Nephrostomy

Aris Caesariano

Fitriliani
Lind Octaviani Irawan
Meta Sakina

Pengertian
Tindakan bedah menggunakan tube, stent, atau
kateter melalui insisi kulit, masuk ke parenkim
ginjal dan berakhir di bagian pelvis renalis atau
kaliks
Jenis nefrostomi

Nefrostomi terbuka

Nefrostomi perkutan

Overview
Indikasi dan kontraindikasi

Prosedur
Teknik dilated and non dilated kidney

Komplikasi

Indikasi
1. Tindakan Diagnosis
Akses untuk prosedur endourological
Dilatasi atau stent striktur ureteral
Biopsy atau treatment dari lesi urothelial
Filling defect, benda asing.

2. Tindakan Terapi

Memasukkan obat-obatan kemoterapi ke dalam sistem pengumpul ginjal.

Obstruksi Urinaria

Diversi Urin
Haemorrhagic cystitis
Trauma ureter
Inflammatory atau malignant urinary fistula

Kontraindikasi
1.

Bleeding diathesis (misal coagulopathy tidak terkontrol).

2.

Hiperkalemia
hemodialisisi

3.

Pasien tidak kooperatif

berat

(>7

mEq/L);

koreksi

dengan

Prosedur
1.

Preprosedural

Inform consent

Pemeriksaan laboratorium lengkap

Pemenuhan cairan yang adekuat

Antibiotik profilaksis

Pasien puasa 4-8 jam sebelum prosedur

2. Alat

Atas: kateter malecot

Bawah : kateter pigtail

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?

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

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

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

Consent and
Complications
Major (<5%)
Septic Shock
1-3% ( <10% if
pyonephrosis)
Haemorrhage
1-4%

Bowel Transgression
<1%

Pleural Complications
<1%

 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

Success Rates
Obstructed Dilated system without stones

95-98%

Non-dilated collecting system

80-85%

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

Bleeding
Renal artery divides into
anterior an posterior branches
Posterior branch supplies
30% of the kidney

Brodels Line divides the area

between the anterior and
posterior division
RELATIVELY AVASCULAR

BOWEL

Other anatomical
considerations
LUNG

 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

The Procedure
For dilated collecting systems

US puncture
For Non Dilated collecting systems
Not straightforward.
Hybrid IVU
Frusemide

CT

Kit
Angiocath 16gu

Kellet Needle -19gu

Access Kits

Access Kits

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

Single Stick Technique

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

QuickTime and a
decompressor
are neede d to see this picture.

QuickTime and a
H.264 decompressor
are neede d to see this picture.

QuickTime and a
JVT/AVC Coding decompressor
are neede d to see this picture.

Post Procedural Care

Bed Rest for 4hours
Obs Bp/Pulse 30min for 4 hrs
Temperature

The Non Dilated System

Single stick v Double

Stick

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 -

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

CT guided

Complications

References
Hausegger Percutaneous nephrostomy and antegrade ureteral
stenting: technique indicationscomplications.. Eur Radiol
(2006) 16: 20162030

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 nondilated pelvicaliceal system. J Clin Ultrasound. 1998 MarApr;26(3):177-9.
Quality Improvement Guidelines for Percutaneous Nephrostomy J
Vasc Interv Radiol 2003; 14:S277S281 (SIR website)