Percutaneous Nephrostomy:

Native and Transplanted Kidneys

Wael E.A. Saad, MBBCh,* Meena Moorthy, MD,† and Daniel Ginat, MD, MS†

Percutaneous nephrostomy is a procedure in which access to the renal collecting system

of a native (nontransplanted) or transplanted kidney is obtained through the skin, providing
external drainage and/or a portal for additional minimally invasive procedures. Such addi-
tional minimal invasive procedures include nephrolithotripsy, ureteric stent placement,
ureteric dilation, ureteric embolization/obliteration, and rendezvous procedures with cys-
toscopy. Percutaneous nephrostomy has been proven to be an effective and safe minimally
invasive image-guided procedure. This article discusses the indications, techniques, im-
aging guidance modalities, and outcomes related to percutaneous nephrostomy. Exten-
sions of the nephrostomy procedures, such as ureteric stent placement and nephro–
ureteral stent placement are discussed in subsequent articles in this issue.
Tech Vasc Interventional Rad 12:172-192 © 2009 Elsevier Inc. All rights reserved.

KEYWORDS nephrostomy, transplant, kidney, nephrolithotripsy

P ercutaneous nephrostomy is a procedure in which access

to the renal collecting system of a native (nontransplanted)
or transplanted kidney is obtained through the skin, providing
indication for PCN is decompression of urinary obstruction,
which is secondary to calculi and less often malignancies of
the collecting system or pelvis. Retroperitoneal fibrosis and
external drainage or a portal for minimally invasive procedures pelvic masses, such as large fibroids, cervical and endome-
(Table 1). Percutaneous nephrostomy (PCN) with drain trial carcinoma, prostate, bladder, and lymphoma, as well as
placement, in its simplest form, is a drain/catheter placed in the other soft tissue/stromal malignancy may also result in uri-
intra-renal collecting system (renal pelvic– calyceal system). nary tract obstruction that requires intervention. The preva-
Longer catheters extending into the ureter and/or urinary lence of the cause of obstruction varies depending on the type
bladder are referred by some authors as extensions of PCN of practice and referral specialization.
(Table 1).1 PCN has been proven to be an effective and safe An infected obstructed urinary system is an urgent indica-
minimally invasive procedure. This article discusses the in- tion for PCN. Urinary tract obstruction with impairment of
dications, techniques, imaging guidance modalities, and out- renal function is an urgent rather than an emergent indica-
comes related to PCN. tion. In fact, some practices perform “staggered bilateral per-
cutaneous nephrostomies”; performing 1 at a time within 24
Indications to 72 hours to further reduce the morbidity of the procedure
(authors’ institution). PCN for urinary diversion is performed
The major indications for PCN include urinary diversion for
as an elective procedure. Transplanted kidneys due to their
urinary tract obstruction, nephrolithiasis, urinary tract infec-
precious and clinically unforgiving (functional susceptibility
tions, urinary fistulas, providing access for subsequent ure-
teral interventions, such as stent placement, nephroscopy, and difficulty recovering) nature adds a degree of urgency to
and ureteroscopy (Table 2).1-3 Perhaps the most common the above indications.
It is important to note that hydronephrosis is not in itself
an appropriate indication for PCN. Hydronephrosis does not
*Division of Vascular Interventional Radiology, Department of Radiology, necessarily coexist with obstruction and can persist after an
University of Virginia Health System, Charlottesville, VA. obstruction has been relieved, even lasting for months in the
†Department of Imaging Sciences, University of Rochester Medical Center, elderly patient particularly with long standing obstructions.
Rochester, NY.
Address reprint requests to Wael E.A. Saad, MBBCh, Division of Vascular
Furthermore, hydronephrosis can be physiological in cases,
Interventional Radiology, Department of Radiology, University of Vir- such as: (1) pregnancy, (2) over hydration, (3) diabetes in-
ginia Health System, Charlottesville, VA. E-mail: [email protected] sipidus, (4) diuretics, and (5) post obstructive relief (renal
172 1089-2516/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1053/j.tvir.2009.09.002
Percutaneous nephrostomy 173

Table 1 Extensions of Simple Percutaneous Nephrostomy and dure. Ultimately, it is important to consider the risk vs benefit
Additional Procedures That Use Percutaneous Nephrostomy in performing this procedure. An international normal ratio
as a Percutaneous Portal of Entry (Access to Renal Collect- less than 1.4 to 1.7 and a platelet count of more than 50 to
ing System) 70,000/mm3 is acceptable by most institutions/operators.
Extensions of Additional Minimal Invasive These thresholds are not a product of evidence based medi-
Simple PCN Procedures cine and are subject to institutional guidelines, and operator
Nephro-ueretral stent/ Ureteric balloon dilation (or stent comfort levels.
catheter placement)
Double-J ureteric tent Ureteric embolization/obliteration
Retrograde ilio-renal Percutaneous nephroscopy Pre-Procedural
stent Ureteric biopsies Imaging Evaluation
Nephrolithotripsy (PCNL)
Rendezvous with cystoscopy Before performing the PCN, it is important to evaluate the
Administration of phototherapy patient and the target kidney. Available imaging studies
(experimental/clinical potential) should be reviewed to evaluate the location, anatomy, and
PCN, percutaneous nephrostomy; PCNL, percutaneous nephro- orientation of the target kidney. Characteristics include:
lithotipsy.
● Orientation and site: in cases of malrotation or malpo-
sition of the target kidney, the traditional trans-retroper-
venous or ureteric); among other potential etiologies. Con- itoneal access may not be possible, and a trans-abdom-
versely, obstruction does not necessarily lead to hydrone- inal approach may be required. Preoperative knowledge
phrosis. High grade acute obstruction (from a ureteric stone, of such conditions can expedite patient positioning, re-
for instance) can shut down the renal function rapidly to the duce the time for gaining access, and reduce the risk of
extent that urine does not form, and therefore there would complications.
not be back filling of urine to cause distension of the renal ● Duplication of the collecting system: if there is duplica-
collecting system (hydronephrosis). tion, it is important to know as it is partial or complete,
Therefore, urinary obstruction is a clinical diagnosis cor- and which moiety is obstructed/affected.
roborated with imaging and laboratory findings. It should be ● Cysts or diverticula: under ultrasound these structures
noted that renal function can be preserved with a unilateral can be mistaken for a dilated calyx. Inadvertently access-
kidney obstruction and a healthy unobstructed contralateral ing a cyst will preclude draining the collecting system.
kidney. In the absence of clinical and laboratory finding and ● Tumor: renal tumors are often hypervascular and can
in the presence of at least moderate degree of renal function, hemorrhage profusely. However, such an event can be
a nuclear renal scan with a lasix challenge can be performed readily controlled by balloon catheter tamponade.5 Tu-
to diagnose urinary obstruction. Furthermore, nuclear renal mor seeding may also be considered as an additional
scan can lateralize the most affected kidney and prioritize the risk.
kidney to be treated/drained. ● Stones: calculi in the collecting system can be both ad-
vantageous and disadvantageous. They can be used as
landmarks as the operator is having difficulty accessing
Contraindications the collecting system by ultrasound (see below, needle
The most important and perhaps the only contraindication to access). However, it can also be an obstacle when the
PCN is severe coagulopathy.4 This can be either a relative or stone lies in the calyx and prevents the needle from
absolute contraindication depending on the degree of coagu- passing from the infundibulum to the renal pelvis (see
lopathy, the clinical setting, and the urgency of the proce- below). When planning access for percutaneous neph-

