(Radiographics. 2002;22:503-525.)
© RSNA, 2002
Percutaneous Nephrostomy with Extensions of the Technique: Step by Step1
Raymond B. Dyer, MD,
John D. Regan, MD,
Peter V. Kavanagh, MD,
Elaine G. Khatod, MD,
Michael Y. Chen, MD and
Ronald J. Zagoria, MD
1 From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1088. Presented as an education exhibit at the 2000 RSNA scientific assembly. Received September 7, 2001; revision requested January 14, 2002, and received January 30; accepted January 30. Address correspondence to R.B.D. (e-mail: rdyer@wfubmc.edu).
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Abstract
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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 nephroscopy and ureteroscopy. Bleeding complications can be minimized by entering the kidney in a relatively avascular zone created by branching 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 collecting 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 treatment of obstruction. Transient hematuria occurs in virtually every patient after percutaneous nephrostomy, but severe bleeding that requires transfusion or intervention is uncommon. In patients with an obstructed urinary tract complicated by infection, extensive manipulations pose a risk of septic complications.
© RSNA, 2002
Index Terms: Genitourinary system, interventional procedures, 81.1263 • Kidney, interventional procedures, 81.1263 • Ureter, interventional procedures, 82.1263
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Introduction
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It has been more than 40 years since the initial description of percutaneous nephrostomy appeared in the literature (1). Fueled by technological advances, the ability to rapidly and safely create access to the urinary tract has spawned the field of minimally invasive urologic therapy and altered the day-to-day practice of urology (2–6). This review presents, in stepwise fashion, the technique of percutaneous nephrostomy and the extensions of this basic technique to other applications in the urinary tract. Relevant anatomy essential to the performance of the procedure and associated complications and treatment are illustrated.
Specific topics discussed are indications for percutaneous access to the urinary collecting system, the anatomy relevant to percutaneous renal entry, puncture site selection, the basic nephrostomy technique, extensions of the basic technique, other urinary tract applications, and complications of percutaneous renal entry.
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Indications for Percutaneous Access to the Urinary Collecting System
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Early in its development, percutaneous nephrostomy was used almost exclusively for temporary urinary diversion in cases of an obstructed kidney. The ability to rapidly and safely create even large-bore tracks has significantly broadened the indications for percutaneous access to the urinary collecting system, to the point where relief of urinary tract obstruction may represent a minority of cases (Table). Percutaneous access now enables urologists to perform endourologic procedures (eg, stone removal), which are less invasive and associated with fewer complications than open surgical procedures.
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Anatomy Relevant to Percutaneous Renal Entry
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Familiarity with renal anatomy is necessary for selection of a safe route through the kidney for percutaneous nephrostomy (3,4,8–10). The renal artery divides into major ventral and dorsal branches, which creates a zone of relative avascularity between the divisions (Fig 1). This zone (known as the Brödel bloodless line of incision) (4,8) lies just posterior to the lateral convex border of the kidney. Bleeding complications related to percutaneous nephrostomy can be minimized by traversing this avascular region. The optimal entry plane lies posterolaterally, at the junction of the anterior two-thirds and posterior one-third of the renal parenchyma.
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Figure 1. Vascular anatomy of the kidney. A 25° left posterior oblique image obtained during selective renal arteriography shows bifurcation of the main renal artery into dorsal (D) and ventral (V) branches. The dotted line indicates the area of the avascular plane of Brödel.
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Because of the normal renal rotation about its horizontal axis, the posterior calices are usually oriented with their long axis pointing to this watershed territory (Fig 2). The anteriorly and posteriorly directed calices can be identified fluoroscopically by using iodinated contrast material and air (Fig 3). With the patient prone, urine containing iodinated contrast material opacifies dependent, anteriorly directed calices, which are usually seen tangentially. Air introduced into the collecting system accumulates in the posteriorly directed (nondependent) calices.
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Figure 2a. Avascular plane of the kidney. (a) Computed tomographic (CT) scan shows the arterial and venous structures in the renal sinus. Note the division of the main renal artery into the major dorsal (D) and ventral (V) branches. The avascular plane of the kidney is approximately at the junction of the ventral two-thirds and dorsal one-third of the kidney. (b) Excretory phase CT scan obtained slightly inferior to a shows the posterior calix (arrow), which is directed toward the avascular plane of the kidney. (Reprinted, with permission, from reference 3.)
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Figure 2b. Avascular plane of the kidney. (a) Computed tomographic (CT) scan shows the arterial and venous structures in the renal sinus. Note the division of the main renal artery into the major dorsal (D) and ventral (V) branches. The avascular plane of the kidney is approximately at the junction of the ventral two-thirds and dorsal one-third of the kidney. (b) Excretory phase CT scan obtained slightly inferior to a shows the posterior calix (arrow), which is directed toward the avascular plane of the kidney. (Reprinted, with permission, from reference 3.)
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Figure 3a. Caliceal anatomy identified with contrast material and air. (a) Urogram shows simultaneous opacification of anteriorly and posteriorly oriented calices. Anteriorly directed calices are seen tangentially, and posteriorly directed calices are seen en face due to the renal axis. (b) Retrograde urogram obtained with the patient in the prone position shows preferential filling of the anteriorly directed (dependent) calices with contrast material. (c) Air pyelogram obtained with the patient in the prone position shows air within the posteriorly directed calices (arrows).
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Figure 3b. Caliceal anatomy identified with contrast material and air. (a) Urogram shows simultaneous opacification of anteriorly and posteriorly oriented calices. Anteriorly directed calices are seen tangentially, and posteriorly directed calices are seen en face due to the renal axis. (b) Retrograde urogram obtained with the patient in the prone position shows preferential filling of the anteriorly directed (dependent) calices with contrast material. (c) Air pyelogram obtained with the patient in the prone position shows air within the posteriorly directed calices (arrows).
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Figure 3c. Caliceal anatomy identified with contrast material and air. (a) Urogram shows simultaneous opacification of anteriorly and posteriorly oriented calices. Anteriorly directed calices are seen tangentially, and posteriorly directed calices are seen en face due to the renal axis. (b) Retrograde urogram obtained with the patient in the prone position shows preferential filling of the anteriorly directed (dependent) calices with contrast material. (c) Air pyelogram obtained with the patient in the prone position shows air within the posteriorly directed calices (arrows).
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Oblique fluoroscopy with the image intensifier angled 20 °–30° from the vertical toward the side of the kidney to be punctured can be used for entry into the collecting system, along the fluoroscopic axis. Alternatively, when vertical fluoroscopy is used, the patient may be placed in an oblique position with the side of the kidney to be punctured elevated 20°–30°.
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Puncture Site Selection
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The site of renal entry is dictated by the indication for access with consideration of the anatomic constraints (4,7,11). A lower pole posterior calix accessed via a subcostal approach is usually best for simple urinary drainage. A posterior calix of the upper or middle collecting system offers the easiest access to the ureteropelvic junction for potential ureteral negotiation. A puncture behind a stone may be the most expedient for uncompli-cated stone disease, whereas puncture of a posterior calix in the upper pole (which may require a supracostal approach with a slightly increased frequency of complications) often provides the opportunity for visualization of a greater portion of the collecting system for removal of complex stones. In some difficult cases, a single access may not be sufficient and additional entry sites may need to be created (eg, treatment of staghorn calculi).
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Basic Nephrostomy Technique
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Patient Preparation
Informed consent should always be obtained and should include a discussion of the reason for the procedure, use of conscious sedation or other forms of anesthesia, and the potential complications attendant to the procedure. The major complications of percutaneous nephrostomy are bleeding and infection. For placement of small-bore nephrostomy tubes (8–10 F), historical screening for a bleeding diathesis is probably sufficient. When large-bore tracks or complex interventions are anticipated or in patients with complex medical conditions, a complete blood cell count, including platelets, and a formal coagulation profile are performed. Coagulation abnormalities should be corrected before any intervention. Urinalysis is performed to screen for possible active urinary infection. Prophylactic, broad-spectrum antibiotic therapy is initiated prior to the procedure for those patients clearly or potentially infected (known urinary tract infection, urinary conduit diversions, obstruction with or without fever, or presumed urosepsis). Results of preprocedure ultrasonography (US) or CT, although not routinely performed, should be reviewed, if available, to avoid potential complications (Fig 4).
