Percutaneous Nephrostomy with Extensions of the Technique: Step by Step

Abstract

Minimally invasive therapy in the urinary tract begins with renal access by means of percutaneous nephrostomy. Indications for percutaneous nephrostomy include urinary diversion, treatment of nephrolithiasis and complex urinary tract infections, ureteral intervention, and ne phroscopy and ureteroscopy. Bleeding complications can be minimized by entering the kidney in a relatively avascular zone created by branch ing of the renal artery. The specific site of renal entry is dictated by the indication for access with consideration of the anatomic constraints. Successful percutaneous nephrostomy requires visualization of the col lecting system for selection of an appropriate entry site. The definitive entry site is then selected; ideally, the entry site should be subcostal and lateral to the paraspinous musculature. Small-bore nephrostomy tracks can be created over a guide wire coiled in the renal pelvis. A large-diameter track may be necessary for percutaneous stone therapy, nephroscopy, or antegrade ureteroscopy. The most common extension of percutaneous nephrostomy is placement of a ureteral stent for treat ment of obstruction. Transient hematuria occurs in virtually every pa tient after percutaneous nephrostomy, but severe bleeding that requires transfusion or intervention is uncommon. In patients with an ob structed urinary tract complicated by infection, extensive manipula tions pose a risk of septic complications.

Percutaneous Nephrostomy

“…Injury to the first order segmental renal arteries may occur in the region of the renal pelvis, particularly if the puncture is made too medially. To prevent vascular injury and bleeding complications, the safest approach has been described by approaching the cusp of the papilla as far peripherally as possible, and by entering the kidney via the Brodel's line (Dyer, Regan et al 2002). Brodel's line is a zone of relative avascularity and watershed territory, which is located just posterior to the lateral convex margin of the kidney, between the major anterior and posterior divisions of the renal artery.…”

“…A lower pole posterior calyx for instance, would be best used for simple urinary drainage (Dyer, Regan et al 2002), while those of the upper and middle poles provide better access to the renal pelvis and ureter, especially if ureteral interventions are being considered. A puncture posterior to a calculus may assist in the treatment of calculus disease.…”

“…(Dyer, Regan et al 2002). Prolonged hematuria should alert the physician to the possibility of persistent bleeding from vascular injury.…”

“…A number of published case series have reported major bleeding following percutaneous nephrostomy or percutaneous nephrolithotomy, and this occurs in the range of 1-4% (Lee, Smith et al 1987;von der Recke, Nielsen et al 1994;Dyer, Regan et al 2002;Ramchandani, Cardella et al 2003). This may manifest in prolonged hematuria, hemodynamic instability and perirenal hematomas.…”

“…Pleural complications such as pneumo-, hydro-, or hemothorax and empyema are uncommon but have been known to occur from percutaneous nephrostomy, with a reported rate of 0.1-0.3% (Dyer, Regan et al 2002;Ramchandani, Cardella et al 2003). The risk of pneumo-and hydrothorax is reported to be in the range of 4-12% if a supracostal approach is used for puncture of the renal upper pole (Carey, Siddiq et al 2006), although this may be difficult to avoid if it provides the best access to the collecting system.…”