Table 2 Indication for Percutaneous Nephrostomy

General Indication Specific Indication
Drainage of an obstructed renal collecting system Pyonephrosis (infection/pus in the renal collecting system)
Worsening renal function due to obstructive uropathy
Providing a portal of access for minimally invasive Percutaneous nephro-lithotripsy (PCNL)
urological interventions For ureteric interventions
● Coil embolization of a ureteric fistula
● Balloon dilation of ureteric stricture
● Traversal of transected ureteric
Providing a portal of access for drug Drug, such as bacilli Calmette-Guerin (BCG)
administration (not common)
Urine diversion Ureteric leaks/fistulae
Hemorrhagic cystitis
Relief of pain related to renal calculi and/or Not necessarily obstructive. Can be partly obstructive and/or simply
pregnancy to relieve renal colic refractory to medication
174 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 1 Ultrasound guided definitive needle access for percutaneous nephrostomy. (A, B) Axial contrast enhanced com-
puted tomography (CT) image (Fig. 1A) and a PET CT image (Fig. 1B) at the level of the femoral heads (F) of a patient with
left pelvic mass (asterisk) obstructing the left ureter in its distal course as it approaches the urinary bladder (UB). The
malignant mass takes up radiotracer (asterisk). (C) Grey scale ultrasound image of the left kidney with the operator centered at
the lower pole calyx (asterisk). A dashed line is drawn to show the needle trajectory that is planned. Above the target calyx (asterisk)
lies the mid to lower pole calyx (M). The upper pole calyx (U) is observed continuous with the renal pelvis (RP) that lies deep to the
mid and lower calyces. (D) Grey scale ultrasound image of the left kidney of the same patient. The operator has passed an 18-gauge
needle (arrow at needle tip) directly into the lower pole calyx. (M indicates mid to lower pole calyx; RP, Renal pelvis). (E, F)
Grey scale ultrasound image of the left kidney of the same patient. The operator has passed a 0.0350 inch guide wire (arrows)
through the 18-gauge needle (arrowhead at needle tip) that is in the lower pole calyx. At this point of the procedure,
fluoroscopy is used as the image guidance modality (Figs. 1H-1P). (M indicates mid to lower pole calyx; P, renal pelvis). (G)
Grey scale ultrasound image of the left kidney of the same patient. This is an image obtained after the 8-French nephrostomy
drain (between arrows) has been placed through the lower pole calyx (between arrowheads) ant into the RP. This is an image
which is usually not obtained as the rest of the procedure is usually performed under fluoroscopy (Figs. 1H-1P). The operator
has passed a 0.0350 inch guide wire (arrows) through the 18-gauge needle (arrowhead at needle tip) that is in the lower pole
calyx. (M indicates mid to lower pole calyx; RP, Renal pelvis. (Color version of figure is available online.)

rolithotripsy, the trajectory and angulations must be colon is an uncommon but known entity.1 Review of avail-
taken into account so the urologist/endoscopist can be able laboratory studies, particularly hematology and baseline
able to maneuver from the proposed calyceal access to serum creatinine is also important. Comparison of pre- and
reach all the renal calculi to fragment them. post operative values can serve as an indicator of the proce-
● Residual contrast: contrast from a previous procedure/ dure’s effectiveness.
computed tomography (CT) scan can be useful in local-
izing the collecting system and can eliminate the need
for retrograde instilling contrast material. Techniques
Assessment of the patients’ paranephric anatomy on pre- Before the procedure, the patient should refrain from oral
operative imaging is essential for planning needle trajectory intake for 6 to 8 hours, and intravenous access should be
and avoiding transgression of other organs, such as colon or, obtained. Most patients tolerate PCN with moderate sedation
in case of renal transplants, small bowel. A retroperitoneal only; general anesthesia is usually not required. The patient is
Percutaneous nephrostomy 175

Figure 1 (Continued) (H) Fluoroscopic image obtained after image Figure 1F. The 0.035 inch wire is coiled in the renal
collecting system (arrowhead) as it is passed through the 18-gauge needle (arrow at needle tip). (I, J) Fluoroscopic
images after redirecting the 0.035 inch wire down the ureter (arrowhead) as it is passed through the 18-gauge needle
(arrow at needle tip). (K) Fluoroscopic image as the percutaneous nephrostomy drain is being advanced over the 0.035
inch wire. The nephrostomy drain has a metal stiffener passed coaxially through it with its tip (arrow) at the tip of the
nephrostomy drain (arrowhead). (L) Fluoroscopic image as the percutaneous nephrostomy drain is passed beyond
the inner metal stiffener and over the 0.035 inch wire. The metal stiffener tip (arrow) is stopped at the beginning of the
curve of the wire. The tip of the nephrostomy drain (arrowhead) is just beyond the metal stiffener tip and is still in the
RP. (M) Fluoroscopic image as the percutaneous nephrostomy drain is passed further down and into the ureter
(arrowhead). The metal stiffener tip (arrow) is still stationed at beginning of the curve of the wire.