Successful nephrostomy tube placement requires visualization of the collecting system for appropriate entry site selection. At times, all imaging modalities may be useful, either singly or in concert, depending on the patient’s circumstances. Fluoroscopic imaging after intravenous injection of iodinated contrast material is commonly used to locate the renal pelvis for puncture, unless the patient is azotemic, has high-grade ureteral obstruction sufficient to prevent collecting system opacification, or is allergic to intravascular contrast materials (11). In certain cases, opacification of the renal collecting system can be achieved by retrograde injection of contrast material via a ureteral stent or reflux via a bowel conduit. This method may be especially helpful in a patient with a nondilated collecting system. Direct needle puncture can also be performed onto a visible stone or internal stent, if present. Imaging guidance with US or CT to place an antegrade pyelographic needle or for definitive puncture can be especially useful in azotemic patients or in those with unusual anatomic conditions such as renal malposition or fusion anomaly. These imaging modalities can also be used for identification of anteriorly and posteriorly directed calices, in appropriate circumstances, should the need arise (altered anatomy, a nondilated system, contrast material allergy). Direct antegrade needle pyelography performed from a posterior approach by using fluoroscopy and anatomic landmarks or with the assistance of other imaging guidance is the method most commonly used.
Standard Procedure for Initial Entry
The patient is placed on the fluoroscopy table in the prone position. The back and flank are sterilely cleansed and draped. An entry site into the collecting system is selected based on anatomic landmarks determined from prior imaging or by using other imaging techniques as previously outlined (2,3). After infiltration of the skin and subcutaneous tissues with 1% lidocaine over the selected site (3), respiration is suspended and a 22-gauge needle is passed from a direct posterior approach into the collecting system during vertical posteroanterior fluoroscopy. During passage, two tactile "pops" can be appreciated. The first occurs as the needle traverses the renal capsule; the second occurs as the needle enters the collecting system. Renal entry is suggested by movement of the needle tip in concert with the renal outline during respiratory excursion. Aspiration is performed as the needle is withdrawn, until urine is observed. A urine sample is obtained on entry into the collecting system and sent for culture. Contrast material and air are injected for caliceal definition. Some operators prefer carbon dioxide to air as a contrast material to avoid the unlikely possibility of air embolism.
The definitive entry site is selected, and the image intensifier is rotated approximately 25° from the vertical toward the side to be entered. A point above the selected renal entry site is identified, ideally from a subcostal approach and lateral to the paraspinous musculature. The skin and subcutaneous tissue are infiltrated with 1% lidocaine. A skin incision appropriate to the anticipated nephrostomy tube size is made with a no. 11 blade, taking care to avoid the neurovascular bundle beneath the inferior aspect of the adjacent rib.
Under continuous fluoroscopy, an 18-gauge diamond-tipped needle is advanced along the axis of the fluoroscopy tube from the skin site to the selected renal entry site. After entry into the renal parenchyma, the fluoroscopy tube is returned to the posteroanterior position and puncture of the selected calix is monitored fluoroscopically. Only the posterolateral margin of the collecting system should be punctured. Through-and-through puncture of the anterior margin of the collecting system (and potentially the large anterior arterial branches) is to be avoided. The stylet of the needle is removed. In obstructed systems, there is usually spontaneous efflux of urine. The 18-gauge needle allows direct placement of a 0.038-inch wire, which can be coiled in the renal pelvis (12). In children, in patients with a nondilated collecting system, or when ongoing correction of a coagulopathy is necessary during the procedure, a variety of "one-stick" systems with a 22- or 21-gauge puncture needle that accepts a 0.018-inch wire can be used. Transition dilators then allow placement of a larger-diameter "working wire."
Track Dilation and Nephrostomy Tube Placement
Small-bore (up to 14 F) tracks can be created over a guide wire coiled in the renal pelvis. Sequential dilation with fascial dilators is performed over this guide wire. It may be necessary to overdilate a track by 1–2 F for tubes made of materials with high friction coefficients or when there is significant perirenal scarring. Tubes coated with hydrophilic material are usually easily placed through tracks dilated to an identical French size. At initial placement, a metal stiffening cannula is used to support the tube for passage through the soft tissues. The metal cannula, contained within the nephrostomy tube, is passed over the guide wire to a point just beyond the edge of the collecting system. The tube is advanced off of the metal stiffener into the collecting system over the guide wire.
Tubes with self-retaining properties should always be used to lessen the risk of inadvertent dislodgment. Tubes of 8–10 F are usually sufficient for drainage of noninfected urine. Larger tubes (12–14 F) may be necessary for drainage of infected urine or to ensure appropriate urine flow in procedures complicated by gross hematuria. Once placed, the position of the catheter should be confirmed with an injection of contrast material, with prompt decompression of the collecting system anticipated following optimal catheter positioning. Overdistention of the collecting system at initial tube placement should be avoided, especially in patients with infected urine, to prevent bacteremia. Formal nephrostography should be delayed for 24–48 hours following tube placement in these circumstances.
The catheter is stabilized at the skin with retention sutures or other available devices. The steps outlined in this section are reviewed in Figure 5.
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Figure 5a. Radiographs show the basic technique of percutaneous nephrostomy. (a) With the patient in the prone position, a 22-gauge needle is passed into the renal pelvis from a direct posterior approach while sighting on a nonfunctional stent. After a urine sample is collected, contrast material is injected to confirm the intrapelvic position and a small amount of room air is introduced to identify posteriorly directed calices. (b) From a 25° posterolateral oblique approach, the posteriorly directed interpolar calix filled with air (arrowheads) is targeted for entry, in anticipation of a need to access the ureter after drainage. An 18-gauge needle (arrow) is seen end on, directed toward the central portion of the calix. (c) The definitive puncture is performed with the fluoroscopy tube vertically oriented to prevent puncture of the anterior aspect of the renal pelvis. (d) A wire passes easily into the ureter via the selected approach. (e) The track is sequentially dilated to 10 F. (f) A self-retaining catheter (in this case a Cope loop catheter) is advanced over the wire, and the loop is formed in the renal pelvis. Note the prompt decompression of the collecting system. (g) Without causing overdistention, contrast material is injected to confirm an appropriate position of the nephrostomy tube. Arrangements are made for postoperative care.
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Figure 5b. Radiographs show the basic technique of percutaneous nephrostomy. (a) With the patient in the prone position, a 22-gauge needle is passed into the renal pelvis from a direct posterior approach while sighting on a nonfunctional stent. After a urine sample is collected, contrast material is injected to confirm the intrapelvic position and a small amount of room air is introduced to identify posteriorly directed calices. (b) From a 25° posterolateral oblique approach, the posteriorly directed interpolar calix filled with air (arrowheads) is targeted for entry, in anticipation of a need to access the ureter after drainage. An 18-gauge needle (arrow) is seen end on, directed toward the central portion of the calix. (c) The definitive puncture is performed with the fluoroscopy tube vertically oriented to prevent puncture of the anterior aspect of the renal pelvis. (d) A wire passes easily into the ureter via the selected approach. (e) The track is sequentially dilated to 10 F. (f) A self-retaining catheter (in this case a Cope loop catheter) is advanced over the wire, and the loop is formed in the renal pelvis. Note the prompt decompression of the collecting system. (g) Without causing overdistention, contrast material is injected to confirm an appropriate position of the nephrostomy tube. Arrangements are made for postoperative care.
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Figure 5c. Radiographs show the basic technique of percutaneous nephrostomy. (a) With the patient in the prone position, a 22-gauge needle is passed into the renal pelvis from a direct posterior approach while sighting on a nonfunctional stent. After a urine sample is collected, contrast material is injected to confirm the intrapelvic position and a small amount of room air is introduced to identify posteriorly directed calices. (b) From a 25° posterolateral oblique approach, the posteriorly directed interpolar calix filled with air (arrowheads) is targeted for entry, in anticipation of a need to access the ureter after drainage. An 18-gauge needle (arrow) is seen end on, directed toward the central portion of the calix. (c) The definitive puncture is performed with the fluoroscopy tube vertically oriented to prevent puncture of the anterior aspect of the renal pelvis. (d) A wire passes easily into the ureter via the selected approach. (e) The track is sequentially dilated to 10 F. (f) A self-retaining catheter (in this case a Cope loop catheter) is advanced over the wire, and the loop is formed in the renal pelvis. Note the prompt decompression of the collecting system. (g) Without causing overdistention, contrast material is injected to confirm an appropriate position of the nephrostomy tube. Arrangements are made for postoperative care.
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Figure 5d. Radiographs show the basic technique of percutaneous nephrostomy. (a) With the patient in the prone position, a 22-gauge needle is passed into the renal pelvis from a direct posterior approach while sighting on a nonfunctional stent. After a urine sample is collected, contrast material is injected to confirm the intrapelvic position and a small amount of room air is introduced to identify posteriorly directed calices. (b) From a 25° posterolateral oblique approach, the posteriorly directed interpolar calix filled with air (arrowheads) is targeted for entry, in anticipation of a need to access the ureter after drainage. An 18-gauge needle (arrow) is seen end on, directed toward the central portion of the calix. (c) The definitive puncture is performed with the fluoroscopy tube vertically oriented to prevent puncture of the anterior aspect of the renal pelvis. (d) A wire passes easily into the ureter via the selected approach. (e) The track is sequentially dilated to 10 F. (f) A self-retaining catheter (in this case a Cope loop catheter) is advanced over the wire, and the loop is formed in the renal pelvis. Note the prompt decompression of the collecting system. (g) Without causing overdistention, contrast material is injected to confirm an appropriate position of the nephrostomy tube. Arrangements are made for postoperative care.
