What are the guidelines for inserting and managing a nephrostomy tube?

Nephrostomy Tube Insertion and Management Guidelines

Indications for Nephrostomy Tube Placement

Percutaneous nephrostomy (PCN) is indicated for urinary obstruction with declining renal function or pyonephrosis, and should be performed with image guidance to achieve technical success rates approaching 100%. 1

• PCN is beneficial when there is evidence of declining renal function or pyonephrosis in obstructive uropathy 1
• The Society of Interventional Radiology sets technical success thresholds at 95% for urinary obstruction without stones and 80% for nondilated collecting systems 1
• For complex stone disease including staghorn calculus, the minimal threshold is 85% 1
• PCN can be performed safely as an outpatient procedure in selected low-risk patients with same-day discharge 1

Insertion Technique and Image Guidance

Use ultrasound for initial access followed by fluoroscopy for nephrostomy tube placement, as this approach achieves optimal visualization while minimizing radiation exposure. 1, 2

• Most operators use ultrasound for initial access and then fluoroscopy to place the nephrostomy tube 1
• CT guidance is a reliable alternative that involves no radiation exposure for the interventional radiologist, with procedure times ranging from 9-26 minutes 2, 3
• CT-guided PCN is particularly preferable in patients with minimal or no dilatation of the renal pelvis 3
• MRI can be used in special circumstances 1

Complication Rates and Management

Overall complication rates for PCN are low at approximately 6-10%, with most complications being minor and manageable without surgical intervention. 1, 4

Major Complications (with SIR Quality Improvement Thresholds):

• Septic shock: 4% threshold (10% in pyonephrosis) 1
• Hemorrhage requiring transfusion: 4% threshold 1
• Vascular injury requiring embolization or nephrectomy: 1% threshold 1
• Bowel injury: <1% threshold 1
• Pleural complications (pneumothorax, empyema, hemothorax): 1% threshold 1

Minor Complications:

• Mild hematuria occurs in approximately 50% of patients after PCN and is clinically asymptomatic 1
• Catheter displacement, bleeding, and sepsis are the most common adverse events 1
• Delayed complications (>24 hours) include dislodgement (11%), occlusion (6%), and peritubular leakage (1%) 4

Risk Factors and Prevention:

• Thrombocytopenia increases bleeding risk 1
• Pneumothorax is more common with upper-pole calyceal puncture 1
• Persistent bleeding should prompt arteriographic evaluation for pseudoaneurysms, fistulas, or extravasation, which can usually be treated with transcatheter embolization 1

Specific Clinical Scenarios

Trauma Setting:

In damage control situations where immediate repair is not possible, perform ureteral ligation with percutaneous nephrostomy tube placement followed by delayed definitive reconstruction. 1

• When incomplete ureteral injuries are diagnosed postoperatively, attempt retrograde ureteral stent placement first 1
• If stent placement is unsuccessful or not possible, perform percutaneous nephrostomy with delayed repair as needed 1
• For endoscopic ureteral injuries, manage with a ureteral stent and/or percutaneous nephrostomy tube when possible 1

Post-Removal Care:

After nephrostomy tube removal, frequent urination is normal as the urinary system adjusts, with complete healing of the tract typically occurring within 1-2 weeks. 5

• Monitor the nephrostomy site for proper healing; keep it clean and covered with a sterile dressing until fully closed 5
• Avoid strenuous activities for 1-2 weeks after tube removal 5
• Mild hematuria is common in approximately 50% of patients and can persist briefly after tube removal 5

Red Flags Requiring Immediate Evaluation:

• Fever, flank pain, or purulent drainage from the nephrostomy site indicating infection 5
• Severe or persistent hematuria beyond the expected timeframe 5
• Complete absence of urination suggesting obstruction 5

Accidental Tube Removal Management

Immediate assessment of clinical parameters is essential to determine if tube replacement is necessary, with urgent replacement indicated for active infection with obstruction, bilateral obstruction, or solitary kidney with obstruction. 6

Patients Who May NOT Require Replacement:

• No evidence of infection 6
• Stable or improving renal function 6
• Adequate urine output 6
• Unilateral obstruction with functioning contralateral kidney 6

Patients Requiring Urgent Replacement:

• Active infection with obstruction 6
• Bilateral obstruction 6
• Solitary kidney with obstruction 6
• Declining renal function 6
• Malignant obstruction 6

Imaging and Intervention:

• Use ultrasound as first-line imaging to assess hydronephrosis, followed by CT if inconclusive 6
• Percutaneous nephrostomy replacement has technical success rates approaching 100% 6
• Retrograde ureteral stenting is an alternative option for immediate intervention 6

Common Pitfalls to Avoid

• Do not assume asymptomatic bacteriuria requires treatment in well-appearing patients with nephrostomy tubes 7
• Do not ignore prolonged hematuria or return of hematuria after previous resolution, as this may indicate hematoma formation or delayed vascular injury 7
• Do not attempt subclavian access in hemodialysis patients or those with advanced kidney disease to avoid subclavian vein stenosis 1
• Do not delay specialty consultation when serious complications including dislodgement, obstruction, infection, or bleeding are suspected, particularly in immunocompromised patients 7