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{{Short description|Surgical procedure that creates a long-term opening between the kidney and the skin}}
{{Interventions infobox |
{{Infobox interventions |
Name = Nephrostomy |
Name = Nephrostomy |
Image = N01224 H nephrostomy.jpg|
Image = N01224 H nephrostomy.jpg|
Line 6: Line 7:
ICD9 = {{ICD9proc|55.02}} |
ICD9 = {{ICD9proc|55.02}} |
MeshID = D009403 |
MeshID = D009403 |
OPS301 = {{OPS301|5-550}} |
OtherCodes = |
OtherCodes = |
}}
}}
[[File:Ultrasonography of percutaneous nephrostomy tube.jpg|thumb|right|(A) [[Renal ultrasonograph]] of [[percutaneous]] nephrostomy tube placed through a calyx in the lower pole of a kidney with hydronephrosis. (B) The pigtail catheter is placed in the dilated calyx. The tube in (A) and the pigtail in (B) are marked with white arrows.<ref name=Hansen2015>Content initially copied from: {{cite journal | vauthors = Hansen KL, Nielsen MB, Ewertsen C | title = Ultrasonography of the Kidney: A Pictorial Review | journal = Diagnostics | volume = 6 | issue = 1 | pages = 2 | date = December 2015 | pmid = 26838799 | pmc = 4808817 | doi = 10.3390/diagnostics6010002 | doi-access = free }} [https://creativecommons.org/licenses/by/4.0/ (CC-BY 4.0)]</ref>]]
A '''nephrostomy''' is an artificial opening created between the [[kidney]] and the [[skin]] which allows for the [[urinary diversion]] directly from the upper part of the urinary system ([[renal pelvis]]).
A '''nephrostomy''' or '''percutaneous nephrostomy''' is an artificial opening created between the [[kidney]] and the [[skin]] which allows for the [[urinary diversion]] directly from the upper part of the urinary system ([[renal pelvis]]).<ref>{{Citation |last=Young |first=Michael |title=Percutaneous Nephrostomy |date=2022 |url=https://www.ncbi.nlm.nih.gov/books/NBK493205/ |work=StatPearls |access-date=2023-11-24 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29630257 |last2=Leslie |first2=Stephen}}</ref> It is an [[interventional radiology]]/[[surgical procedure]] in which the [[renal pelvis]] is punctured whilst using imaging as guidance. Images are obtained once an antegrade [[pyelogram]] (an injection of contrast), with a fine needle, has been performed. A nephrostomy tube may then be placed to allow drainage.<ref name="OHCM">{{cite book | vauthors = Longmore M, Wilkinson I, Turmezei T, Cheung CK | title=Oxford Handbook of Clinical Medicine | edition = 7th | publisher=Oxford University Press | year=2007 | pages=731 | isbn=978-0-19-856837-7 }}</ref>


An [[urostomy]] is a related procedure performed more distally along the urinary system to provide urinary diversion.
An [[urostomy]] is a related procedure performed more distally along the urinary system to provide urinary diversion.


==Uses==
==Uses==
A nephrostomy is performed whenever a blockage keeps urine from passing from the kidneys, through the [[ureter]] and into the [[urinary bladder]]. Without another way for urine to drain, pressure would rise within the urinary system and the kidneys would be damaged.
A nephrostomy is performed whenever a blockage keeps urine from passing from the kidneys, through the [[ureter]] and into the [[urinary bladder]]. Without another way for urine to drain, pressure would rise within the urinary system and the kidneys would be damaged.<ref>[[NHS]] University Hospital of North Midlands - Patients Information Leaflet 2024</ref>


The most common cause of blockage necessitating a nephrostomy is [[cancer]], especially [[ovarian cancer]] and [[colon cancer]]. Nephrostomies may also be required to treat [[pyonephrosis]], [[hydronephrosis]] and [[nephrolithiasis|kidney stones]].
The most common cause of blockage necessitating a nephrostomy is [[cancer]], especially [[ovarian cancer]] and [[colon cancer]]. Nephrostomies may also be required to treat [[pyonephrosis]], [[hydronephrosis]] and [[nephrolithiasis|kidney stones]].<ref name="Hautmann2015">{{cite web |url=http://emedicine.medscape.com/article/445893-overview?pa=pC8%2FFlcO9Ct%2BlOAK%2FAKFNgiS1HjlvHRvG3BSLJo75GId1slAYaK5a0AD6KQl97Q5dBf%2Feq%2FcP1%2F%2BlH9e44KIdVYqX3o7uERl4%2FsN1L4s3ks%3D |title=Nephrostomy |last=Hautmann |first=Stefan H |date=October 22, 2015 |website=Medscape |publisher=WebMD LLC |access-date=September 16, 2017 }}</ref>