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Figure 5e. Radiographs show the basic technique of percutaneous nephrostomy. (a) With the patient in the prone position, a 22-gauge needle is passed into the renal pelvis from a direct posterior approach while sighting on a nonfunctional stent. After a urine sample is collected, contrast material is injected to confirm the intrapelvic position and a small amount of room air is introduced to identify posteriorly directed calices. (b) From a 25° posterolateral oblique approach, the posteriorly directed interpolar calix filled with air (arrowheads) is targeted for entry, in anticipation of a need to access the ureter after drainage. An 18-gauge needle (arrow) is seen end on, directed toward the central portion of the calix. (c) The definitive puncture is performed with the fluoroscopy tube vertically oriented to prevent puncture of the anterior aspect of the renal pelvis. (d) A wire passes easily into the ureter via the selected approach. (e) The track is sequentially dilated to 10 F. (f) A self-retaining catheter (in this case a Cope loop catheter) is advanced over the wire, and the loop is formed in the renal pelvis. Note the prompt decompression of the collecting system. (g) Without causing overdistention, contrast material is injected to confirm an appropriate position of the nephrostomy tube. Arrangements are made for postoperative care.
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Figure 5f. Radiographs show the basic technique of percutaneous nephrostomy. (a) With the patient in the prone position, a 22-gauge needle is passed into the renal pelvis from a direct posterior approach while sighting on a nonfunctional stent. After a urine sample is collected, contrast material is injected to confirm the intrapelvic position and a small amount of room air is introduced to identify posteriorly directed calices. (b) From a 25° posterolateral oblique approach, the posteriorly directed interpolar calix filled with air (arrowheads) is targeted for entry, in anticipation of a need to access the ureter after drainage. An 18-gauge needle (arrow) is seen end on, directed toward the central portion of the calix. (c) The definitive puncture is performed with the fluoroscopy tube vertically oriented to prevent puncture of the anterior aspect of the renal pelvis. (d) A wire passes easily into the ureter via the selected approach. (e) The track is sequentially dilated to 10 F. (f) A self-retaining catheter (in this case a Cope loop catheter) is advanced over the wire, and the loop is formed in the renal pelvis. Note the prompt decompression of the collecting system. (g) Without causing overdistention, contrast material is injected to confirm an appropriate position of the nephrostomy tube. Arrangements are made for postoperative care.
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Figure 5g. Radiographs show the basic technique of percutaneous nephrostomy. (a) With the patient in the prone position, a 22-gauge needle is passed into the renal pelvis from a direct posterior approach while sighting on a nonfunctional stent. After a urine sample is collected, contrast material is injected to confirm the intrapelvic position and a small amount of room air is introduced to identify posteriorly directed calices. (b) From a 25° posterolateral oblique approach, the posteriorly directed interpolar calix filled with air (arrowheads) is targeted for entry, in anticipation of a need to access the ureter after drainage. An 18-gauge needle (arrow) is seen end on, directed toward the central portion of the calix. (c) The definitive puncture is performed with the fluoroscopy tube vertically oriented to prevent puncture of the anterior aspect of the renal pelvis. (d) A wire passes easily into the ureter via the selected approach. (e) The track is sequentially dilated to 10 F. (f) A self-retaining catheter (in this case a Cope loop catheter) is advanced over the wire, and the loop is formed in the renal pelvis. Note the prompt decompression of the collecting system. (g) Without causing overdistention, contrast material is injected to confirm an appropriate position of the nephrostomy tube. Arrangements are made for postoperative care.
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Postoperative Care
Frequent vital signs should be obtained to evaluate for the potential of ongoing blood loss or for the development of septic complications in those at risk (7,11). Careful charting of the nephrostomy tube output to assess adequacy of drainage should also be performed. Hematuria, which is initially present in virtually all patients in whom percutaneous renal entry is performed, should diminish gradually over 24–48 hours. Narcotics may be required for pain relief, especially in patients with intercostal entries. Arrangements should be made for ongoing tube care and maintenance if long-term drainage is anticipated. In most institutions, patients will be admitted overnight after initial nephrostomy tube placement. In some patients, it may be appropriate to place a nephrostomy tube in an outpatient setting.
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Extensions of the Basic Technique
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Large-Bore Track Creation
A large-diameter track may be necessary for percutaneous stone therapy, nephroscopy, or antegrade ureteroscopy (13–16). For such complex manipulations, a "safety" wire is always placed in a stable position (preferably down the ureter) in addition to the working wire. This preserves access through the nephrostomy track should the working wire become dislodged during procedural manipulation. A variety of thin-walled sheaths can be used to insert a second wire after initial wire placement. Tracks of 30 F or larger can be created by using balloon dilation systems, coaxial dilators, or combined balloon-sheath systems. Nephroscopy should be performed through a sheath to tamponade the freshly created track to prevent extravasation of irrigant infused during the procedure. Following the procedure, a large-bore tube (24–30 F) is inserted through the sheath into the kidney to provide urinary drainage and track tamponade, and the sheath is removed.
These tubes are often removed 1–7 days following the procedure, depending on the indication for the procedure. If bleeding or other complications are encountered during the procedure, the tubes should be left in place for longer periods (7–14 days) to allow the track to mature. This procedure is reviewed in Figure 6.
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Figure 6a. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Figure 6b. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Figure 6c. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Figure 6d. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Figure 6e. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Figure 6f. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Figure 6g. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Figure 6h. Radiographs show placement of a large-bore nephrostomy tube for stone removal. (a) Large stones are identified within the renal pelvis, and smaller stones (arrowheads) are identified in a lower calix. A double-J stent is also in place. Direct puncture onto the renal pelvic stones is performed for opacification. (b) The lowermost calix is targeted for entry to create an access to address all of the stones. The needle is passed into the infundibulum just above the stones. Successful access might also have been achieved through the middle of the kidney or the upper pole. (c) Definitive puncture is performed while the x-ray tube is in the posteroanterior position. (d) A guide wire is advanced through the needle and coiled within the renal pelvis. (e) An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire. (f) In addition to the working wire (arrowhead), a safety guide wire is also placed (arrow). A balloon dilation catheter is now used to enlarge the nephrostomy track. (g) Semirigid coaxial Amplatz dilators (arrow) are now used to further dilate the track. (h) After dilation, the track is maintained with a 28-F, red Robinson catheter.
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Ureteral Intervention
The most common extension of percutaneous nephrostomy is ureteral stent placement for obstruction (2,3,17–19). Ureteral stent placement is often possible from an antegrade approach, even when retrograde cystoscopic attempts are not successful. The need for ureteral stent placement should be anticipated at the time of initial renal entry, and access through a posterior, upper or middle renal calix should be used to facilitate access to the ureteropelvic junction. After initial renal entry, as described earlier, a safety wire is placed and a working wire is manipulated down the ureter. Negotiation of the obstructed ureter is often facilitated with the use of simple curved angiographic catheters and hydrophilic guide wires. Once the obstructed segment has been traversed, the wire-catheter combination is coiled within the bladder. When ureteral passage is not possible at the time of initial nephrostomy entry, it may be successful after 5–7 days of external drainage. Drainage will often reduce redundancy of the ureter proximal to the obstruction and mucosal edema within the obstructed segment.
The appropriate stent length is determined by using the "bent guide wire" technique (Fig 7). The stent is inserted with a pusher catheter, first deploying the bladder loop and then the renal pelvic loop. It is often beneficial to leave a nephrostomy tube in place for 24 hours after stent placement. External drainage is continued for the first 12 hours, after which time the tube is clamped to ensure that good internal drainage can be accomplished via the stent. The nephrostomy tube should be removed with fluoroscopic assistance to prevent inadvertent dislodgment of the stent caused by entanglement of the stent with the retention loop of the nephrostomy tube. The procedure of internal stent placement is reviewed in Figure 8.
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Figure 7a. Drawings show the bent guide wire technique for determination of stent catheter length. (a) A guide wire is advanced through an angiographic catheter that has been passed down the ureter into the bladder, to the approximate site of the ureterovesical junction (arrow). The wire is kinked at the catheter hub. (b) The wire is withdrawn to the ureteropelvic junction (arrow), and a second kink is made in the wire as it exits the catheter hub. The absolute distance between the two kinks in the wire provides a measure of appropriate catheter length or hole position in a customized internal-external drainage catheter.