placed prone, or oblique prone, on the fluoroscopy table, and enough to avoid the major lumbar muscles.1,2 Visualizing the
the target kidney is imaged using ultrasound to again assess lung base under fluoroscopy and the use of general anesthe-
its location and anatomy. The region of interest should be sia can reduce the occurrence of complications, such as
prepared using surgical standards of cleansing/disinfecting pneumothorax, related to punctures above the 11th rib.14,15
and draping. Far lateral approaches increase the risk of transgressing the
Needle access for PCN is usually obtained through ultra- colon in native kidneys. In most cases, a posterolateral ap-
sound guidance, fluoroscopy, or a combination of the proach with the needle directed to the mid-to lower calyx will
two.6-10 At least for percutaneous nephrolithotomy (PCNL), provide optimal results.1 In addition, to calyceal accessibility,
ultrasound-guided access is of comparable efficacy to fluoro- the likelihood of future procedures must also be factored. In
scopic guidance and may actually be associated with fewer particular, sharp angulations between the retroperitoneal
complications,11,12 although most institutions perform PCNL tract and the ureter may hinder subsequent maneuvers.
under fluoroscopic guidance only. Alternatively, PCN under
CT guidance can be performed safely and with fewer radia- Needle Access
tion exposure to the operator than through fluoroscopic One-Step Ultrasound Guided Definitive Needle Access
guidance,13 however, it is not common practice to use CT This technique requires some degree of hydronephrosis
guidance. CT guidance is resorted to when all other guidance (Fig. 1). The more dilated the collecting system, the more
modalities fail. Access should be obtained below the level of amenable the kidney is to definitive ultrasound guided
the 11th rib to avoid the thoracic cavity/pleura, and lateral needle access.
176 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 1 (Continued) (N) Fluoroscopic image as the percutaneous nephrostomy drain that has been passed down and
into the ureter (arrowhead). The metal stiffener and wire have been removed. The asterisk represents the site of the RP
and the arrow points to the vicinity of the uretero–pelvic junction (UPJ). (O) Fluoroscopic image as the percutaneous
nephrostomy drain after its pigtail (Cope) end has been formed in the RP (asterisk). The Cope/pigtail loop is locked
(arrow). Usually the steps from Figure 1H to Figure 1O are performed with contrast in the renal collecting system to
confirm the adequate placement of the nephrostomy drain. These images show that a nephrostomy drains can be placed
without contrast (in cases of contrast allergy, for instance). However, this is more feasible with hydronephrosis and
when the wire and drain conform easily and without resistance to the predicted anatomy of the urinary collecting
system. (P) Fluoroscopic image after injecting contrast through the percutaneous nephrostomy drain. The image shows
adequate placement of the pigtail in the RP (asterisk). The entry calyx (arrow) is also observed.

After infiltrating the region of interest with lidocaine, a renal pelvis. Contrast is then injected into the renal collecting
small incision is made using an scalpel. The operator pans the system through the renal pelvis needle. Air can be injected to
ultrasound probe to obtain a visual on the target calyx (Fig. delineate the posterior calyces with the patient prone.17 The
1C). An 18- to 22-gauge access needle is then passed directly use of dilators can be avoided by combining the Seldinger
into the target calyx under real time ultrasound guidance, and Goodwin techniques.18 Definitive needle access into the
using a “single stick” technique (Fig. 1D). The needle should lower to mid renal calyces is then achieved under fluoroscopy
be passed smoothly, with no hesitation. The ultrasound (see below) (Fig. 2). The advantage of ultrasound localization
probe should be held absolutely still to ensure visibility of the and access of the renal pelvis is that it is real time and does not
needle tip and the target calyx. The current authors recom- rely on land marks. This is because the kidney can change in
mend larger caliber needles for definitive access (Figs. 1D- position (typically becomes cephalad) with moderate seda-
1J). Large caliber needle are stiffer and are more likely to tion leading to inaccurate access on the basis of fluoroscopic
maintain a straight path towards the target calyx during ul- land marks obtained with reference to preprocedural CT im-
trasound guided insertion. Furthermore, 18- to 19-gauge ages (see below).
needles accept a 0.035 inch wire that is a platform used for
Two-Step Needle Access Using
dilators and nephrostomy tubes (Figs. 1D-1J). In contrast,
Fluoroscopic Guided Renal Pelvis Access Followed
20- to 21-gauge needles only accept a 0.018 inch wires,
by Definitive Fluoroscopic Guided Needle Access
which require a composite/telescoped access system (tapered
Two-step needle access under fluoroscopy is the traditional
down to a 0.18-inch inner diameter) to larger the 0.018 inch
method for performing PCN (Fig. 2). It predates the ultra-
wire to a 0.035- or 0.038 inch wire/platform (see below)
sound era. This technique remains useful in cases of decom-
(Figs. 2M-2Q). Alternatively, direct access to the collecting
pressed renal collecting systems and in the presence of radio-
system can be obtained using a trocar system technique un-
opaque renal stones occupying the entire target renal calyx or
der ultrasound visualization.16
renal collecting system (not uncommon in PCNL cases).
Two-Step Needle Access Using If there is a radio-opaque stone in the target calyx, contrast
Ultrasound Guided Renal Pelvis Access Followed is not necessary1 and a single definitive “gun site” needle stick
by Definitive Fluoroscopic Guided Needle Access is needed (Fig. 3). However, if no radio-opaque stone is
This technique is no longer commonly implemented. It is present, intravenous contrast (renal function and allergy per-
reserved for situations in which there is not much or no mitting) can be given to visualize the renal collecting system
calyceal dilation, and when intravenous contrast with delin- (pyelogram). Contrast can also be given through cystoscopy.
eate the renal collecting system cannot be administered. Ul- This practice is common when performing a rendezvous with
trasound is used to guide a 21- to 22-gauge needle into the urology on PCNL cases. If neither is feasible, a 22-gauge
Percutaneous nephrostomy 177