===Diagnosis===
Percutaneous nephrostomy is used in Whitaker test to differentiate recurrent obstruction or permanent dilatation after an operative surgery that corrects the cause of obstruction. This procedure is also used for [[Pyelogram#Anterograde pyelogram|antegrade pyelography]] to visualize the upper urinary tract system.<ref name="Jairath 2017">{{cite journal | vauthors = Jairath A, Ganpule A, Desai M |date=2017-11-29 |title=Percutaneous nephrostomy step by step |url=http://misjournal.net/article/view/2173 |journal=Mini-invasive Surgery |volume=1 |pages=180–185 |doi=10.20517/2574-1225.2017.24 |issn=2574-1225|doi-access=free }}</ref>

===Treatment===
Percutaneous nephrostomy is also used to treat [[hydronephrosis]] caused by kidney stones, pregnancy, stricture of the urinary tract, urinary tract/cervical/prostate tumours. Besides, infections such as urosepsis and [[pyonephrosis]] can also be drained by nephrostomy tube insertion.<ref name="Jairath 2017"/> Percutaneous nephrostomy is also useful in divert urine away from diseased site to enhance healing. Examples of conditions that can be treated with such method are malignant/traumatic/inflammatory [[fistula]], and [[haemorrhagic cystitis]].<ref name="Jairath 2017"/>

Percutaneous nephrostomy is also used to provide access for chemotherapy/antibiotic/antifungal therapy, antegrade urethral stent placement, stone retrieval, and endopyelotomy (endoscopic surgery for the enlargement of the junction of renal pelvis and ureter).<ref name="Jairath 2017"/>


==Process==
==Process==
[[File:Pigtail catheter settings.jpg|thumb|300px|Various settings of a 6 [[French catheter scale|French]] pigtail catheter with locking string, obturator (also called ''stiffening cannula'') and puncture needle. <br>'''A'''. Overview <br>'''B'''. Both puncture needle and obturator engaged, allowing for direct insertion. <br>'''C'''. Puncture needle retracted. Obturator engaged. Used for example in steady advancement of the catheter on a guidewire previously inserted into the renal pelvis through a thin needle.<br>'''D'''. Both obturator and puncture needle retracted, when the catheter is in the renal pelvis. <br>'''E'''. Locking string is pulled (bottom center) and then wrapped and attach to the superficial end of the catheter.]]
Nephrostomies are created by [[surgeon]]s or [[interventional radiology|interventional radiologist]]s and typically consist of a [[catheter]] which pierces the [[skin]] and rests in the [[urinary tract]]. It is performed under ultrasound guidance, CT fluoroscopy or under image intensifier. Local anesthetic infiltration is used to numb the area where the needle would pass through to make the puncture on the kidney.

Nephrostomies are created either by [[surgeon]]s or [[interventional radiology|interventional radiologist]]s.

Under interventional radiology, the subject either lies down on the side or in a prone position. An area is selected below the 12th rib, bounded laterally by the posterior axillary line and the muscles of the spine and from below by the pelvic bone. The exact area is then located by ultrasound. Local anesthetic infiltration is used to numb the area. Then a needle would pass through to make the puncture on the kidney. Then, urine from the kidney is aspirated and check for its contents. If the urine is clear, dye will be injected to delineate the [[renal pelvis]] and [[renal calyx]]. If the urine is turbid, it means the urine is infected. Dye injection is avoided in case of turbid urine to prevent the spread of infection to other parts of the urinary system.<ref name="Jairath 2017"/> Then, a guidewire is inserted into the through the needle and parked within the upper renal calyx or within the [[ureter]] under [[fluoroscopy]] guidance. Then the puncture tract is dilated using a dilator.<ref name="Jairath 2017"/> Various types of catheters such as pigtail catheter<ref>{{Cite journal |last=Elyaderani |first=Morteza K. |last2=Dorn |first2=Jonathan S. |last3=Gabriele |first3=O. F. |date=September 1979 |title=Percutaneous Nephrostomy Utilizing a Pigtail Catheter: A New Technique |url=http://pubs.rsna.org/doi/10.1148/132.3.750 |journal=Radiology |language=en |volume=132 |issue=3 |pages=750–750 |doi=10.1148/132.3.750 |issn=0033-8419}}</ref> or Malecot catheter (a catheter that has a special mechanism for preventing blockage in case of thick pus in [[pyonephrosis]] and not easily dislodged when compared to pigtail catheter) can be used.<ref name="Jairath 2017"/> The catheter is inserted through the guidewire and is secured in place by suturing it to the skin. The other end of the catheter is attached to a urine bag for drainage of urine from the kidney.<ref name="Jairath 2017"/>