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Figure 7b. Drawings show the bent guide wire technique for determination of stent catheter length. (a) A guide wire is advanced through an angiographic catheter that has been passed down the ureter into the bladder, to the approximate site of the ureterovesical junction (arrow). The wire is kinked at the catheter hub. (b) The wire is withdrawn to the ureteropelvic junction (arrow), and a second kink is made in the wire as it exits the catheter hub. The absolute distance between the two kinks in the wire provides a measure of appropriate catheter length or hole position in a customized internal-external drainage catheter.
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Figure 8a. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8b. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8c. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8d. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8e. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8f. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8g. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8h. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8i. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Figure 8j. Radiographs show placement of an internal stent. The patient had ureteral obstruction from a postoperative stricture, which was treated with balloon dilation and placement of a ureteral stent. (a) Antegrade pyelogram obtained at the time of initial nephrostomy shows marked hydroureteronephrosis. (b) Antegrade ureterogram shows a tight stricture in the distal ureter. At initial entry, this stricture could not be negotiated. External nephrostomy drainage was established. (c) After 1 week of external drainage, a wire is advanced down the ureter. (d) Negotiation of the obstruction is now possible by using the catheter and guide wire technique. A Berenstein catheter has been advanced through the stricture into the bladder. (e) The position of the catheter within the bladder is confirmed with contrast material injection. (f) A guide wire is advanced through the catheter, and the site of the ureterovesical junction (arrowhead) is marked. The wire is kinked at the hub of the catheter. (g) The wire is withdrawn to the level of the ureteropelvic junction (arrow), and a second kink is made in the wire. The distance between the two bends in the wire provides an estimate of ureteral length and assists with selection of the appropriate stent length (Fig 7). (h) The ureteral stricture is balloon dilated to assist with stent passage. (i) A 28-cm-long 7-F double-J stent is advanced over the wire. The distal loop is deployed in the bladder. (j) Once an appropriate position of the stent is confirmed, the wire is withdrawn, allowing the proximal loop to reconstitute in the renal pelvis. A nephrostomy tube is placed in the renal pelvis to allow external drainage for 12 hours. This tube allows any clot or debris to drain externally. The nephrostomy tube can then be clamped to ensure antegrade urine flow. The nephrostomy tube should be removed under fluoroscopic control over a guide wire to prevent inadvertent dislodgment of the stent.
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Balloon dilation of the ureter may provide durable therapy in up to 50% of patients with benign ureteral strictures (2,3,20). After negotiation of the obstructed segment, balloon dilation with 8–10-mm-diameter balloons at the ureteropelvic junction, 6–8-mm-diameter balloons in the ureter, and 6–10-mm-diameter balloons at the ureterovesical junction is performed. After balloon dilation, the ureteral segment is supported with a ureteral stent. In cases where repeated entry into the ureter may be necessary (as for repeated dilation), an internal-external stent can be placed (Fig 9). This preserves percutaneous renal access for further interventions, as well as providing mechanical support to the treated ureteral segment. After balloon dilation, the stent is left in place for 4–6 weeks. The stent can then be exchanged for a nephrostomy tube, which is clamped to determine adequacy of antegrade flow. Ureteral dilation supported with stent placement is performed up to three times before abandoning it as a primary therapy. Balloon dilation may also be used to assist with placement of a permanent indwelling stent in the obstructed ureter (Fig 8).
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Figure 9a. Radiographs show placement of an internal-external stent for an acute ureteral injury. The patient had severe right flank pain on awakening after a radical hysterectomy. US demonstrated moderate right-sided hydronephrosis. (a) Urogram shows right-sided hydronephrosis and extravasation of urine from the right collecting system. (b) Nephrostomy is performed. (c) Antegrade pyelogram obtained immediately after nephrostomy shows occlusion of the ureter (arrow) just above the ureterovesical junction. The occlusion could not be negotiated at initial nephrostomy. (d) Antegrade pyeloureterogram obtained 1 week after nephrostomy shows a narrowed but patent distal ureter. (e) A guide wire is negotiated through the narrow ureteral segment into the bladder. (f) A 10-F internal-external stent is negotiated through the stricture area. This catheter was left in place for 6 weeks to support the stricture. (g) Follow-up nephrostogram shows wide patency of the distal ureter. No further intervention was performed.
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Figure 9b. Radiographs show placement of an internal-external stent for an acute ureteral injury. The patient had severe right flank pain on awakening after a radical hysterectomy. US demonstrated moderate right-sided hydronephrosis. (a) Urogram shows right-sided hydronephrosis and extravasation of urine from the right collecting system. (b) Nephrostomy is performed. (c) Antegrade pyelogram obtained immediately after nephrostomy shows occlusion of the ureter (arrow) just above the ureterovesical junction. The occlusion could not be negotiated at initial nephrostomy. (d) Antegrade pyeloureterogram obtained 1 week after nephrostomy shows a narrowed but patent distal ureter. (e) A guide wire is negotiated through the narrow ureteral segment into the bladder. (f) A 10-F internal-external stent is negotiated through the stricture area. This catheter was left in place for 6 weeks to support the stricture. (g) Follow-up nephrostogram shows wide patency of the distal ureter. No further intervention was performed.
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Figure 9c. Radiographs show placement of an internal-external stent for an acute ureteral injury. The patient had severe right flank pain on awakening after a radical hysterectomy. US demonstrated moderate right-sided hydronephrosis. (a) Urogram shows right-sided hydronephrosis and extravasation of urine from the right collecting system. (b) Nephrostomy is performed. (c) Antegrade pyelogram obtained immediately after nephrostomy shows occlusion of the ureter (arrow) just above the ureterovesical junction. The occlusion could not be negotiated at initial nephrostomy. (d) Antegrade pyeloureterogram obtained 1 week after nephrostomy shows a narrowed but patent distal ureter. (e) A guide wire is negotiated through the narrow ureteral segment into the bladder. (f) A 10-F internal-external stent is negotiated through the stricture area. This catheter was left in place for 6 weeks to support the stricture. (g) Follow-up nephrostogram shows wide patency of the distal ureter. No further intervention was performed.
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Figure 9d. Radiographs show placement of an internal-external stent for an acute ureteral injury. The patient had severe right flank pain on awakening after a radical hysterectomy. US demonstrated moderate right-sided hydronephrosis. (a) Urogram shows right-sided hydronephrosis and extravasation of urine from the right collecting system. (b) Nephrostomy is performed. (c) Antegrade pyelogram obtained immediately after nephrostomy shows occlusion of the ureter (arrow) just above the ureterovesical junction. The occlusion could not be negotiated at initial nephrostomy. (d) Antegrade pyeloureterogram obtained 1 week after nephrostomy shows a narrowed but patent distal ureter. (e) A guide wire is negotiated through the narrow ureteral segment into the bladder. (f) A 10-F internal-external stent is negotiated through the stricture area. This catheter was left in place for 6 weeks to support the stricture. (g) Follow-up nephrostogram shows wide patency of the distal ureter. No further intervention was performed.
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Figure 9e. Radiographs show placement of an internal-external stent for an acute ureteral injury. The patient had severe right flank pain on awakening after a radical hysterectomy. US demonstrated moderate right-sided hydronephrosis. (a) Urogram shows right-sided hydronephrosis and extravasation of urine from the right collecting system. (b) Nephrostomy is performed. (c) Antegrade pyelogram obtained immediately after nephrostomy shows occlusion of the ureter (arrow) just above the ureterovesical junction. The occlusion could not be negotiated at initial nephrostomy. (d) Antegrade pyeloureterogram obtained 1 week after nephrostomy shows a narrowed but patent distal ureter. (e) A guide wire is negotiated through the narrow ureteral segment into the bladder. (f) A 10-F internal-external stent is negotiated through the stricture area. This catheter was left in place for 6 weeks to support the stricture. (g) Follow-up nephrostogram shows wide patency of the distal ureter. No further intervention was performed.
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Figure 9f. Radiographs show placement of an internal-external stent for an acute ureteral injury. The patient had severe right flank pain on awakening after a radical hysterectomy. US demonstrated moderate right-sided hydronephrosis. (a) Urogram shows right-sided hydronephrosis and extravasation of urine from the right collecting system. (b) Nephrostomy is performed. (c) Antegrade pyelogram obtained immediately after nephrostomy shows occlusion of the ureter (arrow) just above the ureterovesical junction. The occlusion could not be negotiated at initial nephrostomy. (d) Antegrade pyeloureterogram obtained 1 week after nephrostomy shows a narrowed but patent distal ureter. (e) A guide wire is negotiated through the narrow ureteral segment into the bladder. (f) A 10-F internal-external stent is negotiated through the stricture area. This catheter was left in place for 6 weeks to support the stricture. (g) Follow-up nephrostogram shows wide patency of the distal ureter. No further intervention was performed.
