obstructive pyelonephritis/pyonephrosis with sepsis

  • Patients presenting with fever, leukocytosis, flank pain, and signs of sepsis require immediate decompression 1
  • PCN is lifesaving in these cases and should not be delayed
  • Serum C-reactive protein may help guide urgency of placement 1

• Acute renal failure due to obstruction

  • Significant elevation in serum creatinine with hydronephrosis
  • Recent data shows statistically significant improvement in renal function after PCN placement 2

Non-Emergent Indications

• Malignant ureteral obstruction

  • Most beneficial when:
    • Obstruction is due to untreated primary malignancy 3
    • Obstruction is from relapsed disease with viable treatment options 3
    • Obstruction is caused by non-malignant complications of previous surgery/radiation 3
  • Not recommended when:
    • Patient has relapsed disease with no conventional treatment options (median survival only 38 days) 3

• Post-urinary diversion obstruction

  • When loopogram shows no reflux into distal ureters suggesting inherent stricture 1
  • When retrograde access is difficult due to altered anatomy 1

• Stone disease

  • To provide temporary drainage before definitive treatment
  • As access for percutaneous nephrolithotomy for large stones (>20mm) 4
  • When infection with obstruction is present (mandatory before attempting stone removal) 4

Technical Considerations

Success Rates and Approach

• Technical success rates:
  • 95-100% for dilated collecting systems 1
  • 80-90% for non-dilated systems 1
  • Most operators use ultrasound for initial access followed by fluoroscopy 1

Complications

• Overall complication rate: 6.3-10% 1
• Common complications:
  • Catheter displacement
  • Bleeding (mild hematuria in ~50% of patients)
  • Sepsis
  • Risk factors for post-procedural sepsis include diabetes and renal calculi 1

Special Considerations

Malignant Obstruction

• Strict selection criteria should be applied:
  • Evaluate if there are viable treatment options for the underlying malignancy
  • Consider patient's overall prognosis and quality of life
  • PCN may improve quality of life and allow patients to return home 5
  • Unilateral PCN may be sufficient in many cases 5

Alternative Options

• Retrograde ureteral stenting should be considered first when feasible
• Subcutaneous ureteral bypass may be an alternative to permanent nephrostomy in select patients with malignant ureteral obstruction 6
• Percutaneous nephroureteral catheters (PCNU) for internal drainage through the ureter and bladder 1

Follow-up Management

• Regular monitoring of renal function
• Catheter exchanges typically every 2-3 months
• Assessment for long-term complications and functionality 2

Contraindications

• Uncorrected coagulopathy
• Lack of safe percutaneous access
• Terminal illness with very short life expectancy and no viable treatment options 3

PCN is a well-established and effective procedure for urinary tract decompression with high technical success rates. Patient selection is crucial, particularly in malignant obstruction, where the presence of viable treatment options significantly impacts outcomes.