==Risks==
Percutaneous nephrostomy is overall a very safe procedure.<ref name=uhs>{{cite web|url=http://www.uhs.nhs.uk/OurServices/Radiology-scansandimaging/PatientInformation/PercutaneousNephrostomy.aspx|title=Percutaneous Nephrostomy|website=University Hospital Southampton, NHS Foundation Trust|access-date=2019-02-06}}</ref> Risks and complications include:<ref name=uhs/>
* Malposition
* Intra-[[peritoneal]] leakage, causing [[ascites]]
* [[Hemorrhage]]
* [[Infection]]. This can generally be treated with [[antibiotics]].

Although pneumothorax and colonic injury are more common on subcostal needle insertion, these are rare complications.<ref name="Jairath 2017"/>


Blood in urine usually clears up after 48 to 72 hours. Bleeding longer than this period may signifies more serious bleeding complication. About 2–4% of percutaneous nephrostomy cases require blood transfusion.<ref>{{cite journal | vauthors = Smith M, Rochon PJ, Ray CE | title = Traversing the Renal Pelvis during Percutaneous Nephrostomy Tube Placement ("Kidney Kabob") | journal = Seminars in Interventional Radiology | volume = 29 | issue = 2 | pages = 150–152 | date = June 2012 | pmid = 23729987 | pmc = 3444877 | doi = 10.1055/s-0032-1312578 }}</ref> Arteriovenous fistula is a rare complication.<ref name="pmid8304796">{{cite journal | vauthors = Marchal Escalona C, Chicharro Molero JA, del Rosal Samaniego JM, Ruíz Domínguez JL, Fuentes Lupiañez C, Burgos Rodríguez R | title = [An arteriovenous fistula as a complication of percutaneous nephrostomy] | language = es | journal = Archivos Espanoles De Urologia | volume = 46 | issue = 9 | pages = 807–9 | date = November 1993 | pmid = 8304796 | doi = | url = }}</ref>
Newer technologies such as 3D fluoroscopy are being developed to aid in placement of these types of drainage tubes.<ref>Macaluso JN: Editorial Comment Urology March 2009 Vol. 73, Issue 3, 652-653, on Effectiveness of Three-dimensional Fluoroscopy in Percutaneous Nephrostomy: An Animal Model Study March 2009 Vol. 73, Issue 3, 649-652</ref>


The [[BMJ]] has published original research of this condition and its treatment,
Urine is collected in an external bag which can be emptied as often as necessary.
* Malignant ureteric obstruction (MUO) in the context of metastatic cancer indicates a poor prognosis.
* Nephrostomy is commonly used for renal decompression in these cases but rarely confers survival benefit.
* Living with a nephrostomy is associated with complications and a reduced quality of life.
* The extremely poor mortality ... displayed in this study will aid clinicians in being more selective when offering patients nephrostomy when presenting with MUO.<ref>[[BMJ]] report "High early mortality following percutaneous nephrostomy in metastatic cancer: a national analysis of outcomes"; Amandeep Dosanjh1, Benjamin Coupland, Jemma Mytton, Stephen King, Harriet Mintz, Anna Lock, Veronica Nanton, Param Mariappan, Nigel Trudgill and Prashant Patel,[[https://spcare.bmj.com/content/14/e2/e2100]]{{Creative Commons text attribution notice|cc=by4|from this source=yes}}</ref>


== See also ==
== See also ==
* [[Interventional Radiology]]
* [[Interventional radiology]]
* [[List of surgeries by type]]