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Figure 9g. Radiographs show placement of an internal-external stent for an acute ureteral injury. The patient had severe right flank pain on awakening after a radical hysterectomy. US demonstrated moderate right-sided hydronephrosis. (a) Urogram shows right-sided hydronephrosis and extravasation of urine from the right collecting system. (b) Nephrostomy is performed. (c) Antegrade pyelogram obtained immediately after nephrostomy shows occlusion of the ureter (arrow) just above the ureterovesical junction. The occlusion could not be negotiated at initial nephrostomy. (d) Antegrade pyeloureterogram obtained 1 week after nephrostomy shows a narrowed but patent distal ureter. (e) A guide wire is negotiated through the narrow ureteral segment into the bladder. (f) A 10-F internal-external stent is negotiated through the stricture area. This catheter was left in place for 6 weeks to support the stricture. (g) Follow-up nephrostogram shows wide patency of the distal ureter. No further intervention was performed.
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Small urinary leaks may seal after urinary diversion with a nephrostomy tube. Larger leaks are usually best managed by urinary diversion coupled with ureteral stent placement (21). In these circumstances, internal-external stents are placed because of the anticipated need for multiple percutaneous ureteral interventions and prolonged urinary drainage. Internal-external catheters of 8–10 F are usually placed. Holes are created in the internal-external catheter above and below the site of leakage, with a solid portion of the tube traversing the site of the urinary leak. The presence of the tube is thought to hasten development of epithelial bridges in addition to providing preservation of luminal diameter during healing. This procedure is reviewed in Figure 10.
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Figure 10a. Radiographs show management of a fistula. (a) A stab wound to the flank resulted in division of the right ureter, which was primarily surgically repaired over a small-bore stent. (b) The stent was inadvertently withdrawn. Repeat retrograde ureterogram obtained during an attempt at stent replacement shows an area of extravasation from the midureter, at the site of surgical repair. (c) A small-bore catheter was negotiated into the collecting system, but the patient developed urine drainage from the flank wound. Nephrostomy tube placement for urinary diversion was requested. (d) A nephrostomy tube has been placed. In addition, a catheter has been placed into a large urinoma via the flank wound. (e) It was ultimately possible to pass a catheter antegradely across the site of ureteral injury into the bladder. An internal-external stent was placed. Pyeloureterogram obtained after approximately 4 weeks of external drainage shows a continued small leak (arrow) at the site of injury. (f) After 10 weeks of drainage, the internal-external stent was withdrawn to a nephrostomy position. Repeat nephrostogram shows complete healing of the ureteral injury, with no evidence of leakage. (Fig 10c, Fig 10e, and Fig 10f reprinted, with permission, from reference 3.)
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Figure 10b. Radiographs show management of a fistula. (a) A stab wound to the flank resulted in division of the right ureter, which was primarily surgically repaired over a small-bore stent. (b) The stent was inadvertently withdrawn. Repeat retrograde ureterogram obtained during an attempt at stent replacement shows an area of extravasation from the midureter, at the site of surgical repair. (c) A small-bore catheter was negotiated into the collecting system, but the patient developed urine drainage from the flank wound. Nephrostomy tube placement for urinary diversion was requested. (d) A nephrostomy tube has been placed. In addition, a catheter has been placed into a large urinoma via the flank wound. (e) It was ultimately possible to pass a catheter antegradely across the site of ureteral injury into the bladder. An internal-external stent was placed. Pyeloureterogram obtained after approximately 4 weeks of external drainage shows a continued small leak (arrow) at the site of injury. (f) After 10 weeks of drainage, the internal-external stent was withdrawn to a nephrostomy position. Repeat nephrostogram shows complete healing of the ureteral injury, with no evidence of leakage. (Fig 10c, Fig 10e, and Fig 10f reprinted, with permission, from reference 3.)
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Figure 10c. Radiographs show management of a fistula. (a) A stab wound to the flank resulted in division of the right ureter, which was primarily surgically repaired over a small-bore stent. (b) The stent was inadvertently withdrawn. Repeat retrograde ureterogram obtained during an attempt at stent replacement shows an area of extravasation from the midureter, at the site of surgical repair. (c) A small-bore catheter was negotiated into the collecting system, but the patient developed urine drainage from the flank wound. Nephrostomy tube placement for urinary diversion was requested. (d) A nephrostomy tube has been placed. In addition, a catheter has been placed into a large urinoma via the flank wound. (e) It was ultimately possible to pass a catheter antegradely across the site of ureteral injury into the bladder. An internal-external stent was placed. Pyeloureterogram obtained after approximately 4 weeks of external drainage shows a continued small leak (arrow) at the site of injury. (f) After 10 weeks of drainage, the internal-external stent was withdrawn to a nephrostomy position. Repeat nephrostogram shows complete healing of the ureteral injury, with no evidence of leakage. (Fig 10c, Fig 10e, and Fig 10f reprinted, with permission, from reference 3.)
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Figure 10d. Radiographs show management of a fistula. (a) A stab wound to the flank resulted in division of the right ureter, which was primarily surgically repaired over a small-bore stent. (b) The stent was inadvertently withdrawn. Repeat retrograde ureterogram obtained during an attempt at stent replacement shows an area of extravasation from the midureter, at the site of surgical repair. (c) A small-bore catheter was negotiated into the collecting system, but the patient developed urine drainage from the flank wound. Nephrostomy tube placement for urinary diversion was requested. (d) A nephrostomy tube has been placed. In addition, a catheter has been placed into a large urinoma via the flank wound. (e) It was ultimately possible to pass a catheter antegradely across the site of ureteral injury into the bladder. An internal-external stent was placed. Pyeloureterogram obtained after approximately 4 weeks of external drainage shows a continued small leak (arrow) at the site of injury. (f) After 10 weeks of drainage, the internal-external stent was withdrawn to a nephrostomy position. Repeat nephrostogram shows complete healing of the ureteral injury, with no evidence of leakage. (Fig 10c, Fig 10e, and Fig 10f reprinted, with permission, from reference 3.)
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Figure 10e. Radiographs show management of a fistula. (a) A stab wound to the flank resulted in division of the right ureter, which was primarily surgically repaired over a small-bore stent. (b) The stent was inadvertently withdrawn. Repeat retrograde ureterogram obtained during an attempt at stent replacement shows an area of extravasation from the midureter, at the site of surgical repair. (c) A small-bore catheter was negotiated into the collecting system, but the patient developed urine drainage from the flank wound. Nephrostomy tube placement for urinary diversion was requested. (d) A nephrostomy tube has been placed. In addition, a catheter has been placed into a large urinoma via the flank wound. (e) It was ultimately possible to pass a catheter antegradely across the site of ureteral injury into the bladder. An internal-external stent was placed. Pyeloureterogram obtained after approximately 4 weeks of external drainage shows a continued small leak (arrow) at the site of injury. (f) After 10 weeks of drainage, the internal-external stent was withdrawn to a nephrostomy position. Repeat nephrostogram shows complete healing of the ureteral injury, with no evidence of leakage. (Fig 10c, Fig 10e, and Fig 10f reprinted, with permission, from reference 3.)
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Figure 10f. Radiographs show management of a fistula. (a) A stab wound to the flank resulted in division of the right ureter, which was primarily surgically repaired over a small-bore stent. (b) The stent was inadvertently withdrawn. Repeat retrograde ureterogram obtained during an attempt at stent replacement shows an area of extravasation from the midureter, at the site of surgical repair. (c) A small-bore catheter was negotiated into the collecting system, but the patient developed urine drainage from the flank wound. Nephrostomy tube placement for urinary diversion was requested. (d) A nephrostomy tube has been placed. In addition, a catheter has been placed into a large urinoma via the flank wound. (e) It was ultimately possible to pass a catheter antegradely across the site of ureteral injury into the bladder. An internal-external stent was placed. Pyeloureterogram obtained after approximately 4 weeks of external drainage shows a continued small leak (arrow) at the site of injury. (f) After 10 weeks of drainage, the internal-external stent was withdrawn to a nephrostomy position. Repeat nephrostogram shows complete healing of the ureteral injury, with no evidence of leakage. (Fig 10c, Fig 10e, and Fig 10f reprinted, with permission, from reference 3.)
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A number of methods of permanent ureteral occlusion can be used in the setting of a large urinary fistula, which is often associated with a neoplasm. The methods described include detachable balloons and plugs, tissue adhesives, electrocautery, percutaneous ureteral clipping, or creation of occlusive nests of embolization coils and absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich) (22,23) (Fig 11).
