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| Tze Wah FRCR is a consultant
radiologist based at St James’s
University Hospital in Leeds, United
Kingdom. She undertook her
radiology training in Leeds, at the
Institute of Urology and Nephrology
in London and at Massachusetts
General Hospital, Boston, USA.
Her special interests are urological
imaging, interventional uroradiology
and image-guided tumour ablation
therapy for solid organ tumours. |
Percutaneous nephrostomy and antegrade ureteric stenting
Tze Wah
Department of Radiology,
St James’s University Hospital, Leeds, UK
Address for correspondence:
Dr T M Wah
Department of Radiology
St James’s University Hospital
Beckett Street, Leeds LS9 7TF UK
Tel: +44 (0)113 2065525
Fax: +44 (0)113 2064640
Email: Tze.Wah@leedsth.nhs.uk
Abstract
The past 30 years have seen a remarkable increase in
interventional uroradiological procedures. There is now
a wide variety of procedures for patients who require
long-term urinary drainage with percutaneous
nephrostomy (PCN) or ureteric stenting. This review
article aims to give an overview of the current status
for the techniques, indications and complications of
PCN and antegrade ureteric stent insertion.
Introduction
There is now a wide variety of interventional
uroradiological procedures for patients requiring
temporary or long-term urinary drainage. The
management is dependent upon the underlying
pathology, type and length of ureteric stricture and also
the patient’s preference. Percutaneous nephrostomy
(PCN) can provide temporary or permanent drainage
of an obstructed urinary system. Patients with
benign/malignant ureteric strictures are often treated
with ureteric stenting via an antegrade, retrograde or
combined approach.
Percutaneous nephrostomy
Indications
PCN was first described in 1955 by Goodwin1 and is
an important technique for providing temporary or
permanent drainage of an obstructed urinary system or
for establishing diversion of urine flow. Out-of-hours
PCN is frequently performed for patients with
pyonephrosis and acute renal failure following urinary
obstruction. After midnight, any PCN should be
performed only if this is deemed to be a life-saving
procedure.2 Long-term urinary diversion with PCN is
used when internal ureteric stenting is impossible
or unsuitable.
Techniques
We employ two different ultrasound-guided techniques:
the ‘Seldinger’ technique and the ‘one-stab’ technique.3
Patients are placed in a prone or prone-oblique position
for the procedure. Prophylactic antibiotics are routinely
administered to patients with suspected pyonephrosis
and renal stone disease, and coagulation profiles should
be obtained.
The selection criteria for each technique are
dependent upon the collecting system configuration.
The ‘Seldinger’ technique is used for minimally or
non-dilated collecting systems and cases with
suspected pyonephrosis. This technique, performed with
fluoroscopic guidance, is also the usual technique for
out-of-hours cases in order to have both ultrasound and
X-ray screening available if difficulties are encountered.
The ‘one stab’ (Bonanno) technique is used without
fluoroscopic guidance for moderate-to-severe dilated
collecting systems.
The ‘Seldinger’ technique involves ultrasound-guided
puncture of the dilated collecting system with a 19 G
sheathed needle, insertion of a 0.038” heavy-duty J
guidewire and serial track dilation with 6-10 F dilators to accommodate 8-12 F nephrostomy catheters with
or without fluoroscopic guidance (Figures 1a–c).With
fluoroscopic guidance, we routinely administer 5 mls of
Urograffin contrast to confirm the position of the 19 G
sheathed needle prior to guide wire insertion.We use
either All Purpose Drainage (APD) catheters (Boston
Scientific, USA) or Locking-Loop Pigtail (LLP) catheters
(Cook Inc, USA) for nephrostomies.
 |
Figure 1. (a) A markedly hydronephrotic
right pelvicalyceal system from
malignant ureteric obstruction.
(b) Under ultrasound and fluoroscopic
guidance, a 19 G sheathed needle is
inserted into the lower pole calyx and
this is followed by guidewire insertion.
(c) An 8.5 F Locking-Loop Pigtail
nephrostomy catheter is inserted |
The second technique used is the ultrasound-guided
‘one-stab’ technique using a 6 F Bonanno catheter
(Beckton Dickinson UK Ltd). This 6 F pigtail Teflon
catheter is mounted on a hollow 18 G needle that has
a sharp bevelled edge. Under ultrasound guidance, the
needle tip is inserted into the dilated pelvicalyceal
system, urine backflow is obtained and the catheter slid
over the needle into the collecting system.
