Nephrostomy

1. Nephrostomy Dr Christopher Watts Consultant Radiologist Salisbury District Hospital

2. Talk Overview • Indications & Contraindications • Patient preparation • Consent • Kit • Techniques – dilated and non dilated kidney • Complications

3. Indications • Relief of Urinary Obstruction • Urosepsis or possible infection • Acute Renal failure • Urinary Diversion • Haemorrhagic cystitis • Trauma or iatrogenic ureteral injury • Inflammatory or malignant urinary fistula • Access for endourological procedure • Dilating or stenting ureteral stricture • Biopsy or treatment of urothelial lesions • Foreign body retrieval

6. Contraindications Relative Absolute • ? None… • Dying patient • Uncorrectable severe coagulopathy / bleeding diathesis • Severe hyperkalaemia and/or metabolic acidosis • Pregnancy

7. IR or Urologists? • Part of RCR specialty IR training • Not just a drainage…. • Who should do it? • When should it be done? • During the day • Possibly during the night • Single kidney • Sepsis

8. The referral • Speak to your urologist • Get a detailed overview of the problem and the patient’s current state of health • Discuss the urgency of the case • Review relevant imaging • Is there another way?

9. Patient Preparation Bloods….. Bleeding Risk Assessment Evidence of coagulopathy Is the patient on warfarin FBC – plts >50 x 109 INR - <1.5 Hyperkalaemia K >6.5 – call your medic / anesthetist. Can the patient be dialysed?

10. Patient Preparation • Sedation • I like it BUT the patient may become agitated. • If giving conscious sedation the patient needs to be appropriately starved • 6 hours solids • 2 hours clear fluids • Combination of an opiate and benzodiazepine • E.g. morphine & Midazolam • Check local policy or guidelines • Monitoring and Oxygen

11. Patient Preparation • Antibiotics – evidence is weak • Potentially infected, obstructed system • Very easy to make the patient worse when trying to make them better • Septicaemia • Antibiotics to consider • Gentamycin 160-240mg IV • Cefuroxime 1.5gm iv • CHECK HOSPITAL GUIDELINES

12. Consent and Complications Major (<5%) • Septic Shock 1-3% ( <10% if pyonephrosis) • Haemorrhage • 1-4% • Bowel Transgression • <1% • Pleural Complications • <1%

13. SIR classification • MINOR • A no therapy or consequence • B nominal therapy, no consequence, overnight admission for observation only • MAJOR • C therapy , minor hospitalisation <48 hrs • D major therapy, increased care, prolonged hospitalisation >48hours • E permanent adverse sequelae • F death

14. Success Rates • Obstructed Dilated system without stones 95-98% • Non-dilated collecting system 80-85%

15. Where to Puncture? Considerations: • Anatomy – Where am I least likely to cause significant complications • Bleeding • Perforation • Pneumothorax • Next intervention • Simple nephrostomy • Ureteral intervention • Patient comfort

16. Bleeding • Renal artery divides into anterior an posterior branches • Posterior branch supplies 30% of the kidney • Brodel’s Line divides the area between the anterior and posterior division • RELATIVELY AVASCULAR

17. Other anatomical considerations LUNG BOWEL

18. Upper pole Puncture • May be easier for stenting but risks pleural transgression • Interpolar region • Reasonably safe, good for antegrade ureteric work • Lower pole • Safe. Simple for nephrostomy, may be harder for ureteric access

19. The Procedure • For dilated collecting systems • US puncture • For Non Dilated collecting systems • Not straightforward. • ‘Hybrid IVU’ • Frusemide • CT

20. Kit • Angiocath 16gu • Kellet Needle -19gu

21. Access Kits

22. Access Kits

23. KIT • 18 needle • Some sort of micropuncture kit • Eg Neff Set • 22gu access needle • Platinum tipped 018 wire • 4Fr catheter and metal stiffener • Outer 7Fr catheter • Ultrasound probe cover • Local – 1% lignocaine • Iodinated contrast and extension tube • Metal wire e.g. amplatz super stiff, J or Bentson • Dilate to 1Fr > than intended nephrostomy drain • 6-8Fr. • Drainage bag

24. Single Stick Technique

25. The Procedure • Performed Prone • Check with US access is suitable • TIPS • Pillow under the abdomen • Semi prone – kidney to puncture uppermost

28. Post Procedural Care • Bed Rest for 4hours • Obs – Bp/Pulse 30min for 4 hrs • Temperature

29. The Non Dilated System

30. Single stick v Double Stick

32. Non Dilated US guided • 22gu needle better for single stick • If good views may be successful • Small volumes of contrast • Consider frusemide to plump up the calyces • Eg 40mg IV -

33. Fluoro IVU US FIRST to ensure a safe passage 22Gu spinal needle 50 ml contrast >300mg/dl 5 mins CENTRED AP PELVIS PUNCTURE Aspirate – contrast – air Opposite 20° AO

34. CT guided

36. Complications

37. References Hausegger Percutaneous nephrostomy and antegrade ureteral stenting: technique— indications—complications.. Eur Radiol (2006) 16: 2016–2030 Patel & Hussain Percutaneous Nephrostomy of non-dilated renal collecting systems with fluoroscopic guidance: Techniques and Results.. Radiology 2004; 233:226-233 Barbaric et al. Percutaneous nephrostomy: placement under CT and fluoroscopic guidance. AJR 1997; 169(1):151-5 Gupta et al Ultrasound-guided percutaneous nephrostomy in non-dilated pelvicaliceal system. J Clin Ultrasound. 1998 Mar-Apr;26(3):177-9. Quality Improvement Guidelines for Percutaneous Nephrostomy J Vasc Interv Radiol 2003; 14:S277–S281 (SIR website)