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Figure 11a. Ureteral occlusion in a 76-year-old man with bladder carcinoma who underwent creation of an ileal conduit. During the surgery, extensive pelvic disease was discovered, and the patient developed leakage from the conduit. The patient was referred for external drainage. Nephrostomy drainage was established, but the patient continued to have urine leakage via a pelvic drain, and ureteral occlusion was requested. (a) Radiograph shows that nests of absorbable gelatin sponge and coils have been placed in the ureters bilaterally (arrows). Note the nephrostomy tubes in place in both kidneys. An inferior vena caval filter is also present. (b) Nephrostogram obtained several days after ureteral occlusion shows complete obstruction at the level of the absorbable gelatin sponge-coil nests. Output via the pelvic drain promptly ceased. (Reprinted, with permission, from reference 3.)
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Figure 11b. Ureteral occlusion in a 76-year-old man with bladder carcinoma who underwent creation of an ileal conduit. During the surgery, extensive pelvic disease was discovered, and the patient developed leakage from the conduit. The patient was referred for external drainage. Nephrostomy drainage was established, but the patient continued to have urine leakage via a pelvic drain, and ureteral occlusion was requested. (a) Radiograph shows that nests of absorbable gelatin sponge and coils have been placed in the ureters bilaterally (arrows). Note the nephrostomy tubes in place in both kidneys. An inferior vena caval filter is also present. (b) Nephrostogram obtained several days after ureteral occlusion shows complete obstruction at the level of the absorbable gelatin sponge-coil nests. Output via the pelvic drain promptly ceased. (Reprinted, with permission, from reference 3.)
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Other Urinary Tract Applications
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The basic nephrostomy technique can be extended to other urinary tract applications (3). These include entry for treatment of stones in or percutaneous ablation of a caliceal diverticulum (24,25), drainage or ablation of renal cysts (2), and drainage of localized renal or perirenal infections (Figs 12, 13). Identical conditions that occur in the transplanted kidney can also be managed by using the techniques described herein (26,27). Similar techniques for percutaneous entry, track creation, and drainage can also be used for placement of suprapubic bladder catheters.
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Figure 12a. Treatment of an infection in a 56-year-old woman with left flank pain and fever. Nonenhanced CT was performed for evaluation of possible stone disease. (a) CT scan obtained through the upper portion of the left kidney shows gas (arrow) within the left renal pelvis. (b) CT scan obtained at a slightly lower level also shows gas, as well as an obstructing left ureteral stone (arrow). With the stone used as a landmark, the left renal pelvis was punctured from a direct posterior approach. (c) Radiograph shows gas (arrow) within the collecting system, as well as debris above the stone in the renal pelvis. This appearance is indicative of emphysematous pyelitis. (d) Radiograph shows a 12-F nephrostomy tube, which was placed for decompression of the collecting system. In cases such as this, placement of a nephrostomy tube is frequently more expeditious and efficient than attempts at retrograde stent placement in a critically ill patient. Aggressive manipulations are avoided during the initial procedure to prevent induction of a septic episode.
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Figure 12b. Treatment of an infection in a 56-year-old woman with left flank pain and fever. Nonenhanced CT was performed for evaluation of possible stone disease. (a) CT scan obtained through the upper portion of the left kidney shows gas (arrow) within the left renal pelvis. (b) CT scan obtained at a slightly lower level also shows gas, as well as an obstructing left ureteral stone (arrow). With the stone used as a landmark, the left renal pelvis was punctured from a direct posterior approach. (c) Radiograph shows gas (arrow) within the collecting system, as well as debris above the stone in the renal pelvis. This appearance is indicative of emphysematous pyelitis. (d) Radiograph shows a 12-F nephrostomy tube, which was placed for decompression of the collecting system. In cases such as this, placement of a nephrostomy tube is frequently more expeditious and efficient than attempts at retrograde stent placement in a critically ill patient. Aggressive manipulations are avoided during the initial procedure to prevent induction of a septic episode.
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Figure 12c. Treatment of an infection in a 56-year-old woman with left flank pain and fever. Nonenhanced CT was performed for evaluation of possible stone disease. (a) CT scan obtained through the upper portion of the left kidney shows gas (arrow) within the left renal pelvis. (b) CT scan obtained at a slightly lower level also shows gas, as well as an obstructing left ureteral stone (arrow). With the stone used as a landmark, the left renal pelvis was punctured from a direct posterior approach. (c) Radiograph shows gas (arrow) within the collecting system, as well as debris above the stone in the renal pelvis. This appearance is indicative of emphysematous pyelitis. (d) Radiograph shows a 12-F nephrostomy tube, which was placed for decompression of the collecting system. In cases such as this, placement of a nephrostomy tube is frequently more expeditious and efficient than attempts at retrograde stent placement in a critically ill patient. Aggressive manipulations are avoided during the initial procedure to prevent induction of a septic episode.
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Figure 12d. Treatment of an infection in a 56-year-old woman with left flank pain and fever. Nonenhanced CT was performed for evaluation of possible stone disease. (a) CT scan obtained through the upper portion of the left kidney shows gas (arrow) within the left renal pelvis. (b) CT scan obtained at a slightly lower level also shows gas, as well as an obstructing left ureteral stone (arrow). With the stone used as a landmark, the left renal pelvis was punctured from a direct posterior approach. (c) Radiograph shows gas (arrow) within the collecting system, as well as debris above the stone in the renal pelvis. This appearance is indicative of emphysematous pyelitis. (d) Radiograph shows a 12-F nephrostomy tube, which was placed for decompression of the collecting system. In cases such as this, placement of a nephrostomy tube is frequently more expeditious and efficient than attempts at retrograde stent placement in a critically ill patient. Aggressive manipulations are avoided during the initial procedure to prevent induction of a septic episode.
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Figure 13a. Treatment of an infection in a 6-week-old boy with recurrent urinary tract infections. (a) Longitudinal US image of the right kidney shows marked hydronephrosis, with a large amount of debris within the dependent portions of the renal pelvis. (b) Longitudinal US image of the lower abdomen shows a massively dilated ureter with a urine-debris level (arrowheads). These findings indicate pyonephrosis. (c) Radiograph shows a 6-F nephrostomy tube placed in the dilated collecting system. (d) Radiograph shows injection of a small amount of contrast material, which is used to confirm an appropriate position of the catheter after decompression of the collecting system. Under these circumstances, care is taken to avoid overdistention of the system and possible induction of sepsis. (e) Follow-up antegrade pyeloureterogram obtained after several days of external drainage and antibiotic therapy shows a congenital stricture of the ureterovesical junction. The stricture was repaired surgically without consequences.
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Figure 13b. Treatment of an infection in a 6-week-old boy with recurrent urinary tract infections. (a) Longitudinal US image of the right kidney shows marked hydronephrosis, with a large amount of debris within the dependent portions of the renal pelvis. (b) Longitudinal US image of the lower abdomen shows a massively dilated ureter with a urine-debris level (arrowheads). These findings indicate pyonephrosis. (c) Radiograph shows a 6-F nephrostomy tube placed in the dilated collecting system. (d) Radiograph shows injection of a small amount of contrast material, which is used to confirm an appropriate position of the catheter after decompression of the collecting system. Under these circumstances, care is taken to avoid overdistention of the system and possible induction of sepsis. (e) Follow-up antegrade pyeloureterogram obtained after several days of external drainage and antibiotic therapy shows a congenital stricture of the ureterovesical junction. The stricture was repaired surgically without consequences.
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Figure 13c. Treatment of an infection in a 6-week-old boy with recurrent urinary tract infections. (a) Longitudinal US image of the right kidney shows marked hydronephrosis, with a large amount of debris within the dependent portions of the renal pelvis. (b) Longitudinal US image of the lower abdomen shows a massively dilated ureter with a urine-debris level (arrowheads). These findings indicate pyonephrosis. (c) Radiograph shows a 6-F nephrostomy tube placed in the dilated collecting system. (d) Radiograph shows injection of a small amount of contrast material, which is used to confirm an appropriate position of the catheter after decompression of the collecting system. Under these circumstances, care is taken to avoid overdistention of the system and possible induction of sepsis. (e) Follow-up antegrade pyeloureterogram obtained after several days of external drainage and antibiotic therapy shows a congenital stricture of the ureterovesical junction. The stricture was repaired surgically without consequences.
