Nephrostomy, percutaneous

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). 

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. 

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... 

Goodwin WE, Casey WC, Woolf W (1955) Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA 157 891-894... 

Lang EK (1982) Diagnosis and management of ureteral fistulas by percutaneous nephrostomy and antegrade stent catheter. Radiology 138 311-317... 

CRJ (1996) Longterm outcome after percutaneous treatment of TCC of the renal pelvis. J Urol 155 868-874 Stables DP, Ginsberg NJ, Johnson ML (1978) Percutaneous nephrostomy a series and review of the literature. AJR Am J Roentgenol 130 75-82... 

Renal Abscess. Indications for percutaneous drainage of renal fluid collections are perinephric and large intra-renal abscesses, as well as small intrarenal abscesses not responding to antibiotic therapy. Another indication are infected urinomas, which are treated by a single percutaneous drainage, or in combination with additional nephrostomy when a communication between the uri-noma and the urinary collecting system persists. 

Pseudoaneurysms or arteriovenous fistulas occur after 0.2-2% of biopsies in transplant kidneys. Similarly after percutaneous nephrostomy the incidence of significant arterial injury is around 1%. Although vascular injuries typically manifest within the first week or so, delayed presentations out to 21 months after initial nephrostomy have been reported [38]. Although most papers report only a few patients [39, 40], embolization is well accepted as the preferred... 

Peene P, Wihns G, Baert AL (1990) Embolization of iatrogenic renal hemorrhage following percutaneous nephrostomy. Urol Radiol 12 84-87... 

Ueda J, FurukawaT,Takahashi S, Miyake O, Itatani H.Araki Y (1996) Arterial embolization to control renal hemorrhage in patients with percutaneous nephrostomy. Abdom Imaging 21 361-363... 

Winters WD (1996) Power Doppler US evaluation of APN in children. J Ultrasound Med 15 91-96 Yadin O, Gradus Ben-Ezer D, Golan A et al (1988) Survival of a premature neonate with obstructive anuria due to Candida. Eur J Pediatr 147 653-656 Yavascan O, Aksu N, Egdogan H et al (2005) Percutaneous nephrostomy in children. Diagnostic and therapeutic importance. Pediatr Nephrol 20 768-772 Zamir G, Sakran W, Horowitz Y et al (2004) UTI is there a need for routine renal US Arch Dis Child 89 466-468... 

Percutaneous nephrostomy drainage can be performed in these patients and the function reassessed after 4 weeks (Fig. 18.1). Nephrectomy is usually the treatment of choice when the function remains poor (Ransley et al. 1990). Percutaneous nephrostomy drainage is also the initial treatment of choice in infants who present with a pyonephrosis. 

In this condition there is an adynamic segment of the distal ureter just prior to its insertion into the bladder resulting in obstruction to urine flow. Rarely a patient may present with a pyonephrosis. If the patient is ill, a percutaneous nephrostomy catheter should be inserted to drain the pus. A functional assessment of the kidney is undertaken in approximately 4 weeks, and a decision taken as to whether to proceed to nephrectomy or a ureteric reimplantation. 

Fig. 21. 5a-c. Acute rise of serum creatinine and oliguria 8 weeks after successful RTx. US with DS (a) shows a moderate distension of the renal pelvis without severe reduction of renal perfusion. Immediate percutaneous nephrostomy with antegrade filling (b) confirms distal ureteral stenosis caused by ureteral necrosis. Antegrade filling before surgical reconstruction and after stabilization of the renal function (c)... 

Percutaneous treatment of diseases affecting the urinary tract most often begins with accessing a collecting system and placing a nephrostomy tube. Thus, nephrostomy insertion is the basic technique upon which percutaneous surgical procedures are built. This chapter discusses nephrostomy tube insertion, ureteral stent insertion, ureteral stricture dilatation, nephrostomy tract dilatation, percutaneous removal of calculi, endopyelotomy techniques used in the treatment of UPJ strictures and percutaneous renal angioplasty for treatment of renovascular hypertension. 

Nephrostomy insertion is the building block for most urinary tract interventions. The percutaneous nephrostomy technique was first described for the treatment of hydronephrosis (Goodwin et al. 1955). About 20 years later, the first percutaneous stone removal was performed (Fernstrom and JOHANASSON 1976). Endourologic technology was... 

