Nephrostomy Tubes Are NOT Standard When Ureteral Stents Are Successfully Placed
No, it is not standard practice to place nephrostomy tubes when ureteral stents are successfully placed. These are alternative drainage methods, not complementary procedures, and the choice between them depends on clinical circumstances and technical feasibility.
Standard Approach: Stents vs Nephrostomy Tubes
Primary Drainage Strategy
Ureteral stents and nephrostomy tubes serve as alternative methods for urinary drainage, not concurrent procedures 1.
In the majority of cases, a ureteral stent can be placed either via the bladder (retrograde) or via the kidney (antegrade), and this is typically the preferred approach when technically feasible 1.
Nephrostomy tubes are reserved for situations where ureteral stenting fails or is not possible 1, 2.
When Nephrostomy Is Used Instead of Stenting
Percutaneous nephrostomy should be performed when stent placement is unsuccessful or not possible 1, 2.
Specific scenarios requiring nephrostomy include:
- Complete ureteral transection where the proximal ureter cannot be cannulated in a retrograde fashion 1
- Patient instability that precludes attempts at retrograde stent placement 1
- Failed retrograde ureteral access despite multiple attempts 2
- Damage control situations where immediate repair is not feasible, requiring temporary ureteral ligation with nephrostomy placement followed by delayed reconstruction 1, 2
Special Circumstances: Combined or Sequential Approaches
Antegrade Stenting After Initial Nephrostomy
In some cases, nephrostomy is placed first, and then a ureteral stent is subsequently placed through the nephrostomy tract (antegrade approach) 1.
"Rendez-vous" techniques or even one-step antegrade stent placement (without leaving the nephrostomy as a safety measure) can yield successful alternative approaches 1.
This sequential approach is used when retrograde access is not possible, such as with large impacted upper ureteral stones, after urinary diversion, or when retrograde access has failed 2.
When Both May Be Temporarily Present
If nephrostomy alone does not adequately control a urine leak after ureteral injury, options include placement of a periureteral drain or immediate open repair—not routine dual drainage 1.
In malignant obstruction cases where single stents fail, placement of two parallel ipsilateral ureteral stents may obviate the need for nephrostomy tube placement 3.
Clinical Decision-Making Algorithm
For Ureteral Obstruction Management
- First-line approach: Attempt retrograde ureteral stent placement 2, 4
- If retrograde stenting fails: Place percutaneous nephrostomy 1, 2
- After nephrostomy placement: Consider subsequent antegrade stent placement if appropriate 1
- Remove nephrostomy once stent is functioning: The nephrostomy is not maintained alongside a functioning stent 1
For Ureteral Trauma
- Incomplete injuries: Attempt stent placement first; if unsuccessful, proceed to nephrostomy with delayed repair 1, 2
- Complete transections requiring repair: Primary repair over a ureteral stent (not with concurrent nephrostomy) 1, 2
- Damage control scenarios: Ureteral ligation with nephrostomy, followed by delayed definitive repair with stenting 1, 2
Common Pitfalls to Avoid
Do not routinely place nephrostomy tubes alongside successfully functioning ureteral stents—this adds unnecessary morbidity and external drainage burden 1.
Do not persist with failed retrograde stenting attempts when nephrostomy is clearly indicated—this delays appropriate drainage and risks complications 1, 2.
Failing to recognize that in malignant obstruction, internal ureteral stents have a higher failure rate (11%) compared to nephrostomy tubes (1.3%), requiring closer monitoring for ongoing obstruction 4.
Underestimating that nephrostomy tubes have their own complications, including a 6-15% complication rate and frequent need for rehospitalization, making successful stenting preferable when feasible 1, 4, 5.