All catheters are secured to the skin by a catheter
fixation disc, covered with adhesive dressings and
connected to a closed system urinary drainage bag.
For patients requiring long-term urinary drainage with
percutaneous nephrostomy, we exchange all the 8 F
APD and 6 F Bonanno catheters with the 8 F LLP
catheters.We routinely exchange the nephrostomy
catheters every 3 months in our screening suite as an
outpatient procedure.
Complications
Generally, PCN is a relatively safe procedure when
performed by skilled and well-trained radiologists.
The major complications (4-8%) include significant
haemorrhage that requires blood transfusion,
septicaemia and inadvertent puncturing of the pleura
or viscera such as liver, colon and spleen. Minor
complications (3-15%) include retroperitoneal urine
extravasation and significant macroscopic haematuria
causing clot colic and/or catheter blockage
necessitating further interventions.4,5
Ureteric stenting
Indications
Long-term urinary drainage in patients with malignant
and benign ureteric strictures is often treated with
ureteric stenting. This renders the patient ‘tubeless’
and provides a better quality of life.
Technique - antegrade approach
These strictures may be negotiated using a combination
of wires and catheters to traverse the stricture. Usually
an angled tip hydrophilic Terumo wire is used to
negotiate through the ureteric strictures and pass into
the bladder. In most cases, a 6 F torque-controlled
manipulation catheter is used to cannulate the stricture
and bladder (Figures 2a–d), although in difficult cases, a
4 or 5 F hydrophilic-coated Cobra catheter may
be used.
 |
| Figure 2. (a) Nephrostogram shows a tight right distal malignant ureteric
stricture. (b) This is negotiated with a slippery Terumo guidewire. (c) It is
followed by cannulation of the ureteric stricture and bladder with a 5 F Tefloncoated
catheter. (d) A 7 F Optimed ureteric stent (Optimed Technologies Inc,
Germany) is inserted uneventfully. (Patient in a prone position.) |
The Terumo wire is then removed and replaced by a
stiffer wire (e.g. Amplatz superstiff wire; Boston
Scientific, USA) over which the ureteric stent can be
inserted. Occasionally, a benign stricture can be treated
by dilation with a balloon catheter or a PTFE-coated Van
Andel dilator.We routinely use a 6 to 8 F (Meditech,
USA; Boston Scientific, USA) or 7 F (Optimed
Technologies Inc, Germany) ureteric stent.
These are changed electively every 3 to 6 months to
prevent encrustation.
Complications
The most common early complication is septicaemia
in up to 60% of patients.6 Other complications include
failure to stent and stent blockage/encrustation.
Key Learning
• Depending on the indications, both PCN and ureteric stenting may provide temporary and permanent
urinary drainage.
• PCN may be used to provide temporary urinary drainage in acute and elective settings
• Out-of-hours PCNs are frequently performed for pyonephrosis and acute renal failure
• After midnight, PCN should be performed only if it is deemed to be a life-saving procedure.
• PCN is generally a safe procedure with a major complications range from 4–8% and a minor complications
range from 3–15%
• For long-term urinary drainage, antegrade ureteric stenting may be used to avoid the need for external
drainage and provide a better quality of life
• Awareness of the complications that may arise with both PCN and antegrade ureteric stenting should
be at the forefront of the physician’s mind and patients should provide fully informed consent |
References
1. Goodwin WE, Casey WC,Woolf W. Percutaneous trocar (needle)
nephrostomy in hydronephrosis. JAMA 1955;157:891–4.
2.Wah TM,Weston MJ, Irving HC. Out of hours percutaneous nephrostomy:
lessons learnt from a one year prospective audit. Abstract published in BSIR
Congress Series 2003 (November).
3.Wah TM,Weston MJ, Irving HC. Percutaneous nephrostomy insertion:
outcome data from a prospective multi-operator study at a UK training
centre. Clin Radiol 2004;59:255–61.
4. Farrell TA, Hicks ME. A review of radiologically guided percutaneous
nephrostomies in 303 patients. J Vasc Interv Radiol 1997;8:769–74.
5. Stables DP, Ginsburg NJ, Johnson ML. Percutaneous nephrostomy: a series
and review of the literature. AJR Am J Roentgenol 1978;130:75–82.
6. Paz A, Amiel GE, Pick N, et al. Febrile complications following insertion of
100 double-J ureteral stents. J Endourol 2005;19:147–50.
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