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Figure 13d. Treatment of an infection in a 6-week-old boy with recurrent urinary tract infections. (a) Longitudinal US image of the right kidney shows marked hydronephrosis, with a large amount of debris within the dependent portions of the renal pelvis. (b) Longitudinal US image of the lower abdomen shows a massively dilated ureter with a urine-debris level (arrowheads). These findings indicate pyonephrosis. (c) Radiograph shows a 6-F nephrostomy tube placed in the dilated collecting system. (d) Radiograph shows injection of a small amount of contrast material, which is used to confirm an appropriate position of the catheter after decompression of the collecting system. Under these circumstances, care is taken to avoid overdistention of the system and possible induction of sepsis. (e) Follow-up antegrade pyeloureterogram obtained after several days of external drainage and antibiotic therapy shows a congenital stricture of the ureterovesical junction. The stricture was repaired surgically without consequences.
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Figure 13e. Treatment of an infection in a 6-week-old boy with recurrent urinary tract infections. (a) Longitudinal US image of the right kidney shows marked hydronephrosis, with a large amount of debris within the dependent portions of the renal pelvis. (b) Longitudinal US image of the lower abdomen shows a massively dilated ureter with a urine-debris level (arrowheads). These findings indicate pyonephrosis. (c) Radiograph shows a 6-F nephrostomy tube placed in the dilated collecting system. (d) Radiograph shows injection of a small amount of contrast material, which is used to confirm an appropriate position of the catheter after decompression of the collecting system. Under these circumstances, care is taken to avoid overdistention of the system and possible induction of sepsis. (e) Follow-up antegrade pyeloureterogram obtained after several days of external drainage and antibiotic therapy shows a congenital stricture of the ureterovesical junction. The stricture was repaired surgically without consequences.
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Complications of Percutaneous Renal Entry
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Minor complications that require no specific therapy may be seen in 15%–25% of patients who undergo a nephrostomy procedure (28–30). The mortality rate for percutaneous renal entry is low (0.046%–0.3%) (15,29–31). Transient hematuria occurs in virtually every patient. Severe bleeding that requires transfusion or intervention occurs in 1%–3% of patients (32) (Fig 14). In most instances, significant bleeding noted at the time of nephrostomy can be controlled by tamponade of the track with a nephrostomy catheter for a small-bore track or with a balloon dilation catheter for large tracks (28,33). When this fails or when significant blood loss develops several days after nephrostomy tube placement or removal, angiographic evaluation for identification of a renal arteriovenous fistula, pseudoaneurysm, or vessel laceration is indicated. Most of these vascular injuries can be managed with angiographic embolization (Figs 15–17), and surgical intervention is rarely necessary (34).
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Figure 14a. Subcapsular hematoma. Nonenhanced CT was performed for evaluation of persistent pain after nephrostomy tube placement. (a) CT scan shows a high-attenuation subcapsular collection about the left kidney. (b) CT scan shows an appropriate position of the nephrostomy tube. Perirenal bleeding probably occurs in a significant number of patients but is usually without symptoms. This process usually resolves without sequelae.
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Figure 14b. Subcapsular hematoma. Nonenhanced CT was performed for evaluation of persistent pain after nephrostomy tube placement. (a) CT scan shows a high-attenuation subcapsular collection about the left kidney. (b) CT scan shows an appropriate position of the nephrostomy tube. Perirenal bleeding probably occurs in a significant number of patients but is usually without symptoms. This process usually resolves without sequelae.
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Figure 15a. Radiographs show treatment of a vascular laceration. During attempted removal of a large-bore nephrostomy tube placed for stone removal, the patient developed gross hematuria. A Foley catheter was quickly advanced through the nephrostomy track. (a) Contrast material injection demonstrated a filling defect in the renal pelvis and a linear defect (arrows) in the ureter, which represented clots. (b) The catheter was withdrawn, and the balloon was inflated with dilute contrast material in the renal parenchymal track. This procedure resulted in cessation of the gross hematuria. (c) The patient was taken to the angiography suite, and the catheter was removed over a guide wire. Removal over a guide wire was performed to allow prompt reinsertion of the catheter should the patient’s condition become unstable. Injection of the main renal artery demonstrated an area of irregularity (arrowhead) along one of the ventral branches of the renal artery, a finding indicative of a laceration. (d) Note the opacification of the nephrostomy track, which indicates the volume of blood loss. (e) Embolization of the lacerated vessel with a coil (arrow) resulted in abrupt cessation of the bleeding. No further bleeding occurred.
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Figure 15b. Radiographs show treatment of a vascular laceration. During attempted removal of a large-bore nephrostomy tube placed for stone removal, the patient developed gross hematuria. A Foley catheter was quickly advanced through the nephrostomy track. (a) Contrast material injection demonstrated a filling defect in the renal pelvis and a linear defect (arrows) in the ureter, which represented clots. (b) The catheter was withdrawn, and the balloon was inflated with dilute contrast material in the renal parenchymal track. This procedure resulted in cessation of the gross hematuria. (c) The patient was taken to the angiography suite, and the catheter was removed over a guide wire. Removal over a guide wire was performed to allow prompt reinsertion of the catheter should the patient’s condition become unstable. Injection of the main renal artery demonstrated an area of irregularity (arrowhead) along one of the ventral branches of the renal artery, a finding indicative of a laceration. (d) Note the opacification of the nephrostomy track, which indicates the volume of blood loss. (e) Embolization of the lacerated vessel with a coil (arrow) resulted in abrupt cessation of the bleeding. No further bleeding occurred.
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Figure 15c. Radiographs show treatment of a vascular laceration. During attempted removal of a large-bore nephrostomy tube placed for stone removal, the patient developed gross hematuria. A Foley catheter was quickly advanced through the nephrostomy track. (a) Contrast material injection demonstrated a filling defect in the renal pelvis and a linear defect (arrows) in the ureter, which represented clots. (b) The catheter was withdrawn, and the balloon was inflated with dilute contrast material in the renal parenchymal track. This procedure resulted in cessation of the gross hematuria. (c) The patient was taken to the angiography suite, and the catheter was removed over a guide wire. Removal over a guide wire was performed to allow prompt reinsertion of the catheter should the patient’s condition become unstable. Injection of the main renal artery demonstrated an area of irregularity (arrowhead) along one of the ventral branches of the renal artery, a finding indicative of a laceration. (d) Note the opacification of the nephrostomy track, which indicates the volume of blood loss. (e) Embolization of the lacerated vessel with a coil (arrow) resulted in abrupt cessation of the bleeding. No further bleeding occurred.
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Figure 15d. Radiographs show treatment of a vascular laceration. During attempted removal of a large-bore nephrostomy tube placed for stone removal, the patient developed gross hematuria. A Foley catheter was quickly advanced through the nephrostomy track. (a) Contrast material injection demonstrated a filling defect in the renal pelvis and a linear defect (arrows) in the ureter, which represented clots. (b) The catheter was withdrawn, and the balloon was inflated with dilute contrast material in the renal parenchymal track. This procedure resulted in cessation of the gross hematuria. (c) The patient was taken to the angiography suite, and the catheter was removed over a guide wire. Removal over a guide wire was performed to allow prompt reinsertion of the catheter should the patient’s condition become unstable. Injection of the main renal artery demonstrated an area of irregularity (arrowhead) along one of the ventral branches of the renal artery, a finding indicative of a laceration. (d) Note the opacification of the nephrostomy track, which indicates the volume of blood loss. (e) Embolization of the lacerated vessel with a coil (arrow) resulted in abrupt cessation of the bleeding. No further bleeding occurred.
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Figure 15e. Radiographs show treatment of a vascular laceration. During attempted removal of a large-bore nephrostomy tube placed for stone removal, the patient developed gross hematuria. A Foley catheter was quickly advanced through the nephrostomy track. (a) Contrast material injection demonstrated a filling defect in the renal pelvis and a linear defect (arrows) in the ureter, which represented clots. (b) The catheter was withdrawn, and the balloon was inflated with dilute contrast material in the renal parenchymal track. This procedure resulted in cessation of the gross hematuria. (c) The patient was taken to the angiography suite, and the catheter was removed over a guide wire. Removal over a guide wire was performed to allow prompt reinsertion of the catheter should the patient’s condition become unstable. Injection of the main renal artery demonstrated an area of irregularity (arrowhead) along one of the ventral branches of the renal artery, a finding indicative of a laceration. (d) Note the opacification of the nephrostomy track, which indicates the volume of blood loss. (e) Embolization of the lacerated vessel with a coil (arrow) resulted in abrupt cessation of the bleeding. No further bleeding occurred.
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Figure 16a. Pseudoaneurysm resulting from puncture of a ventral branch vessel after nephrostomy tube placement. (a) Radiograph shows a nephrostomy tube, which was placed for stone removal. The tube was removed without incident, but the patient developed gross hematuria several days after tube removal. The patient was referred for angiographic investigation. (b) Selective right renal angiogram shows a pseudoaneurysm (arrow) involving a lower-pole ventral branch. This site of vascular injury is not susceptible to tamponade by the nephrostomy tube. (c) Angiogram shows that coil embolization of the injured vessel resulted in loss of a small amount of renal parenchyma. The hematuria promptly resolved.
