Percutaneous nephrostomy utilizing B‐mode and real‐time ultrasound guidance: The lateral approach and puncture facilitation with furosemide

Abstract

Percutaneous nephrostomy is becoming a wellestablished technique for permanent or temporary urinary diversion. la2 The procedure is usually accomplished by a posterior approach under fluoroscopic guidance after contrast injection. However, in the interest of patient comfort and ease of catheter management, we elect to puncture obstructed urinary systems using a lateral (or near-lateral) approach under ultrasound guidance. This approach is not commonly used in this country, as several structures (bowel, liver, etc.) are to be avoided, but with ultrasound guidance the safe passage of the catheter is relatively assured. The following is our initial experience with this technique using B-mode and real-time ultrasound guidance and furosemide (Lasix) augmentation of renal pelvic size, when appropriate. MATERIALS AND METHODSing bowel gas from the lateral soft tissues and kidney parenchyma. The transducer was angled cephalad from a more caudad position to avoid the liver in the appropriate setting. No specific attempt was made to avoid the peritoneum; however, as much kidney parenchyma as possible was included in the path to the pelvicaliceal system to provide catheter stability and support. The system was then punctured with a n 18-gauge, Teflon-sheathed needle to a depth indicated by caliper measurements from the B-mode image. The progress and final position of the needle tip were followed and documented, when necessary, with a linear array real-time transducer positioned posteriorly on the flank (Fig 1). After successful cannulation, the needle was removed (leaving the soft sheath in place) and the patients were transferred to Special Procedures Radiology for placement of a pigtailed catheter (Cook, Inc.) under fluoroscopic guidance.A 20-mg intravenous (IV) bolus of furosemide Ten patients were referred for 13 nephrostomy tube placements to the Division of Ultrasound and Special Procedures Radiology. The patients were examined in the prone position whenever possible and Foley catheter (if present) clamped. The was given prior to five punctures in order to provide sufficient pelvicaliceal dilatation for safe ultrasound guidance and catheter placement.pelvicaliceal system was located during full in-COMPLICATIONS AND FOLLOW-UP spiration with longitudinal scanning that commenced in the midaxillary line and progressed posteriorly when necessary to exclude intervenNo immediate complications were encountered during any of the puctures. However, self-limited macroscopic bleeding was noted in the urine of one patient, who required four passes of the nee-