Figure 2 Fluoroscopic guided two-stick nephrostomy with planning on the basis of previous CT. (A) Contrast enhanced axial
CT image of the abdomen at the level of the right renal hilum. The axial image demonstrates a renal stone affected in the UPJ
(arrow). The 2 parallel arrows show the width of the RP that correlates and would project over the right transverse lumbar
process. This helps the operator predict the site of the RP by fluoroscopy: On the AP projection (anteroposterior to the spine),
the RP at the level of the affected stone spans across and projects over the right transverse process.(A indicates aorta; I, inferior
vena cava (IVC); V, vertebral body). (B) Contrast enhanced axial CT image of the abdomen at a level above the right renal
hilum (above the level of Fig. 2A). The lower stone of 2 in the mid to upper calyces is observed (black arrow). The top of the
RP is observed (asterisk). The long dashed arrow runs parallel to the lateral wall of the vertebral column, but 1 transverse
process away. This line coincides with the most medial aspect of the upper portion of the RP. Another transverse process
across (more lateral) coincides with the renal stone (black arrow). This (findings and explanations of Figs. 2A and B) is how
operators can assess and where to access the RP on the basis of fluoroscopic boney land marks (or vena cava (IVC); V,
vertebral body). The white arrow points to the lower most right-sided rib. (C) Two identical images of a AP fluoroscopic
projection over the right kidney (patient is prone), however, with different superimposed drawings and annotations. The 2
parallel vertical arrows on the left are parallel to the vertebral body and 1 transverse processes (TP) across. They are the
equivalent of the 2 white vertical dotted lines on the right and the 2 parallel arrows in Figure 2A. The 2 horizontal black
arrows on the right represent the axial cut levels of the CT images in ion, on the right the kidney and its collecting system are
drawn out on the basis of the soft tissue renal shadow and according to the CT land marks (see Figs. 2A and 2B). The box
formed on the right image between the 2 pairs of parallel lines (black and white pair of parallel dotted lines) is the target box
(between white solid arrows) to access the RP. The white cross is where the operator eventually accessed the RP with a
22-gauge needle. The black arrows on the left point to the upper to mid renal calyceal stones. The arrowhead on the left points
to the pelvic renal calculus that is affected at the UPJ. There are 2 parallel bidirectional arrows (white dotted arrow shafts with
black arrowheads) on the left image. These show the distance difference between the most medial aspect of the lower calyceal
stone (marked by asterisk) and 2 TP across from the vertebral body. If you look at the CT image of cided over the calyceal
stone. This lack of correlation occurs in small targets. It is a limitation of translating CT landmarks to fluoroscopic landmarks
on small targets. Patient positioning is different, the imaging modalities are different, and one must take into account
centering and parallax.
178 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 2 (Continued) (D) Anteroposterior fluoroscopic projection over the right kidney (patient is prone), showing a
metal clamp placed over the patient’s back side with the clamp tip over the target site for accessing the RP (clamp tip
correlates with the white cross in product of the though process and landmark mapping in arrowhead points to the
affected UPJ stone and the black arrows point to the upper pole calyceal stones. (E) Anteroposterior fluoroscopic
projection over the right kidney (patient is prone), showing a 22-gauge Chiba needle being passed down through the
retro-peritoneum. The image intensifier is almost “looking down the barrel” of the needle. This 15 cm long needle is
observed short with the need le hub (hollow arrow) and the needle tip (solid black arrow) close to one another. The
arrowhead points to the affected UPJ stone. (F) Anteroposterior fluoroscopic projection over the right kidney (patient
is prone). The operator has aspirated urine (pus, in this particular case) and now has a contrast syringe (CS) connected
to the 22-gauge Chiba needle hub (hollow arrow) through a short connector tube (black arrowhead). The needle tip
(black arrow) is now presumed to be in the RP. The dashed arrows point to the upper pole calyceal stones clearly
observed in this magnified view. (G) Anteroposterior fluoroscopic projection over the right kidney (patient is prone) as
the operator injects contrast through the 22-gauge Chiba needle. The needle tip (white arrow) is confirmed to be in the
RP as contrast slowly fills the renal collecting system. The affected radio-opaque stone (arrowhead) is again observed in
the UPJ. Notice that the contrast does not reach the radio-opaque portion of the stone (can be observed in er because
the stone is larger than what it seems by fluoroscopy and that its peripheral component is fewer radio-opaque or that
there is inspissated pus around the stone. The dashed arrows point to the upper pole calyceal stones clearly observed
on this magnified view. (H) Anteroposterior fluoroscopic projection over the right kidney (patient is prone) as the
operator continues to injects contrast through the 22-gauge Chiba needle. The needle tip (white arrow) is in the RP as
contrast slowly fills the RP and starts filling the calyces. Notice the filling defects, for instance, just below the needle hub
in the upper pole collecting system (not marked or annotated). Also, notice the “hot wax drip” (authors term)
appearance of contrast in the middle calyceal system (not marked or annotated). These filling defects and wax drip
appearance reflects the thick pus content of the collecting system. The lower pole calyx is visualized (hollow arrow).
The dashed arrows point to the upper pole calyceal stones clearly observed in this magnified view. Notice the right
hemi-colon clearly observed due to contrast filling from previous CT. The colon is close to the lower pole calyx on this
projection. (I) Oblique fluoroscopic projection orthogonal to the access needle (white arrow at access needle tip) over
the right kidney (patient is prone) just as the operator has accessed the lower pole calyx (hollow arrow) with a 21-gauge
diamond tip needle (Accustick Introducer system II, Boston Scientific, Natick, MA) under real-time fluoroscopic
guidance. This was achieved using the gun site technique that involves several steps missing in e observed in ures 3A
through 3H. Notice the right hemi-colon is observed a distance from the lower pole calyx on this projection. The
arrowhead points to the UPJ stone that seems to have concentric layers to it.
Percutaneous nephrostomy 179

Figure 2 (Continued) (J) Anteroposterior (AP) fluoroscopic projection again of the same stage of the procedure as Figure
2I. Again noted is the 21-gauge diamond tip needle (Accustick Introducer system II, Boston Scientific, Natick, MA) with
its tip (solid white arrow) in the target lower pole calyx (hollow arrow). Again the right hemi-colon is observed a
distance from the lower pole calyx on this projection. The arrowhead points to the UPJ stone and the dashed white
arrows point to the upper pole calyceal stones. All accesses and organs are confirmed on 2 projections: the oblique (Fig.
2I) and the AP (Fig. 2J) projections. (K) AP fluoroscopic projection. The operator has passed a 0.018 inch glide wire
(arrowheads) (Terumo, Corp, Tokyo, Japan) through the 21-gauge diamond tip needle (Accustick Introducer system
II, Boston Scientific, Natick, MA) with its tip (solid white arrow) in the target lower pole calyx (hollow arrow). The
0.018 inch glide wire heads to the UPJ and turns sharply (white arrowhead) upwards towards the upper pole calyx
(black arrowhead) where it dislodges the most superior stone of the upper pole calyceal stones (dashed white arrows);
compare with Figure 2I. (L) AP fluoroscopic projection. The operator has removed the 21-gauge diamond tip needle
and replaced it with the telescoped Accustick introducer system (Accustick Introducer system II, Boston Scientific,
Natick, MA) that has an inner most metal stiffener with its tip (solid white arrow) approaching the target lower pole
calyx (hollow arrow) as it is pushed over the 0.018 inch glide wire. The outer most part of this introducer system has
a radio-opaque marker near its end (arrowhead). (M) AP fluoroscopic projection. The operator is pushing the outer
most part of this introducer system (arrowhead at its radio-opaque marker near its end) over the 0.018 inch glide wire
(white dashed arrows) as the metal stiffener is left outside the target calyx (solid white arrow at tip of metal stiffener).
Some operators would have passed the metal stiffener over the wire (in other words, the whole introducer system,
including its inner metal stiffener) all the way into the RP and stopped the stiffener where the 0.018 inch wire starts
taking a turn. Here between the lower dashed arrow (pointing to the apex of the turn of the wire) and the arrowhead
(pointing to the radio-opaque marker). (N) AP fluoroscopic projection. The operator has pushed the outer most part
of this introducer system (arrowhead at its radio-opaque marker near its end) over the 0.018 inch glide wire and the
metal stiffener has been removed. The 0.018 inch glide wire (Terumo, Corp, Tokyo, Japan) is doubled back at the upper
pole calyces and its tip is near the UPJ (dashed white arrow). (O) AP fluoroscopic projection. The operator is injecting
contrast into the RP to confirm that the introducer system (arrowhead at its radio-opaque marker near its end) is in the
RP. The 0.018 inch glide wire (dashed white arrow at wire tip) is maintained by a check-flow valve or two-way adapter
at the hub of the introducer system (Accustick Introducer system II, Boston Scientific, Natick, MA). Notice that the RP
22-gauge access needle is in place. Although the Accustick system is confirmed to be in place through the definitive
calyx, the 22-gauge Chiba need is removed.
180 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 2 (Continued) (P) AP fluoroscopic projection. The operator has removed the RP 22-gauge access Chiba needle.
The 0.018 inch glide wire has been removed and replaced with a 0.035 inch wire (dashed white arrow at wire tip)
through the introducer system (Accustick Introducer system II, Boston Scientific, Natick, MA) (Arrowhead at radio-
opaque marker). (Q) AP fluoroscopic projection. The operator has placed an 8-French nephrostomy catheter/drain
(dashed white arrows along its course). It was placed in a similar manner (over an inner stiffener) as in Figures 1K
through 1N. The tip of the nephrostomy catheter/drain is in the upper pole calyces (black arrowhead) and it enters, as
it should typically do, through the lower pole calyx (hollow arrow). Notice the affected UPJ stone (asterisk). (R) AP
fluoroscopic projection. The operator has formed the 8-French nephrostomy catheter/drain (contorted pigtail between
dashed white arrows). It was formed by pulling the drain back and at the same time pulling its locking pigtail string.
Once there is room for the pigtail to form the pigtail forms. However, if there is no significant hydronephrosis the pigtail
will not make the perfectly circular appearance observed in Figure 1O. The tip of the nephrostomy catheter/drain is in
the RP (black arrowhead). Again noted is the lower pole calyx entry site (hollow arrow) and the affected UPJ stone
(asterisk). (S) AP fluoroscopic projection. The operator has injected contrast through the formed 8-French nephros-
tomy catheter/drain (contorted pigtail between dashed white arrows and nephrostomy drain tip at black arrowhead).
Again noted is the lower pole calyx entry site (hollow arrow) and the affected UPJ stone (asterisk). Notice the filling
defects (#-signs) in the superior aspect of the pelvi– calyceal system. They represent inspissated pus owing to how thick
and particulate the contents of the renal collecting system. The black arrows point to findings consistent with papillary
necrosis. Upper arrow pointing to central papillary necrosis and the lower arrow points to a “claw sign.”