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Figure 16b. Pseudoaneurysm resulting from puncture of a ventral branch vessel after nephrostomy tube placement. (a) Radiograph shows a nephrostomy tube, which was placed for stone removal. The tube was removed without incident, but the patient developed gross hematuria several days after tube removal. The patient was referred for angiographic investigation. (b) Selective right renal angiogram shows a pseudoaneurysm (arrow) involving a lower-pole ventral branch. This site of vascular injury is not susceptible to tamponade by the nephrostomy tube. (c) Angiogram shows that coil embolization of the injured vessel resulted in loss of a small amount of renal parenchyma. The hematuria promptly resolved.
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Figure 16c. Pseudoaneurysm resulting from puncture of a ventral branch vessel after nephrostomy tube placement. (a) Radiograph shows a nephrostomy tube, which was placed for stone removal. The tube was removed without incident, but the patient developed gross hematuria several days after tube removal. The patient was referred for angiographic investigation. (b) Selective right renal angiogram shows a pseudoaneurysm (arrow) involving a lower-pole ventral branch. This site of vascular injury is not susceptible to tamponade by the nephrostomy tube. (c) Angiogram shows that coil embolization of the injured vessel resulted in loss of a small amount of renal parenchyma. The hematuria promptly resolved.
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Figure 17a. Arteriovenous fistula. After percutaneous stone retrieval, the patient developed gross hematuria 2 days after nephrostomy tube removal. (a) Image from right-sided retrograde urography shows a filling defect in the renal pelvis that extends into the ureter. (b) Selective right renal angiogram shows injury to a ventral branch. (c) Angiogram shows prompt filling of the renal vein. These angiographic findings are indicative of an arteriovenous fistula. (d) Radiograph shows that the source artery was embolized with a Gianturco coil (arrow). The embolization resulted in prompt cessation of the hematuria.
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Figure 17b. Arteriovenous fistula. After percutaneous stone retrieval, the patient developed gross hematuria 2 days after nephrostomy tube removal. (a) Image from right-sided retrograde urography shows a filling defect in the renal pelvis that extends into the ureter. (b) Selective right renal angiogram shows injury to a ventral branch. (c) Angiogram shows prompt filling of the renal vein. These angiographic findings are indicative of an arteriovenous fistula. (d) Radiograph shows that the source artery was embolized with a Gianturco coil (arrow). The embolization resulted in prompt cessation of the hematuria.
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Figure 17c. Arteriovenous fistula. After percutaneous stone retrieval, the patient developed gross hematuria 2 days after nephrostomy tube removal. (a) Image from right-sided retrograde urography shows a filling defect in the renal pelvis that extends into the ureter. (b) Selective right renal angiogram shows injury to a ventral branch. (c) Angiogram shows prompt filling of the renal vein. These angiographic findings are indicative of an arteriovenous fistula. (d) Radiograph shows that the source artery was embolized with a Gianturco coil (arrow). The embolization resulted in prompt cessation of the hematuria.
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Figure 17d. Arteriovenous fistula. After percutaneous stone retrieval, the patient developed gross hematuria 2 days after nephrostomy tube removal. (a) Image from right-sided retrograde urography shows a filling defect in the renal pelvis that extends into the ureter. (b) Selective right renal angiogram shows injury to a ventral branch. (c) Angiogram shows prompt filling of the renal vein. These angiographic findings are indicative of an arteriovenous fistula. (d) Radiograph shows that the source artery was embolized with a Gianturco coil (arrow). The embolization resulted in prompt cessation of the hematuria.
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Instrumentation of the obstructed urinary tract poses a risk of septic complications (1%–2.5%). Manipulation must be kept to a minimum in patients with obstruction complicated by infection. Further imaging and manipulation should be undertaken only after 48–72 hours of external urinary drainage, institution of appropriate antibiotic therapy, and clinical stabilization (28,31). The prevalence of septic complications in patients with pyonephrosis who undergo percutaneous drainage is 25% or greater (33,35).
Puncture of adjacent organs may also occur. A retrorenal colon, an uncommon anatomic variant, may be transgressed (36–38) (Fig 18). Hydrothorax and pneumothorax can also occur (0.1%–0.3%), and their prevalence increases with supracostal entries (39,40) (Fig 19). Complications related to violation of the pleural space are likely to increase in number with the greater use of access to the upper-pole collecting system for stone therapy.
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Figure 18a. Colon injury. Nephrostomy tube placement was undertaken for complex stone disease. During placement, the operator noted a large amount of air exiting the nephrostomy track. Therefore, a small-bore tube was placed, and the patient was evaluated with CT. (a) CT scan obtained through the middle of the left kidney shows a small amount of air in the collecting system. The high attenuation in the collecting system is a combination of contrast material and a stone. Note the contrast material (arrow) in the colon. No oral contrast material had been administered. (b) CT scan shows that the nephrostomy tube has passed through the most posterior aspect of a retrorenal colon (arrow). Conservative management of this complication may be possible. (c) Radiograph shows that the nephrostomy tube has been withdrawn over a guide wire and positioned in the colon. An internal double-J stent is then placed to ensure antegrade urine flow. The stent should allow the potential communication between the kidney and the colon to seal. The percutaneous access into the colon is allowed to epithelialize for 10-14 days. The patient is also placed on a regimen of broadspectrum antibiotics. Before tube removal, repeat CT is performed to ensure that there has been no development of an infectious complication in the retroperitoneum. Although no surgery was required in this case and the stones were later removed via a higher access, such patients require close monitoring and follow-up.
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Figure 18b. Colon injury. Nephrostomy tube placement was undertaken for complex stone disease. During placement, the operator noted a large amount of air exiting the nephrostomy track. Therefore, a small-bore tube was placed, and the patient was evaluated with CT. (a) CT scan obtained through the middle of the left kidney shows a small amount of air in the collecting system. The high attenuation in the collecting system is a combination of contrast material and a stone. Note the contrast material (arrow) in the colon. No oral contrast material had been administered. (b) CT scan shows that the nephrostomy tube has passed through the most posterior aspect of a retrorenal colon (arrow). Conservative management of this complication may be possible. (c) Radiograph shows that the nephrostomy tube has been withdrawn over a guide wire and positioned in the colon. An internal double-J stent is then placed to ensure antegrade urine flow. The stent should allow the potential communication between the kidney and the colon to seal. The percutaneous access into the colon is allowed to epithelialize for 10-14 days. The patient is also placed on a regimen of broadspectrum antibiotics. Before tube removal, repeat CT is performed to ensure that there has been no development of an infectious complication in the retroperitoneum. Although no surgery was required in this case and the stones were later removed via a higher access, such patients require close monitoring and follow-up.
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Figure 18c. Colon injury. Nephrostomy tube placement was undertaken for complex stone disease. During placement, the operator noted a large amount of air exiting the nephrostomy track. Therefore, a small-bore tube was placed, and the patient was evaluated with CT. (a) CT scan obtained through the middle of the left kidney shows a small amount of air in the collecting system. The high attenuation in the collecting system is a combination of contrast material and a stone. Note the contrast material (arrow) in the colon. No oral contrast material had been administered. (b) CT scan shows that the nephrostomy tube has passed through the most posterior aspect of a retrorenal colon (arrow). Conservative management of this complication may be possible. (c) Radiograph shows that the nephrostomy tube has been withdrawn over a guide wire and positioned in the colon. An internal double-J stent is then placed to ensure antegrade urine flow. The stent should allow the potential communication between the kidney and the colon to seal. The percutaneous access into the colon is allowed to epithelialize for 10-14 days. The patient is also placed on a regimen of broadspectrum antibiotics. Before tube removal, repeat CT is performed to ensure that there has been no development of an infectious complication in the retroperitoneum. Although no surgery was required in this case and the stones were later removed via a higher access, such patients require close monitoring and follow-up.
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Figure 19. Hydropneumothorax. Upper-pole access has the potential for the greatest visualization of the collecting system. However, there is increased risk of transgression of the pleural space. Nephrostogram obtained before removal of a large-bore tube shows a communication between the nephrostomy track and the pleural space. The patient was asymptomatic. In this case, the nephrostomy tube was left in place to allow the track to epithelialize. At removal, the tube is treated in a similar fashion as a chest tube. No sequelae occurred in this patient. In a symptomatic patient with pneumo- or hydrothorax, placement of a small-bore chest tube may be necessary. (Reprinted, with permission, from reference 3.)
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Conclusions
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The safe creation of nephrostomy access provides minimally invasive alternatives for therapy of a number of urologic conditions. Familiarity with the basic procedure and its extensions is important, along with knowledge of the potential complications.
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References
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Abstract
Introduction
