Overview
Definition:
Nephrostomy tube placement is a medical procedure to create an artificial opening through the skin into the renal pelvis or calyx to drain urine
It is typically performed percutaneously under fluoroscopic or ultrasound guidance
Perioperative care encompasses the management of the patient before, during, and immediately after the procedure to optimize outcomes and minimize complications.
Epidemiology:
The incidence of nephrostomy tube placement varies based on the indications, which include malignant or benign ureteral obstruction, infection, trauma, and as an adjunct to other urological procedures
It is a common interventional radiology and urological procedure performed across diverse patient populations.
Clinical Significance:
Effective perioperative care for nephrostomy tube placement is crucial for preventing serious complications such as bleeding, infection, urine extravasation, and pain
Optimal management ensures adequate urine drainage, preserves renal function, and facilitates patient recovery, impacting the overall success of the intervention and patient well-being.
Indications And Contraindications
Indications:
Complete or partial ureteral obstruction from stone, stricture, or malignancy
Pyonephrosis requiring drainage
Renal transplant allograft dysfunction
Urinary diversion
Facilitation of other urological procedures, e.g., ureteroscopy or lithotripsy.
Contraindications:
Uncorrected coagulopathy
Severe systemic infection not amenable to rapid control
Lack of suitable renal access route
Patient refusal or inability to cooperate with post-procedure care.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on renal function, coagulopathy, allergies, and previous abdominal surgeries
Assessment of hydration status and electrolyte balance.
Laboratory Investigations:
Complete blood count (CBC) to assess hemoglobin and platelet count
Coagulation profile (PT/INR, PTT) to assess hemostatic function
Serum creatinine and urea to assess renal function
Urine culture and sensitivity to identify potential pathogens and guide antibiotic prophylaxis.
Imaging Studies:
Renal ultrasound to visualize pelvicalyceal anatomy and identify hydronephrosis
CT scan or MRI may be used to delineate the extent of obstruction and identify adjacent structures.
Medications:
Discontinuation of anticoagulants and antiplatelet agents as per established protocols
Prophylactic antibiotics, typically a broad-spectrum cephalosporin or fluoroquinolone, administered 30-60 minutes prior to the procedure
Adequate hydration to optimize renal perfusion.
Patient Education:
Explanation of the procedure, potential risks and benefits, and post-procedure expectations
Informed consent obtained after addressing all patient concerns.
Perioperative Management During Procedure
Anesthesia And Sedation:
Local anesthesia is often sufficient for percutaneous access
Sedation (e.g., midazolam, fentanyl) may be administered for patient comfort, especially in longer procedures or anxious patients
General anesthesia may be required for specific complex cases or pediatric patients.
Imaging Guidance:
Real-time fluoroscopic or ultrasound guidance is essential for accurate needle placement and guidewire manipulation
Contrast medium is used to opacify the collecting system and delineate anatomy.
Technique Overview:
A skin incision is made over the chosen calyx
A needle is advanced into the collecting system under imaging guidance
A guidewire is then advanced through the needle into the renal pelvis and down the ureter if possible
The tract is dilated, and the nephrostomy tube (e.g., Malecot, pigtail) is inserted over a dilator or the guidewire.
Monitoring:
Continuous monitoring of vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) throughout the procedure
Regular assessment for signs of bleeding or discomfort.
Postoperative Care And Monitoring
Immediate Postoperative Phase:
Close monitoring of vital signs for hemodynamic stability
Assessment for pain and provision of analgesia
Observation of the nephrostomy tube drainage for color, volume, and presence of blood clots
Ensuring the tube is secured adequately to prevent dislodgement.
Pain Management:
Administering appropriate analgesics (e.g., NSAIDs, opioids) as needed for post-procedure pain
Positioning the patient for comfort.
Fluid Management:
Maintaining adequate hydration to ensure good urine output and prevent dehydration
Intravenous fluids may be administered as required.
Infection Control:
Monitoring for signs and symptoms of urinary tract infection (fever, chills, flank pain, purulent drainage)
Administering appropriate antibiotics if infection is suspected or confirmed by urine culture.
Tube Care And Drainage:
Regularly checking the drainage bag and tubing for patency and output
Gentle irrigation of the tube with sterile saline may be performed if there is suspicion of obstruction, following established protocols
Ensuring aseptic technique during tube manipulation or dressing changes.
Complications And Management
Early Complications:
Bleeding: Minor hematuria is common
significant bleeding may require transfusion or interventional embolization
Infection (urosepsis): Monitor for systemic signs
treat with antibiotics and potentially tube repositioning or drainage
Urine extravasation: Can occur if tract is not adequately sealed or tube dislodges
managed by tube repositioning or drainage
Pain: Managed with analgesics
Damage to adjacent organs: Rare, but possible with misplaced needle.
Late Complications:
Tube dislodgement: Requires prompt reinsertion
Tube blockage: Due to clots or encrustation
managed by irrigation or tube exchange
Nephrolithiasis: Formation of stones around the tube
Fistula formation: Persistent urine leakage after tube removal
Stenosis of the nephrostomy tract.
Prevention Strategies:
Meticulous technique during placement
Adequate anticoagulation reversal
Prompt recognition and management of coagulopathy
Appropriate antibiotic prophylaxis
Careful tube selection and secure fixation
Patient education on activity restrictions and signs of complications
Regular monitoring of tube patency and drainage.
Key Points
Exam Focus:
Understanding indications for nephrostomy
Key steps in percutaneous placement
Management of common complications like bleeding and infection
Importance of prophylactic antibiotics and anticoagulation reversal
Post-operative monitoring parameters.
Clinical Pearls:
Always confirm adequate anticoagulation reversal prior to procedure
Use a curved tip guidewire for easier navigation of the pelvicalyceal system
Secure the tube meticulously to prevent accidental dislodgement
Educate patients to report any fever, chills, or significant flank pain immediately
Regular urine output monitoring is critical for assessing renal function and tube patency.
Common Mistakes:
Inadequate pre-procedure assessment of coagulopathy
Aggressive manipulation of guidewire leading to injury
Poor tube fixation resulting in dislodgement
Failure to administer prophylactic antibiotics
Delay in recognizing and managing complications like sepsis or significant bleeding.