needle is passed trans-retroperitoneally under fluoroscopy in with or without air is injected in the renal pelvis to delineate
a blind manner, guided by bony landmarks and per-opera- the renal collecting system and the posterior calyces, respec-
tive CT scans. The most important landmark is L2, with the tively (see above) (Fig. 2). Once the target renal calyx is
renal pelvis expected to be 2 to 3 cm lateral of the transverse chosen, a definitive fluoroscopic needle access is achieved
process. By carefully examining previous CT images the site using a 21- to 18-gauge needle (Figs. 2-4). The technique
(medial to lateral) and the level (cephalad to caudad) can used is the “gun site technique” (Fig. 3). The image intensifier
be estimated/determined (Fig. 2). However, the operator is tilted to approximately 20 to 30 degrees in the ipsilateral
must be cognizant that the level of the renal pelvis may oblique.7 This lies along the least vascular plane (avascular
change from placing the patient prone (in CT the patient is plane of Brodel or Brodel bloodless line of incision) of a
usually supine). In addition, with moderate sedation the in- normally oriented native kidney.1 The needle is passed down
spiratory effort is reduced and the kidney (renal pelvis in- this angle along the axis of the image intensifier and overlay-
cluded) migrates cephalad. Once urine is aspirated, contrast ing the target calyx (Fig. 3). Once a significant needle depth is
Percutaneous nephrostomy 181

Figure 3 Fluoroscopic guided one-stick nephrostomy with “gun-site technique.” (A) AP fluoroscopic projection over the
left kidney (patient is prone) with a magnified insert in the bottom left corner. The images show a radio-opaque
stag-horn calculus/stone (S) in the RP extending into the lower pole calyx. The operator has placed a metal clamp on
the patient’s back with the tip of the clamp projecting over the stone. Both the stone and clamp project lower than the
lower border (dotted white line in insert) of the lower most rib (LR) on the left. (B) Slightly oblique fluoroscopic
projection over the left kidney (patient is prone). The operator has placed a 18-gauge diamond tip needle on the
patient’s back where the clamp lay (the needle is not in the patient). The needle tip (black arrow) projects over the
lower/calyceal aspect of the stone (S). (C) Slightly oblique fluoroscopic projection over the left kidney (patient is prone).
The operator has placed the 18-gauge diamond tip needle end-on on the patient’s back (the needle is not in the patient)
and held by the clamp. The needle tip (black arrow) projects over the lower/calyceal aspect of the stone (S). (D) Slightly
oblique magnified fluoroscopic projection over the left kidney (patient is prone). The operator has advanced the
18-gauge diamond tip needle end-on (black arrow: tip of needle close to hollow arrow: needle hub) through the
patient’s back. The needle tip (black arrow) projects over the lower border of the infundibulum of the lower pole calyx.
The bulk of the stone (S) lies above.

achieved as evidenced by minimal needle sway, an orthogo- the definitive needle. An access wire 0.018-inch to 0.038-
nal image intensifier angle is optimal to gauge the needle inch wire is then passed into the renal collecting system (see
depth and visualize the needle entry into the target calyx below).
(Figs. 2-4). Urine aspiration followed by contrast injection When accessing a renal collecting system that is occupied
(latter is not necessary and may obscure the target if needle in its entirety by renal calculus (stag horn calculus), the cur-
not adequately in calyx) to confirm adequate placement of rent authors prefer a diamond tip 18-gauge needle to access
182 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 3 (Continued) (E) Oblique fluoroscopic projection over the left kidney that is orthogonal to the needle. This
projection allows the operator to gauge the depth of the needle and helps confirm contact of the needle with the target
(asterisk). The needle tip (black arrow) is not deep enough to hit the target. The operator observes that the 18-gauge
needle trajectory will probably not hit the target calyx (asterisk) filled by the stag horn stone (S). The operator at this
point manipulates the needle upwards (directional curved white arrow). (F-H) Oblique fluoroscopic projection over
the left kidney that is orthogonal to the needle. The operator repositioned the needle upwards and has advanced it so
the needle tip (black arrow) hits the target calyx/stone in calyx (asterisk). The distance between the stone (S) and the
vertebra is highlighted by the white bidirectional arrow (Fig. 3G). The operator pushes harder (represented by hollow
directional arrow) to dig into the stone. The force of the needle push can be appreciated by the reduction in the stone
vertebral distance (bidirectional arrow in Fig. 3G) and (single solid white arrow in Fig. 3H). (I, J) Oblique fluoroscopic
projection over the left kidney that is orthogonal to the needle. The operator has removed the diamond tip stylet of the
18-gauge needle. The tip of the outer needle (black solid arrow) is in contact with the stone (S). A 0.035 inch angled
tip glide wire (Terumo, Corp, Tokyo, Japan) (hollow arrow) is advanced down the ureter.