Percutaneous nephrostomy has been successful in over 97% of pediatric patients ranging in age from 1 day to 18 years (Irving et al. 1987 Winfield et al. 1984 LiPuma et al. 1984). These results compare favorably with surgical management (Gonzalez-Serva et al. 1977). 

The most common indications for percutaneous nephrostomy is for relief of symptomatic urinary tract obstruction (Fig. 26.1) and pyonephrosis (Man et al. 1983 Pode et al. 1982). In a series of 50 percutaneous nephrostomies in the pediatric population reported by Stanley and colleagues (1983), the most frequent causes of obstruction were uretero-pelvic junction (UPJ) narrowing and obstruction after ureteral reimplantation. 

The benefits of percutaneous nephrostomy are related to the ease of placement under sedation and... 

Percutaneous nephrostomy can be utilized as a temporizing measure prior to definitive therapy of underlying obstruction. Percutaneous decompression of the obstruction allows time for improvement in renal function, treatment of urinary sepsis, and a more accurate assessment of the renal unit. Children with postoperative ureteral edema, leakage, or obstruction from extrinsic compression of calculi insertion or a percutaneous nephrostomy may be cured. 

In rare instances, obstruction caused by a fungus ball may be treated with a combination of percutaneous nephrostomy and infusion of amphotericin (Fig. 26.3) (Matsumoto et al. 1990). In asymptomatic children with hydronephrosis, antegrade pyelography and pressure measurement (Whitaker test) maybe performed prior to surgical or endouro-logic correction to document the level and nature of the obstruction. Finally, percutaneous nephrostomy... 

Contraindications to percutaneous nephrostomy are uncommon and include an uncorrectable coagulopathy and an unfavorable anatomy, making percutaneous access impossible or dangerous. 

Local anesthetic and intravenous sedation are used in almost all cases for placement of a nephrostomy catheter. The patient is placed either in a prone or prone-oblique position. An entry site is selected on the flank using anatomic landmarks alone or with imaging. With ultrasound, an entry site is selected beneath the costal margin in approximately the mid-scapular line. The puncture site selected should allow for puncture into a middle or lower pole calyx. If a percutaneous surgical procedure is planned, it is usually best to enter the renal pelvis via a middle pole calyx. However, the best entry site depends on the procedure to be performed. 

In patients with renal transplants, the approach to percutaneous nephrostomy depends upon the surgical anatomy. Most transplants are extraperito-neal and located in the iliac fossa. Thus, the renal pelvis usually faces posteromedially. As a result, an anterolateral approach is usually best to avoid passage through the peritoneal cavity. In most cases, real time ultrasound is used to guide needle puncture. With intraperitoneal renal transplants, CT guidance may he necessary to avoid inadvertent injury to the howel (Hunter et al. 1983). 

Major complications resulting from insertion of a percutaneous nephrostomy are unusual in children. Initially, percutaneous nephrostomy was considered less applicable to the pediatric population because of the need for general anesthetic. However, improvements in sedation techniques, monitoring equipment, catheters, and the widespread use of ultrasound for needle puncture guidance has helped percutaneous nephrostomy become a safe and effective procedure in the pediatric population (Ball et al. 1986 Pfister et al. 1981 Stanley 1986). 

Transient mild hematuria is common after percutaneous nephrostomy and usually clears within 48 h. This can be ignored and should probably not be considered a complication. Severe bleeding at the... 

Nephrostomy-related urinoma formation has been reported in the pediatric population. This complication is more likely when the renal parenchyma is thin, as in children with chronic reflux or where the free wall of the renal pelvis is punctured. If the urinoma is large or becomes infected, percutaneous drainage may be required (Gonzalez-Serva et al. 1977 Ball et al. 1986). While a small amount of urine leakage around the nephrostomy catheter can be considered normal, excessive leakage is usually due to catheter blockage, especially in patients with pyonephrosis or excessive bleeding. 

Nephrostomy tract dilatation is a procedure that translates a simple drainage entry procedure into percutaneous surgery and r allows the introduction of stents or other devices. 

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