Management of Partially Pulled Out Nephrostomy Tube
If a nephrostomy tube is partially dislodged, immediate medical attention is required—the patient should proceed to the emergency department promptly for evaluation, and the tube should either be repositioned or replaced to prevent loss of renal drainage and potential complications. 1
Immediate Assessment and Stabilization
Upon presentation, perform the following critical evaluations:
- Cover the site with a clean, sterile dressing to minimize contamination risk 1
- Assess for signs of infection including fever, flank pain, or purulent drainage from the nephrostomy site 2, 1
- Evaluate for significant bleeding from the site, though mild hematuria is common and expected 2, 3
- Determine the timing of dislodgement, as this critically affects management approach—tubes dislodged >24 hours ago likely have begun tract closure 1
- Monitor urine output to assess whether the tube is still providing adequate drainage 3
Imaging and Diagnostic Workup
- Obtain ultrasound as first-line imaging to assess for hydronephrosis, which indicates inadequate drainage or obstruction 3
- Consider CT urography for comprehensive evaluation if the clinical situation is complex or ultrasound findings are equivocal 3
- Check serum creatinine to evaluate for worsening renal function from inadequate drainage 3
Management Algorithm Based on Timing and Tube Position
If Tube is Partially Out but Still Draining (Early Presentation <24 hours):
- Attempt gentle repositioning under fluoroscopic guidance if the tube remains partially within the tract 4
- Do not remove the tube completely if it is still providing some drainage—maintain access while arranging definitive management 4
- Place a "safety" wire through the existing tube before any manipulation to maintain access to the collecting system 4
If Tube is Non-Functional or Presentation is Delayed (>24 hours):
- The tract has likely begun to close, requiring new percutaneous access 1
- Perform imaging (ultrasound or CT) to assess for hydronephrosis and guide replacement strategy 1
- Attempt retrograde ureteral stent placement as the preferred initial approach if the underlying condition allows 1
- If retrograde stenting fails and the kidney remains obstructed, a new percutaneous nephrostomy tube must be placed 1
Critical Management Principles
- Never lose access to an obstructed kidney once it has been punctured—always maintain a safety wire during complex manipulations 4
- Ensure adequate urinary drainage before removing any partially dislodged tube to prevent urine leak and infection 4
- Administer appropriate antibiotics if there is any concern for infection or if the tract has been contaminated 4
- In unstable patients with complete ureteral obstruction, prompt nephrostomy tube replacement is critical to prevent further renal damage 1
Monitoring for Complications
- Infection: Monitor for fever, increased pain, or purulent drainage requiring antibiotics and possible drainage 1, 3
- Bleeding: Some hematuria is common after manipulation, but persistent or severe bleeding requires further evaluation and possible angiography with selective embolization 3, 4
- Obstruction: Decreased or absent urine output with flank pain indicates inadequate drainage requiring urgent intervention 3
- Sepsis: In infected, obstructed systems, avoid prolonged or complicated procedures and ensure prompt drainage 4
Common Pitfalls to Avoid
- Do not attempt to forcibly reinsert a tube through a closing tract without imaging guidance, as this risks creating a false passage 4
- Do not panic if bleeding occurs—most can be managed with tract tamponade using a balloon catheter or appropriate-sized nephrostomy tube 4
- Do not delay intervention in patients with signs of obstruction or infection, as this can lead to irreversible renal damage or sepsis 1, 5
- Avoid overdistention of the collecting system during any manipulation, as this increases risk of sepsis and retroperitoneal contamination 4