Nephrostomy Tube

Aka: Nephrostomy Tube, Nephrostomy, Nephrostomy Tube Placement, Percutaneous Nephrostomy, Post-Nephrostomy Tube Infection, Nephrostomy Tube Obstruction

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II. Definitions

  1. Nephrostomy
    1. Surgery to precutaneously (via the skin) access the renal Pelvis
    2. Performed to drain urine in cases of obstructed outflow (e.g. Ureteral Stone), renal stone extraction, medication instillation or endoscopy
  2. Nephrostomy Tube
    1. Catheter tube placed between the skin and the renal Pelvis or calyx in order to drain urine (bypassing the ureter)

III. Indications: Nephrostomy Tube

  1. Urinary obstruction
  2. Urinary diversion
  3. Chemotherapy installation
  4. Endoscopy or other diagnostic testing

IV. Efficacy

  1. Successful placement in 99% of indicated cases
  2. Overall complication rate: <5%

V. Complications: Minor

  1. Skin entry site inflammation (redness, pain)
    1. Evaluate for localized Skin Infection
    2. Granulation tissue and scabbing is common around the insertion site and requires no management
    3. Consider irritation from adhesive dressing or from concentrated urine
      1. Change dressings frequently
      2. Consider Topical Antibiotic or skin protectants (e.g. aquaphor)
  2. Urine leak
    1. Evaluate for collection bag failure (check bag integrity and consider changing)
    2. Evaluate flange for decreased adhesion
    3. Remove hair around the skin anchoring site
  3. Decreased Urine Output
    1. Evaluate hydration status and fluid intake
    2. Evaluate tube for kinks and obstruction (see below)
    3. Evaluate capping applied to tube
    4. May also be affected by patient positioning (in relation to gravity)

VI. Complications: Tube Obstruction

  1. Causes
    1. Increased fluid viscosity
    2. Hypercalciuria
    3. Hyperuricosuria
  2. Differential Diagnosis
    1. Hematoma
    2. Abscess or other infection
    3. Kinked tube
    4. Dislodged Nephrostomy Tube
    5. Valve system incorrect setup
    6. Collection bag damage or dysfunction
  3. Management: Initial tube Flushing and irrigation attempt
    1. Disconnect Nephrostomy Tube from the collection bag using sterile technique
    2. Clean the Nephrostomy Tube tip with Alcohol or Chlorhexidine
    3. Draw 10 cc of sterile saline or sterile water into a syringe
    4. Attempt to gently flush the Nephrostomy Tube with syringe
      1. Avoid aggressive Flushing that may result in renal Trauma
      2. Gently withdraw the syringe plunger if obstruction is met
      3. Reattempt Flushing the tube
    5. Disposition if tube obstruction cleared
      1. Discharge home with instructions for Nephrostomy Tube care and follow-up
  4. Management: Refractory Obstruction
    1. Consider differential diagnosis of tube obstruction (see above)
    2. Evaluation
      1. Complete Blood Count
      2. Basic metabolic panel
      3. Imaging with CT Abdomen and Pelvis with IV contrast (with or without renal Ultrasound)
    3. Specialty Consultation (Tube Placement Consultant: Intervention Radiology or Urology)
      1. Urgent Consultation if anuric or Acute Kidney Injury, or if patient Immunocompromised

VII. Complications: Tube Dislodged or Kinked

  1. Tubes dislodge in 5% of cases (esp. BMI >35 kg/m2)
  2. Findings
    1. Flank Pain or back pain
    2. Decreased Urine Output
    3. Nephrostomy site bleeding or urine leakage
    4. Presentation of a refractory tube obstruction that does not clear with tube Flushing
  3. Management
    1. If tube obstruction presentation, attempt initial management as above
    2. Obtain CT Abdomen and Pelvis with IV contrast to evaluate tube position
    3. Consult placing consultant for dislodged or kinked Nephrostomy Tube