the desired calyx (Fig. 3). The needle is stiff and does not veer ing system. This may be a subtle finding, particularly when
away from the target. In addition, the needle can be used to there is not much room within the collecting system, such as
dig into the stone to provide some space for the access wire in the presence of a large staghorn calculus.
that, still in the authors’ preference, is a regular stiffness an-
gled tip glide wire (Terumo, Corp, Tokyo, Japan) (Fig. 3).
The operator, however, must be careful not to dissect around Over-Wire Tube Access
the pelvicalyceal system with this needle wire combination; If the definitive access needle is a 21- to 2-gauge needle it, will
and if this occurs, the operator must be able to recognize that allow the passage of a 0.018 inch wire. If the definitive needle
the wire has dissected around, rather than within the collect- is 18- to 19-gauge, it will allow a 0.35-inch wire. A 0.018-
Percutaneous nephrostomy 183

Figure 3 (Continued) (K) Oblique fluoroscopic projection over the left kidney. The operator has removed the 18-gauge
needle leaving the 0.035 inch glide wire (Terumo, Corp, Tokyo, Japan) (hollow arrow) down the ureter. The hollow
arrow also points to glide wire as it traverses the vicinity of the UPJ. (L) Oblique fluoroscopic projection over the left
kidney. The operator has advanced a 4-French glide catheter (Terumo, Corp, Tokyo, Japan) (solid black arrow at
catheter tip) over the 0.035 inch glide wire (Terumo, Corp, Tokyo, Japan) (hollow arrow) down the ureter. The
4-French catheter is advanced because it is minimally invasive. It allows the operator to inject contrast with confirm
placement of the catheter in the renal collecting system. In addition, it allows the operator to exchange the relatively
flimsy glide wire with a stiffer more robust wire/platform. (M) Oblique fluoroscopic projection over the left kidney. The
operator has removed the 0.035 inch glide wire leaving the 4-French glide catheter (Terumo, Corp, Tokyo, Japan)
(solid black arrow at catheter tip) the presumed ureter. (N, O) Oblique fluoroscopic projection over the left kidney (N)
and an AP projection (O). The operator has pulled back the 4-French glide catheter slightly (solid black arrow at
catheter tip). Contrast is injected filling the ureter and the pelvic– calyceal system around the stone (S). The spasm in
the ureter (between white arrows) may have helped contrast back fill into the collecting system. The stone (S) seems as
a filling defect relative to the denser contrast around it. Figure 3O is an AP projection with the catheter pulled back
further. (P) Oblique fluoroscopic projection over the left kidney. The operator with the aid of the 4-French catheter has
exchanged the glide wire for a superstiff Amplatz wire (Cook Corp, Bloomington, IN) (hollow arrow). The catheter has
been removed. The stiffness of the wire can be appreciated by it “opening up the angle” (curved bidirectional arrow) at
the UPJ. (Q) Oblique fluoroscopic projection over the left kidney. The operator has advanced an 8-French dilator over
the superstiff Amplatz wire (hollow arrow). The tip of the dilator (black arrow) is at the access calyx. (R) Oblique
fluoroscopic projection over the left kidney. The operator has exchanged the 8-French dilator for an 8-French
nephrostomy drain over the superstiff Amplatz wire (hollow arrow). The tip of the nephrostomy drain (black arrow) is
at the access calyx. The operator should direct the drain upwards (directional curved white arrow) so that it aligns with
the Amplatz wire.

inch wire requires a composite/telescoped access system to The next step is to perform a formal diagnostic antegrade
larger the 0.018-inch wire to a 0.035- or 0.038-inch wire/ pyelogram by injecting a small amount of iodinated contrast
platform (Figs. 2M-2Q). Such access systems are the Nephset through the needle. This opacifies the collecting system and
(Cook, Inc, Bloomington, IN) and the Accustick II Intro- confirm adequate access as well as allow the operator to eval-
ducer system with RO marker (Boston Scientific, Corp, uate the collecting system. During the antegrade pyelogram,
Natick, MA) (Figs. 2M-2Q). the cause and the level of the obstruction can be determined.
184 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 3 (Continued) (S) Oblique fluoroscopic projection over the left kidney. The operator has advanced the 8-French
nephrostomy drain with its inner metal stiffener over the superstiff Amplatz wire (hollow arrow). The tip of the
nephrostomy drain (hollow arrow) is tip-to-tip with the inner metal stiffener (black arrow at stiffener tip). At this point
the operator advances the nephrostomy drain off the metal stiffener and over the wire (see Figs. 1K through 1N). (T)
Oblique fluoroscopic projection over the left kidney. The 8-French nephrostomy drain has been advanced deeper with
its tip (hollow arrow) in the ureter and over the Amplatz wire (solid white arrow). The entry point of the nephrostomy
drain is marked by the opposing dashed white arrows. Residual contrast is accumulating in the calyces (asterisks) and
the stone (S) is visible (no longer appearing as a filling defect). (U) Oblique fluoroscopic projection over the left kidney.
The Amplatz wire has been pulled out leaving the 8-French nephrostomy drain in the ureter. The tip of the drain (white
arrow) curls in the ureter. The black arrows pint to the side holes of the pigtail of the nephrostomy drain. Again noted
is the residual contrast is now accumulating in the calyces (asterisks) and the stone (S) is still visible (no longer
appearing as a filling defect). (V) Oblique fluoroscopic projection over the left kidney. This is the exact same projection
with drain positioning but with contrast injection through the drain to delineate the anatomy further. The tip of the
drain (white arrow) curls in the ureter. The stone (S) is visible as a filling defect. At this moment in time the operator
should pull back the drain (depicted by curved directional arrow) as the string is pulled so the drain forms in the RP.
(W) Oblique fluoroscopic projection over the left kidney. Showing a well formed tight pigtail catheter (Dawson-Mueller
Tube, Cook Corp, Bloomington, IN) in the distal RP (between white arrows) just above the UPJ and below the stone (S).
(X, Y) AP projection (X) and an oblique fluoroscopic projection (Y) over the left kidney. The operator is injecting
contrast through the pigtail catheter (Dawson-Mueller Tube, Cook Corp, Bloomington, IN) in the distal RP (between
white arrows, Fig. 3Y) filling the renal collecting system and ureter (U). the dashed eclipse depicts the skin entry point
on the AP projection (Fig. 3X). The 2 parallel arrows depict the trans-retroperitoneal tract (Fig. 3X). The stone (S) is
observed occupying the RP above the nephrostomy drain. This drain was placed as a future access for a subsequent
percutaneous nephrolithotripsy (PCNL). Not all urologists perform PCNL at the time of the initial percutaneous access.

