Can a patient retain nephrostomy (percutaneous catheter) tubes?

From the Guidelines

Nephrostomy tubes should not be kept permanently, as they are typically intended for short-term use until the underlying problem can be resolved. These tubes are placed through the skin into the kidney to drain urine when there is a blockage in the normal urinary pathway. According to a recent study published in 2023, the infection rate for percutaneous nephrostomy tubes (PCNTs) was found to be 14%, with an infection incidence of 2.65 per 1000 patient-days 1. This highlights the importance of regularly reassessing the need for these devices and removing them when possible to prevent infections.

Key Considerations for Nephrostomy Tube Management

• Patients must have their nephrostomy tubes regularly changed every 2-3 months in a hospital setting to prevent complications such as infection, blockage, or encrustation.
• Long-term management requires professional medical supervision, as these tubes need proper care including daily cleaning around the insertion site with soap and water, monitoring for signs of infection (redness, swelling, discharge, fever), and ensuring the drainage bag is positioned below kidney level.
• While some patients may require nephrostomy tubes for extended periods due to chronic conditions or when surgery isn't possible, this is considered management rather than a permanent solution.
• The goal of treatment is typically to address the underlying cause and eventually remove the tube when possible, as supported by guidelines for the prevention, diagnosis, and management of urinary tract infections 1.

Preventing Infections and Complications

• The use of preprocedural antimicrobials with these clean–contaminated procedures is indicated for elective PCNT and ureteral stent placement and exchange 1.
• Postprocedural preventive strategies, including maintaining a clean exit site area with antiseptic use, regular dressing exchange, and placement of a closed urinary drainage collection bag under the PCNT insertion site, may help decrease the rate of infection 1.
• Concomitant use of Foley catheters with PCNT and ureteral stents should be avoided when feasible, and surveillance urinary cultures and giving treatment to asymptomatic patients should be discouraged to avoid development of infections with multidrug-resistant organisms and inappropriate use of antimicrobials 1.

From the Research

Nephrostomy Tube Placement

• The decision to keep a nephrostomy tube after percutaneous nephrolithotomy (PCNL) depends on various factors, including the patient's condition, stone size, and surgeon's preference 2, 3, 4, 5, 6.
• Studies have shown that nephrostomy tube-free PCNL is a safe and effective procedure for selected patients with minimal hemorrhage after PCNL 3, 4, 5.
• The use of a small-bore nephrostomy tube (≤ 18 Fr) may be associated with a higher rate of hemoglobin reduction and overall complications compared to large-bore tubes (> 18 Fr) 6.
• However, the size of the nephrostomy tube may not affect the stone-free rate or urinary leakage rate 6.

Patient Considerations

• Patients with chronic kidney disease or those who require a supracostal approach may not be suitable for a tubeless approach 5.
• The presence of infection stones or difficult anatomy may require the placement of a larger nephrostomy tube, such as a 20F reentry Malecot catheter or a 20F circle loop 2.
• Patient comfort and postoperative pain should also be considered when deciding on nephrostomy tube placement and size 2, 4, 5.

Surgical Considerations

• The surgeon's experience and preference play a significant role in determining the type and size of nephrostomy tube to be used 2, 6.
• The use of cauterization to control bleeding points in the access tract may make nephrostomy tube-free PCNL a more secure procedure 3.
• The placement of a nephrostomy tube should be individualized based on the patient's specific needs and the surgeon's assessment of the situation 2, 4, 5, 6.