Nephrostomy

Nephrostomy Insertion of a catheter through the skin into the renal pelvis to bypass ureteral obstruction and facilitate urine drainage. 

In a 6-year-old boy, 10 ml of a 2% solution given for bilateral percutaneous nephrostomy produced a degree of cyanosis that demanded methylthioninium chloride treatment (13). 

Treatment of sulfadiazine nephrotoxicity consists in stopping sulfadiazine or decreasing its dosage. The acute kidney injury, however, may resolve despite continuation of the treatment [41]. Hydration and especially alkalinization are the basis for the treatment. Urinary tract obstruction may require placement of ureteral stents [13] or nephrostomy [33]. This complication is essentially reversible and dialysis is rarely needed [27]. 

Fig. 3 IVP after operations for stone removal and loop nephrostomies.

Solomon et al. (2002) used the PAKY robotic system in 16 patients during CT-guided procedures. The accuracy in the phantom calibration test was 0.6° angular and 1.65 mm linear. All 23 procedures (RF ablation, core needle biopsy, nephrostomy, and neobladder access) were performed successfully without complication. However, in four cases, the target was not met adequately, and fine-tuning adj ustment with joystick control was required to ultimately reach the target. In all cases, however, the study showed that the use of the robot reduced radiation exposure for the patient and medical personnel. 

When urgent decompression is needed, the treatment of choice is percutaneous needle nephrostomy under local anesthesia. However, if cystoscopy is being planned and the situation is not urgent, it may be best to insert a retrograde JJ stent at the time of cystoscopy. 

WiCKBOM was the first to describe percutaneous diagnostic antegrade pyelography in 1954. Percutaneous needle nephrostomy to relieve obstruction was subsequently described by Goodwin et al. (1955). Stables et al. (1978) later demonstrated the very low complication rate of this procedure and established it as the treatment of choice for the emergency relief of renal obstruction. 

The sheath is then removed and the tract is dilated using an 8-F fascial dilator. The ideal nephrostomy catheter is an 8-F self-retaining pigtail with adequate side holes (Flexima, Boston Scientific, Watertown, Mass.). 

Infection with septicemia is a serious potential complication whenever a pyonephrosis is decompressed. To avoid this, antibiotic cover should always be given (intravenous gentamicin 160 mg), and during the nephrostomy care must be taken not to over distend the collecting system with contrast, as this will inevitably cause intravasation of infected urine. 

Adjacent organ injury by the nephrostomy needle is rare and, provided it is recognized at the time of puncture, morbidity is low. If an organ such as the gallbladder or colon is punctured, a catheter should be inserted to tamponade the puncture site and allow the track to become covered with epithelium before gradual withdrawal... 

A nephrostomy placed over the twelfth rib in order to access an upper calyx may weU cross the parietal pleura. Dislodgement of a catheter crossing the pleura may cause a pneumothorax or hemothorax. Therefore, it is important that any track over the twelfth rib is protected with a secure nephrostomy catheter. 

A nephrostomy may become displaced if not adequately anchored to the skin. Even with a firm skin attachment, an obese patient will frequently ease a nephrostomy out of a kidney by simply turning in bed. For this reason self-retaining pigtail catheters are preferred. 

Percutaneous stenting of the ureter is commonly requested after a failed cystoscopic retrograde stenting or when there is a percutaneous nephrostomy in place. Whether one or both kidneys are drained depends on the renal function, the general condition of the patient and the ease with which the stents can be inserted. 

When a percutaneous nephrostomy is being inserted with the intention of dilating and stenting a ureteric stricture either at the same sitting or at a later date, a middle or (preferably) upper caliceal track will facflitate subsequent manipulations down the ureter. The track is dilated to 8 F, and an angled catheter is inserted in order to direct a guidewire down the ureter. The first problem that may be encountered is that an obstructed ureter may be kinked or tortuous (Fig. 7.1). As in angiography, this is approached... 

When a tight irregular stricture cannot be crossed with a standard wire, a straight or curved hydrophilic wire (Terumo) is chosen and is followed by a 5-F Van Andell which can usually be coaxed down to the bladder. A super-stiff wire is then advanced for the dilatation. Occasionally a Terumo wire will perforate the ureter. A nephrostomy should then be placed and a few days later, the procedure repeated, using an atraumatic wire, such as the Bentson. 

Fig. 7.3a-<. This patient had carcinoma of the prostate encasing both ureters, a The difficult angle prevented stenting at cystoscopy - right side only shown, b Right nephrostomy, c Antegrade J1 stents...

If simple nephrostomy (unilateral or bilateral, as appropriate) fails to divert the urine, attempts are made to inhibit the passage of urine down the ureter. A nephrostomy catheter coiled in the renal pelvis, with a blind tail in the proximal ureter, will partially block the ureteric lumen, and the presence of the catheter in the ureter will inhibit normal ureteric peristalsis (Fig. 7.6b). 

Ureteric stents with multiple side holes are ineffective, but stents with drainage holes at each end but none in the shaft, combined with a well draining nephrostomy, can help to heal a fistula (Fig. 7.7) (Lang 1982). 

Fig. 7.7. Patient with a leak from an ileal conduit. (Pelvic malignancy and radiotherapy resulted in poor healing.) Urine diversion was achieved via bilateral nephrostomies and a JJ stent crossing from one ureter to other. Stent snared at 6 weeks and removed via the nephrostomy track...

Fig. 7.8a,b. Patient with malignant vesico-vaginal fistula. The patient had a solitary kidney, a Nephrostomy, b Detachable balloon (filled with contrast medium) occluding the lower ureter... 

After dilatation an Amplatz sheath is inserted over the last dilator. The dilators are then removed leaving only the Amplatz sheath and a guidewire in position. Once the tumor is visualized biopsies are taken both of the tumor and of the apparently normal renal pelvis. The tumor is then resected with diathermy. Tamponade of the tract is maintained with a 30-F nephrostomy catheter. The following day brachytherapy is given to the track to ensure that track tumor implantation does not occur (WooDHOUSE et al. 1986). It is stressed that this treatment is used only for low grade TCC or as... 

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