The major contraindication to performing the pyelogram is be tailored to the size of the planned access device/tube to be
urosepsis or when there is evidence of infected urine. In these placed. The device/tube/catheter size could range from
cases, pressurizing the collecting system with contrast may 8-French (2-3 mm incision: for simple nephrostomies for
cause and/or worsen sepsis. normal viscosity urine) to 10- or 12-French (3-4 mm inci-
A skin incision should then be made over the needle to sion: for thick purulent urine), and up to 18- to 22-French
allow for easier insertion of the dilator. The incision should (6-7 mm incision: for PCNL tubular access). Larger incisions
Percutaneous nephrostomy 185

Figure 4 Fluoroscopic guided one-stick nephrostomy with “gun-site technique” with large caliber nephrolithotripsy access. (A) AP
fluoroscopic projection over the abdomen (patient is prone). The image demonstrates bilateral double-J stents (DJs) that were
placed 6 months earlier through cystoscopy/uretroscopy from below. One DJ placed on the left (Lt DJ) and the other placed on the
right (Rt DJ). A right UPJ stone (asterisk) is observed with the upper pigtail of the right double-J stent (Rt DJ) wrapped (3 black
arrows) around the stone. In addition, a midpole calyceal stone (arrowhead) and lower pole calyceal stones (hollow arrow) are
observed. (B) Three consecutive axial images of a noncontrast enhanced CT in bone windows showing the lower pole calyces
(hollow arrow) and the pigtail of the right DJ curling (black arrows) round the uretero–pelvic stone. (A: Aorta; I: Inferior vena cava
(IVC); V: Vertebral body). (C) AP fluoroscopic projection over the right kidney (patient is prone). The operator has placed a clamp
over the patient’s back side so that its tip projects over the midpole calyx (arrowhead). Again noted is the right UPJ stone (asterisk)
with the upper pigtail of the right DJ wrapped (3 black arrows) around the stone as well as the lower pole calyceal stones (hollow
arrow). (D) Oblique fluoroscopic projection over the right kidney that is orthogonal to a 21-gauge needle. The operator used the
same gun site technique (Figs. 3B-3E) to hit the midpole stone (between arrowheads). This image is the equivalent to Figures 3G or
3H. The needle tip (white arrow) has moved the stone. The hollow arrow points to the lower pole calyceal stones. (E) Oblique
fluoroscopic projection over the right kidney that is orthogonal to the needle. The operator has removed the diamond tip stylet of
the 21-gauge needle. The tip of the outer needle (black solid arrow) has been pulled back as the operator probed with a 0.018 inch
angled tip glide wire (Terumo, Corp, Tokyo, Japan) until it passed through and around the midpole stone (between arrowheads)
and into the renal collecting system. The 0.018 -inch is coiled in the collecting system (between solid arrows) from the UPJ stone
(asterisk) to the upper pole calyces. (F) Fluoroscopic projection over the right kidney. The operator has advanced an Accustick
introducer II system (Boston Scientific, Natick, MA) over the 0.018 inch glide wire. The steps for advancing the introducer system
over a 0.018 inch wire can be observed in Figs. 2L through 2N. The radio-opaque marker of the introducer set (solid white arrow)
is observed and contrast is being injected in the RP. The hollow arrow points to the tip of the DJ and the eclipse depicts the vicinity
of the UPJ. Multiple attempts with a variety of wire and catheter combinations where made to traverse the UPJ adjacent to the DJ.
The operator concluded that the aperture of the UPJ was stenosed around the stent or that the stent and stone where adherent to one
another and affecting the UPJ. The operator at this point has 2 choices. Either acquire double wire purchase inside the RP or make
further attempts at passing 2 wires down the ureter for a more traditional PCNL wire purchase/access.
186 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 4 (Continued) (G, H) Fluoroscopic projection over the right kidney with contrast filling the right RP (contrast). Through the
6.5-French introducer system the operator has passed a snare (Angiotech, Gainesville, FL) (solid white arrows) and has grasped the
end of the DJ (hollow arrow) and is pulling it into the 6,5-french outer sheath of the introducer set (Accustick introducer II system,
Boston Scientific, Natick, MA). This is how DJs are removed, but from below (bladder end). The stent is grasped by cystoscopy and
then exchanged over wire. (I) Fluoroscopic projection over the right kidney with contrast filling the right RP (contrast). As the
operator pulls the DJ through the 6.5-French introducer system, the operator passes the outer sheath of the introducer system down
and wedges its radio-opaque tip (black arrowhead) into the UPJ (in other words, uses the snare and double-J as a wire and tries to
pass the introducer sheath over that “wire”). The introducer system does not go any further (down into the ureter). The solid white
arrow points to the point where the snare is grasping to the DJ that is doubled back with its tip lagging behind (hollow arrow) but
within the introducer sheath. (J) Fluoroscopic projection over the right kidney with contrast filling the right RP (contrast). The
operator has pulled the DJ (solid white arrows) through the 6.5-French introducer system and out of the body/hub of the
6.5-French introducer sheath. The lower end of the DJ is in the ureter (lower horizontal solid white arrow). The operator continues
to attempt to pass the outer sheath of the introducer system down over the DJ (using it as a wire) and wedges its radio-opaque tip
(hollow arrow). The introducer system does not go any further (down into the ureter). (K, L) Fluoroscopic projection over the right
kidney with contrast filling the right RP (contrast). The operator has passed a stiff Amplatz wire down the DJ (hollow arrow in Fig.
4K) to give the DJ some structure before pulling it out over the wire. Figure 4K is without pulling on the stent and wire and Figure
4L is with pulling on the stent and wire (depicted by directional hollow arrow). Notice the filling defect appearance (solid arrows at
meniscus border and asterisk at center) of the UPJ in Figure 4L as the operator pulls at the stent and wire. This helps appreciate the
degree of adherence of the stent to the UPJ to the extent of everting the UPJ. Pulling harder (continuous steady tension and not jerky
erratic pulls) finally freed the stent from the UPJ/adherent UPJ stone.
Percutaneous nephrostomy 187

Figure 4 (Continued) (M) Fluoroscopic projection over the right kidney with contrast filling the right RP (contrast). The
operator has removed the DJ over the stiff Amplatz wire. A 7-french peal-away sheath (between arrowheads) has been
advanced down the Amplatz wire partly to “Dotter” the UPJ and also top allow the passage of a second Amplatz wire
down into the ureter. (N, O) Oblique fluoroscopic projection over the right kidney with contrast filling the right RP
(contrast). The operator has passed a second Amplatz wire (dashed white arrows) down into the ureter and is has
advanced a high-pressure balloon (between solid arrows) over the primary Amplatz wire. A waist is observed in Figure
4N (arrowheads), probably representing the calyceal entry site in this image. Figure 4O shows the balloon fully inflated.
The balloon should be used down to the calyceal access site and all the way out to the skin entry site. These images are
routine PCNL after passage of the 2 Amplatz wires down the ureter. (P) Oblique fluoroscopic projection over the right
kidney. The operator passing a 22-French tubular introducer (black arrow at deep end of introducer) mounted over a
dilator and passed over the primary Amplatz wire. The tapered dilator tip (hollow arrow) is at the infundibulum of
accessed calyx. The introducer should be eased down all the way into the calyx. At that point a ureteroscope is
introduced.