==References==
==References==
{{reflist}}
<references/>


==External links==
==External links==
*[http://www.cirse.org/index.php?pid=85 Cardiovascular and Interventional Radiological Society of Europe]
* [http://www.cirse.org/index.php?pid=85 Cardiovascular and Interventional Radiological Society of Europe]
{{Urologic surgical and other procedures}}
{{Urologic surgical and other procedures}}
{{Ectomy, stomy, and otomy}}


[[Category:Urologic surgery]]
[[Category:Urologic surgery]]
[[Category:Interventional radiology]]
[[Category:Nephrology]]

Latest revision as of 21:28, 21 December 2024

Nephrostomy
Drawing of a nephrostomy tube in a human female
ICD-9-CM55.02
MeSHD009403
OPS-301 code5-550
(A) Renal ultrasonograph of percutaneous nephrostomy tube placed through a calyx in the lower pole of a kidney with hydronephrosis. (B) The pigtail catheter is placed in the dilated calyx. The tube in (A) and the pigtail in (B) are marked with white arrows.[1]

A nephrostomy or percutaneous nephrostomy is an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system (renal pelvis).[2] It is an interventional radiology/surgical procedure in which the renal pelvis is punctured whilst using imaging as guidance. Images are obtained once an antegrade pyelogram (an injection of contrast), with a fine needle, has been performed. A nephrostomy tube may then be placed to allow drainage.[3]

An urostomy is a related procedure performed more distally along the urinary system to provide urinary diversion.

Uses

[edit]

A nephrostomy is performed whenever a blockage keeps urine from passing from the kidneys, through the ureter and into the urinary bladder. Without another way for urine to drain, pressure would rise within the urinary system and the kidneys would be damaged.[4]

The most common cause of blockage necessitating a nephrostomy is cancer, especially ovarian cancer and colon cancer. Nephrostomies may also be required to treat pyonephrosis, hydronephrosis and kidney stones.[5]

Diagnosis

[edit]

Percutaneous nephrostomy is used in Whitaker test to differentiate recurrent obstruction or permanent dilatation after an operative surgery that corrects the cause of obstruction. This procedure is also used for antegrade pyelography to visualize the upper urinary tract system.[6]

Treatment

[edit]

Percutaneous nephrostomy is also used to treat hydronephrosis caused by kidney stones, pregnancy, stricture of the urinary tract, urinary tract/cervical/prostate tumours. Besides, infections such as urosepsis and pyonephrosis can also be drained by nephrostomy tube insertion.[6] Percutaneous nephrostomy is also useful in divert urine away from diseased site to enhance healing. Examples of conditions that can be treated with such method are malignant/traumatic/inflammatory fistula, and haemorrhagic cystitis.[6]

Percutaneous nephrostomy is also used to provide access for chemotherapy/antibiotic/antifungal therapy, antegrade urethral stent placement, stone retrieval, and endopyelotomy (endoscopic surgery for the enlargement of the junction of renal pelvis and ureter).[6]

Process

[edit]
Various settings of a 6 French pigtail catheter with locking string, obturator (also called stiffening cannula) and puncture needle.
A. Overview
B. Both puncture needle and obturator engaged, allowing for direct insertion.
C. Puncture needle retracted. Obturator engaged. Used for example in steady advancement of the catheter on a guidewire previously inserted into the renal pelvis through a thin needle.
D. Both obturator and puncture needle retracted, when the catheter is in the renal pelvis.
E. Locking string is pulled (bottom center) and then wrapped and attach to the superficial end of the catheter.

Nephrostomies are created either by surgeons or interventional radiologists.

Under interventional radiology, the subject either lies down on the side or in a prone position. An area is selected below the 12th rib, bounded laterally by the posterior axillary line and the muscles of the spine and from below by the pelvic bone. The exact area is then located by ultrasound. Local anesthetic infiltration is used to numb the area. Then a needle would pass through to make the puncture on the kidney. Then, urine from the kidney is aspirated and check for its contents. If the urine is clear, dye will be injected to delineate the renal pelvis and renal calyx. If the urine is turbid, it means the urine is infected. Dye injection is avoided in case of turbid urine to prevent the spread of infection to other parts of the urinary system.[6] Then, a guidewire is inserted into the through the needle and parked within the upper renal calyx or within the ureter under fluoroscopy guidance. Then the puncture tract is dilated using a dilator.[6] Various types of catheters such as pigtail catheter[7] or Malecot catheter (a catheter that has a special mechanism for preventing blockage in case of thick pus in pyonephrosis and not easily dislodged when compared to pigtail catheter) can be used.[6] The catheter is inserted through the guidewire and is secured in place by suturing it to the skin. The other end of the catheter is attached to a urine bag for drainage of urine from the kidney.[6]

