What are the interventions for a dislodged nephrostomy tube?

Management of Dislodged Nephrostomy Tubes

Immediate re-insertion of the nephrostomy tube through the existing tract is the primary intervention for a dislodged nephrostomy tube, ideally within 24-48 hours of dislodgement to prevent tract closure. 1

Initial Assessment

• Evaluate the timing of dislodgement:

  • Recent dislodgement (within 24-48 hours): Higher chance of successful reinsertion through existing tract
  • Delayed presentation (>48 hours): May require creation of a new tract

• Assess the maturity of the nephrostomy tract:

  • Mature tract (>1-2 weeks old): More likely to remain patent for reinsertion
  • Immature tract (<1-2 weeks): Higher risk of tract closure requiring new access

• Evaluate for complications:

  • Hydronephrosis: Indicates urgent need for reintervention
  • Signs of infection/sepsis: May require antibiotics and urgent drainage
  • Hematoma or urinoma formation: May need additional interventions

Imaging Guidance

• CT scan is the preferred imaging modality for detailed evaluation of:

  • Degree of hydronephrosis
  • Status of nephrostomy tract
  • Presence of urinoma or hematoma
  • Alternative access routes if needed 1

• Ultrasound is useful as first-line imaging to:

  • Assess for hydronephrosis
  • Guide initial access during reinsertion
  • Confirm tube position after replacement 1

Interventional Approach

For Recent Dislodgement (Tract Still Patent)

1. Attempt reinsertion through existing tract:

   • Use ultrasound and fluoroscopic guidance
   • Insert a guidewire through the existing tract
   • Place new nephrostomy tube over the guidewire

2. If reinsertion fails but tract is still identifiable:

   • Consider placement of a smaller caliber tube initially
   • Upsize after 1-2 days once tract is secured

For Delayed Presentation (Tract Closed)

1. Create new nephrostomy access:

   • Use combined ultrasound and fluoroscopic guidance
   • Technical success rates approach 100% for dilated systems and 80-90% for non-dilated systems 1

2. Consider alternative drainage options:

   • Retrograde ureteral stenting if anatomically feasible (technical success rate of 80% compared to 100% for PCN) 1
   • May be preferred in cases where percutaneous access is difficult

Catheter Selection for Replacement

• Foley-type nephrostomy tubes have significantly lower rates of dislodgement compared to pigtail catheters:

  • Mean time to dislodgement: 60.9 days for Foley vs. 20.3 days for pigtail catheters 2
  • Consider Foley-type tubes for patients with history of dislodgement

• Factors affecting dislodgement risk:

  • First-time nephrostomy placement has higher risk of dislodgement (OR 1.95) 2
  • Tubes placed by less experienced operators have higher dislodgement rates (OR 3.39) 2

Prevention of Future Dislodgement

• Secure catheter with both suture and adhesive dressing
• Consider larger retention mechanism (balloon or pigtail) for long-term tubes
• Patient education on tube care and movement restrictions
• Regular follow-up to assess tube position and function

Special Considerations

• Encrusted nephrostomy tubes: Use a vascular sheath technique for safe removal to prevent tract damage 3
• Pediatric patients: Percutaneous nephrostomy is feasible even in infants with high success rates and minimal complications 4
• Malignant obstruction cases: Overall dislodgement rate of 14.4%, with lower rates when using one-step technique for grade IV hydronephrosis 5

Complications to Monitor

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

Persistent bleeding should prompt consideration of arteriographic evaluation for vascular injuries, which may require transcatheter embolization 6.