VIII. Complications: Post-Nephrostomy Tube Infection (Pyonephrosis)

  1. Epidemiology
    1. Onset within first 6-7 weeks of tube placement in most cases
    2. Incidence of post-tube infection: <14%
      1. Asymptomatic Bacteriuria in 7.5% of cases
      2. Highest risk when purulent material aspirated during Nephrostomy Tube Placement
  2. Findings
    1. Systemic infection signs (e.g. fever, chills, Vital Sign changes)
      1. Sepsis and Septic Shock develops in as many as 60% of post-Nephrostomy infection patients
    2. Flank Pain or back pain
    3. Leukocytosis
    4. Urine changes (foul odor, Hematuria, decreased Urine Output)
  3. Causes
    1. Pseudomonas
    2. Escherichia coli
    3. Enterococcus
    4. Klebsiella
    5. Proteus
  4. Evaluation
    1. Complete Blood Count
    2. Basic chemistry panel
    3. Urinalysis and Urine Culture
      1. Obtain urine sample from Nephrostomy Tube (not the collection bag)
      2. Using sterile technique, detach collection bag, clean port with Alcohol swab
      3. Collect urine in sterile specimen cup (allowing drainage via gravity)
      4. Reconnect Nephrostomy Tube to a new collecting bag
      5. Anchor Nephrostomy Tube to prevent dislodgement
    4. Blood Cultures and Lactic Acid (if Sepsis)
    5. CT Abdomen and Pelvis with IV Contrast (if renal abscess or tube obstruction suspected)
  5. Management
    1. Initiate antibiotics for acute, severe Pyelonephritis with catheter associated UTI
    2. Antibiotics should also cover MRSA if patient Sepsis
    3. Consult for tube exchange

IX. Complications: Bleeding or Hematuria

  1. Types
    1. Early Gross Hematuria (first 2-3 days)
      1. Common and expected post-operative bleeding following Nephrostomy Tube Placement
      2. Significant Hemorrhage occurs in up to 4 of patients
      3. Higher risk in patients with preoperative Renal Failure
    2. Delayed Hematoma or Hematuria (>2-3 days after tube placement)
      1. May present weeks to months after Nephrostomy Tube Placement
      2. Most commonly due to intraoperative vascular injury with secondary formation of AV fistula, Hematoma or pseudoaneurysm
      3. In significant blood loss and secondary Anemia, cardiopulmonary symptoms may be present (e.g. Tachycardia, Dyspnea, Syncope)
  2. Evaluation (significant bleeding)
    1. Complete Blood Count
    2. Basic metabolic panel
    3. Urinalysis
    4. INR and PTT
    5. ABO Type and Screen
    6. Bedside Ultrasound (may demonstrate Hydronephrosis, Hematoma)
    7. CT Angiogram Abdomen
  3. Complications
    1. Tube Obstruction (Hematoma related)
    2. Acute Kidney Injury
    3. Anemia
  4. Management
    1. Manage Hemorrhagic Shock
    2. Specialty Consultation
    3. Angiograph with Embolization Indications
      1. Hemorrhagic Shock
      2. Increasing, refractory Hematuria
      3. Hematoma

X. Complications: Lung Injury (during placement)

  1. Complicates 0.3% of Nephrostomy Tube Placements
    1. Pneumothorax
    2. Hydrothorax
    3. Pleural Effusion
  2. Risk Factors
    1. Intercostal renal access between 11th and 12th ribs (higher risk than subcostal approach)
  3. Findings
    1. Decreased breath sounds
    2. Hypoxia
    3. Pleuritic Chest Pain
    4. Hypotension

XI. Resources

  1. Percutaneous Nephrostomy (Stat Pearls)
    1. https://www.ncbi.nlm.nih.gov/books/NBK493205/

XII. References

  1. Long and Swaminathan in Swadron (2022) EM:Rap 22(10): 10-14
  2. Yoo (2021) Am J Emerg Med 50:592-6 +PMID: 34592566 [PubMed]

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