Risks

[edit]

Percutaneous nephrostomy is overall a very safe procedure.[8] Risks and complications include:[8]

Although pneumothorax and colonic injury are more common on subcostal needle insertion, these are rare complications.[6]

Blood in urine usually clears up after 48 to 72 hours. Bleeding longer than this period may signifies more serious bleeding complication. About 2–4% of percutaneous nephrostomy cases require blood transfusion.[9] Arteriovenous fistula is a rare complication.[10]

The BMJ has published original research of this condition and its treatment,

  • Malignant ureteric obstruction (MUO) in the context of metastatic cancer indicates a poor prognosis.
  • Nephrostomy is commonly used for renal decompression in these cases but rarely confers survival benefit.
  • Living with a nephrostomy is associated with complications and a reduced quality of life.
  • The extremely poor mortality ... displayed in this study will aid clinicians in being more selective when offering patients nephrostomy when presenting with MUO.[11]

See also

[edit]

References

[edit]
  1. ^ Content initially copied from: Hansen KL, Nielsen MB, Ewertsen C (December 2015). "Ultrasonography of the Kidney: A Pictorial Review". Diagnostics. 6 (1): 2. doi:10.3390/diagnostics6010002. PMC 4808817. PMID 26838799. (CC-BY 4.0)
  2. ^ Young, Michael; Leslie, Stephen (2022), "Percutaneous Nephrostomy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29630257, retrieved 2023-11-24
  3. ^ Longmore M, Wilkinson I, Turmezei T, Cheung CK (2007). Oxford Handbook of Clinical Medicine (7th ed.). Oxford University Press. p. 731. ISBN 978-0-19-856837-7.
  4. ^ NHS University Hospital of North Midlands - Patients Information Leaflet 2024
  5. ^ Hautmann, Stefan H (October 22, 2015). "Nephrostomy". Medscape. WebMD LLC. Retrieved September 16, 2017.
  6. ^ a b c d e f g h i Jairath A, Ganpule A, Desai M (2017-11-29). "Percutaneous nephrostomy step by step". Mini-invasive Surgery. 1: 180–185. doi:10.20517/2574-1225.2017.24. ISSN 2574-1225.
  7. ^ Elyaderani, Morteza K.; Dorn, Jonathan S.; Gabriele, O. F. (September 1979). "Percutaneous Nephrostomy Utilizing a Pigtail Catheter: A New Technique". Radiology. 132 (3): 750–750. doi:10.1148/132.3.750. ISSN 0033-8419.
  8. ^ a b "Percutaneous Nephrostomy". University Hospital Southampton, NHS Foundation Trust. Retrieved 2019-02-06.
  9. ^ Smith M, Rochon PJ, Ray CE (June 2012). "Traversing the Renal Pelvis during Percutaneous Nephrostomy Tube Placement ("Kidney Kabob")". Seminars in Interventional Radiology. 29 (2): 150–152. doi:10.1055/s-0032-1312578. PMC 3444877. PMID 23729987.
  10. ^ Marchal Escalona C, Chicharro Molero JA, del Rosal Samaniego JM, Ruíz Domínguez JL, Fuentes Lupiañez C, Burgos Rodríguez R (November 1993). "[An arteriovenous fistula as a complication of percutaneous nephrostomy]". Archivos Espanoles De Urologia (in Spanish). 46 (9): 807–9. PMID 8304796.
  11. ^ BMJ report "High early mortality following percutaneous nephrostomy in metastatic cancer: a national analysis of outcomes"; Amandeep Dosanjh1, Benjamin Coupland, Jemma Mytton, Stephen King, Harriet Mintz, Anna Lock, Veronica Nanton, Param Mariappan, Nigel Trudgill and Prashant Patel,[[1]] This article incorporates text from this source, which is available under the CC BY 4.0 license.
[edit]
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