Nephrostomy

A nephrostomy is used for 3 primary conditions:

Urinary tract obstruction — when urine cannot flow from the kidney to the bladder, because something is blocking the way. This could be due to a variety of causes including kidney stones, tumours (cervical, ovarian, colorectal, bladder or prostate cancers), strictures (an abnormal narrowing of a tube after surgery or radiation), blood clots, fungal balls or sloughed papillae.

Pyonephrosis — An infected, blocked kidney. Here, quick drainage can be life-saving,

Hydronephrosis — Swelling of the kidney due to back pressure. Urgent decompression can offer dramatic relief.

Doctors also place a nephrostomy tube, when a standard internal stent cannot be passed or when they need a safe channel to treat large and complex kidney stones later (PCNL). In certain cases, the tube allows doctors to pass medicines to the kidney, like a delivery pipeline. It can also help diagnose difficult blockages.

Overall, nephrostomy can be viewed as both treatment and a method of access for further treatment. As a treatment procedure, it helps relieve kidney pressure, control infection and protect kidney function. As access to further treatment, it is the first step for percutaneous nephrolithotomy (PCNL), it’s used to place stents (antegrade ureteric stent or nephroureteral stent) and for the delivery of medicines (for e.g., antifungals and stone-dissolving agents).

As explained above, a nephrostomy is indicated when it’s hard to pass urine — the kidney can’t pass the fluid normally to the bladder, because something is blocking the way. Some of the symptoms that indicate this are severe pain in the side or back, fever or chills, nausea, and reduced kidney function.

If a patient presents with these, doctors begin with an ultrasound, which can show urine backing up or swelling of the kidney. A CT scan could identify the cause (especially a stone), while urine and blood tests check for infection and see how well the kidneys are working.

Sometimes, these issues with the kidney can be found incidentally, when an ultrasound or CT scan is done for other reasons — bowel symptoms, back pain, investigation of a pelvic mass, potential gall bladder/liver assessment, abdominal discomfort.

• A nephrostomy is typically performed by an interventional radiologist or urologist, under local anesthesia. General anesthesia is reserved for extremely complex cases. The entire procedure may take anywhere between 30-60 minutes.
• The first stage is pre-procedure prep. An ultrasound/CT urography is used to map the kidney, calyces, and a safe needle path. They check for the bowel, liver/spleen and lung in the trajectory. The team explains the procedure, and antibiotics may be given, if there’s a risk of infection.
• The patient lies on their stomach, slightly turned to one side. The skin over their back is cleaned and then administered with local anaesthetic.
• Using an ultrasound and sometimes X-ray guidance, the doctor carefully inserts a fine needle through the skin into the kidney’s urine-collecting area. A guidewire is passed through the needle, and the small channel is gently widened. A drainage tube called a Pigtail Nephrostomy Catether, is then placed in the kidney.
• This tube is then secured with a dressing and hooked to a urine bag. Doctors then check to see if urine is draining properly. The patient is monitored for pain, bleeding, fever and urine output. If necessary, a limited nephrostogram (contrast X-ray, conducted through the tube) is conducted to ensure the tube is correctly positioned and confirm whether drainage from the kidney to bladder is happening.

One of the major advances is the imaging to guide the procedure, and ensure accuracy. Most procedures these days use both ultrasound and live X-ray guidance (fluoroscopy). Ultrasounds help with soft-tissue targeting and detail, while X-rays help with wire/catheter manipulation. If the kidney is difficult to reach — because of a previous surgery, unusual anatomy, surgery, obesity, or bowel lying close to the kidney — CT scanning may be used for extra accuracy.

In some cases, doctors pass the tube further down the ureter or place an internal stent through the nephrostomy route. For complex kidney stones, the nephrostomy route can be adequately enlarged (as an access route) for keyhole stone removal. In certain groups, ultrasound-only access is preferred to reduce radiation exposure where possible. This is preferred for pregnant people. If X-ray exposure can’t entirely be minimized, then, shielding is considered. This may also be considered in cases where a kidney has been transplanted.

The benefits of nephrostomy depend on the condition that it’s addressing. In the case of an obstructed kidney, there is rapid decompression — which can be life-saving in cases of sepsis. Nephrostomy can reduce pain, nausea and the risk of permanent kidney damage. However, the preservation or restoration of renal function is time-sensitive. After 1-2 weeks of obstruction, the recovery potential tends to drop.

It is also a minimally invasive procedure, which is far less painful than surgical drainage, which is rarely used nowadays. Nephrostomy can also offer a temporary bridge, while doctors treat the underlying cause — whether it’s a stone, narrowing or tumor. In many cases, it creates a safe route for later stone treatment or stent placement. As a procedure unto itself, the symptom relief can be dramatic. As an access to further treatment, it makes procedures easier.

A nephrostomy is usually a very successful procedure — the tube can be placed in 98-99% of cases. However, it still does carry some risks. For starters, mild blood staining in urine is very common and tends to settle on its own. About 95% of patients report small temporary bleeding. In 1-4% of patients, more serious bleeding can require a blood transfusion. Major complications including severe infection (sepsis), significant bleeding, injury to a nearby organ, urine leakage, or a chest complication — occur in roughly 2-10%.

In some cases, the tube may leak, become blocked, kink, or accidentally get dislodged (in 12-18% of cases) requiring replacement. If there’s a fever or chills, worsening pain in the sides, no urine draining into the bag or very heavy bleeding, it’s necessary to seek medical help immediately. There are some long-term issues, which may present in some patients such recurrent UTI or skin irritation.

After a nephrostomy, most patients are observed for several hours or overnight; a longer stay may be required if there are any signs of infection, reducing kidney function or severe pain. Mild soreness at the tube site and blood-tinged urine are fairly common, but gradually improve. Home care is crucial. It’s important to keep the tube and dressing clean, dry and securely taped, so it doesn’t get accidentally pulled out. For the first 48 hours, bathing isn’t advised. After that, for the first two weeks, careful showering is allowed but not long baths or soaking in a tub. Once the wound has healed, some doctors allow swimming, but others prefer avoiding it entirely. This advice is provided on a case-by-case basis, depending on the patient’s susceptibility to infection.

Another crucial aspect is emptying the drainage bag, and tracking urine output. Any sudden drop is worth reporting. During the recovery process, it’s essential to drink a lot of fluids and avoid heavy lifting, twisting, contact sports or any rigorous activity, until the site has healed. Most people can resume other life activities like walking and gentle exercises once the site has healed. Patients can also resume sexual activity once they are comfortable and have healed from the procedure; there are no specific restrictions, but it’s advisable to wait until initial soreness and bleeding have settled.

Follow up visits are extremely important to understand the kidney’s response, check drainage, treat the underlying cause and replace the tubes. Tube replacement is done around the 8-12 week mark in most patients, but around the 4-6 week mark in pregnant patients.