What are the indications for nephrostomy (percutaneous nephrostomy tube) placement?

Indications for Percutaneous Nephrostomy Tube Placement

Percutaneous nephrostomy (PCN) is primarily indicated for urinary tract obstruction complicated by infection or sepsis, where it can reduce mortality from gram-negative septicemia from 40% to 8% and should be considered the first-line intervention in these cases. 1

Primary Indications

Urgent/Emergency Indications

• Obstructive uropathy with infection/pyonephrosis

  • Reduces septic shock rates to <4% in standard cases and <10% in pyonephrosis 1
  • Provides immediate decompression in urosepsis, which is a medical emergency 2

• Urinary tract obstruction with renal dysfunction

  • Allows for restoration of renal function in acute obstruction
  • Can be used to predict recoverable renal function in longstanding obstruction 3

• Failed retrograde ureteral stenting

  • PCN has 100% technical success rate compared to 80% for retrograde stenting in obstructive stone disease 1

Non-Emergency Indications

• Malignant ureteral obstruction

  • Particularly for advanced cervical or colorectal cancers 1
  • Higher technical success rate than retrograde stenting for extrinsic compression, obstruction involving the uretero-vesical junction, or ureteral obstruction >3 cm 1

• Urinary diversion before definitive treatment

  • Temporary diversion before surgical intervention for stones, strictures, or other obstructions 1
  • Access route for percutaneous nephrolithotomy or other endourologic procedures 1

• Urinary fistula management

  • Serves as access point for placement of stent catheters to treat fistulas 3

• Ureteral stricture treatment

  • Access for bougie catheters to dilate strictures 3
  • Pathway for antegrade ureteral stent placement 1

Special Populations

Pregnancy

• Indicated in pregnant patients with hydronephrosis, infection, and flank pain unresponsive to conservative management 1
• PCN followed by delayed definitive intervention after delivery is the preferred approach 1

Advanced Malignancy

• Consider patient's prognosis and quality of life before placement
• Most beneficial in patients with reasonable treatment options for their malignancy 1
• May offer little benefit in patients with advanced disease for whom only palliative treatment is planned 1

Technical Considerations

• Success rates:

  • Nearly 100% for dilated systems
  • 80-90% for non-dilated systems 4

• Approach:

  • Most operators use ultrasound for initial access followed by fluoroscopy for tube placement 1
  • Real-time ultrasound guidance alone can achieve 98.5% success rate 5

• Timing for conversion to internal drainage:

  • Allow 1-2 weeks for tract maturation before conversion to retrograde nephrostomy 4

Complications and Prevention

• Overall complication rate: 6-10% 1, 4

• Major complications:

  • Bleeding requiring transfusion: <4% 1
  • Septic shock: <4% (up to 10% in pyonephrosis) 1
  • Vascular injury requiring embolization: <1% 1
  • Bowel injury: <1% 1
  • Pleural complications: <1% 1

• Prevention:

  • Prophylactic antibiotics targeting uropathogens (not just skin flora) for high-risk patients 1
  • Regular assessment of continued need for the device 1
  • Infection rates increase with duration of catheter placement (14% overall with median time to infection of 44 days) 1

Contraindications

• Uncorrected coagulopathy
• Lack of safe percutaneous access route
• Patients with end-stage disease where intervention would not improve quality of life 1

PCN remains a critical intervention in urologic care despite advances in endourologic techniques, with its primary value in emergent decompression of infected obstructed systems and as an alternative when retrograde approaches fail.