need to be deeper to incise the deep fascia. For nephrostomy guide wire in place, and a dilator/balloon should be advanced
tubes of up to 12- to 14-French, sequentially larger fascial into the tract over the wire (Figs. 4N-4P).
dilators can be passed coaxially over the 0.035-inch wire. In the absence of overt infection, and as the procedure has
However, with larger caliber devices (to accommodate an gone smoothly, some operators place nephroureteral stent
endoscope for PCNL, for instance), high-pressure balloons primarily rather than a simple pigtail nephrostomy tubes/
(Figs. 4N-4P) may be required to not only dilate the subcu- drains (Fig. 5). This is a stent that traverses the ureter from
taneous tissue, but the retroperitoneal tract and the renal the renal pelvis to the bladder. Furthermore, some operators
parenchyma all the way down to the accessed renal calyx may place a double-J ureteric stent and a simple pigtail cath-
(Fig. 4N). The needle should then be removed, keeping the eter primarily (Fig. 6). However, many operators consider
188 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 5 Primary placement of a nephro-ureteral stent in a transplant kidney. (A) Fluoroscopic image of the right lower
quadrant in a renal transplant recipient. The patient has a rising serum creatinine. The nephrostomy has been
performed under ultrasound and a 5-French sheath has been advanced with its tip (not observed) in the RP. The
5-French sheath has been paced to accommodate a 5-French catheter system in an attempt to traverse the proximal
ureteric stricture (between black arrows). This stricture is persistent, and is not dynamic due to peristalsis. However,
contrast does reach the UB. Incidentally, noted is an intra-uterine device (IUD) in the pelvic background. (B) Fluoro-
scopic image of the right lower quadrant in the same renal transplant recipient. An 0.035 inch stiff glide wire (Terumo,
Corp, Tokyo, Japan) has been passed down the ureter and into the UB traversing the proximal ureteric stricture
(between black arrows). Again noted is an intra-uterine device (IUD) in the pelvic background. The operator is now
passing the nephro-uretral stent/catheter (arrowhead) into the renal collecting system. (C) Fluoroscopic image of the
right lower quadrant in the same renal transplant recipient. The nephro-uretral stent is in place. It has 2 pigtail parts:
a proximal (white arrow) looped in the RP and a distal (black arrow) looped in the UB. In between the stent traverses
and splinters the ureter (between dashed black arrows). IUD: Intra-uterine device.
Percutaneous nephrostomy 189

Figure 6 Primary placement of a double-J ureteric stent and nephrostomy drain. (A) Fluoroscopic image of the right
kidney (patient prone) just after the lower pole calyx (asterisk) has been accessed with a 22-gauge Chiba needle (arrow
at needle tip) under real time ultrasound guidance. Contrast is being injected to delineate the anatomy and is filling the
renal collecting system, including calyces, RP, and ureter. (B) Fluoroscopic image of the right kidney (patient prone).
The operator is passing a 0.018 inch Nitinol wire through the 22-gauge needle (solid white arrow at needle tip) that is
in the lower pole calyx (asterisk), and into the RP. The wire is deflecting (hollow arrow) off the medial wall of the RP
and down into the ureter. (C) Final fluoroscopic image of the right kidney (patient prone). The operator has placed an
8-French double-J ureteric stent (black arrows along shaft of the stent and the upper pigtail circling the “#-sign”) in the
ureter through the UPJ (hollow arrow). A nephrostomy drain (white arrows) has its pigtail occupying the RP and
centered on the “@-sign”. Again noted is the access (lower pole) calyx (asterisk).

obstructed urine (overt infection or not) as infected and con- attempt to place nephrouerteral stents primarily in instances
sider nephrouerteral stent placement additional manipula- of ureteral disease, such as stricture or leak. The latter in
tion and would rather place a simple nephrostomy drain and particular in an attempt to reduce the leakage and help pro-
allow the patient/renal collecting system to defervesce and mote reduction in the patient’s morbidity.
then bring the patient back for a simple nephrostomy to Finally, the definitive access drain is passed coaxially over
nephroureteral stent conversion. Conversely, some operators the 0.035-inch wire (Figs. 1 and 3). In cases of PCNL, inser-
190 W.E.A. Saad, M. Moorthy, and D. Ginat

Figure 7 Nephrostomy drain placement with contrast extravasation. (A) Fluoroscopic image of the left kidney (patient
prone) just after the lower pole calyx has been accessed with a 18-gauge needle (arrow at needle tip) under real time
ultrasound guidance. (B) Fluoroscopic image of the left kidney (patient prone). Contrast has been injected through the
18-gauge needle (arrow at needle tip) showing contrast in the access lower pole calyx (C) and the ureter (U). However,
contrast is also observed extravasating and tracking down around the ureter (asterisks near UPJ and proximal ureter)
and faintly around the midureter (dashed black arrows). The operator is passing a 0.035 inch wire (hollow arrow)
through the 18-gauge needle and into the RP. The contrast extravasation can be from the current needle access or from
prior needle passes/punctures. (C) Fluoroscopic image of the left kidney (patient prone). The operator has passed a
4-French glide catheter over the wire and into the presumed ureter to confirm that access has been achieved. Contrast
is being injected through the catheter that has its tip (not observed clearly) in the proximal ureter (U). Again observed
is contrast extravasating and tracking down around the ureter (asterisks and dashed arrows). Contrast can also be
observed extravasating around the kidney (solid arrows). (D, E) Final fluoroscopic images of the left kidney (patient
prone) with the nephrostomy drain in place. The images are before (7D) and after (7E) contrast injection through the
nephrostomy drain. The nephrostomy drain pigtail is in good position and is locked (hollow arrow, Fig. 7D). Contrast
is again observed extravasating in the retroperitoneum around the kidney (solid white arrows) and adjacent to the
ureter (asterisks). The contrast in the collecting system delineates the access lower pole calyx (C) and the RP in which
the pigtail drain lies.

tion of 2 stiff wires with generous purchase down to the distal After the nephrostomy tube is advanced over the guide
ureter or urinary bladder is recommended (Figs. 4N-4P). wire its placement should be confirmed. The distal loop is
One of these wires functions as a safety wire to maintain formed in the renal pelvis by pulling on the string of the
adequate access as the first wire is accidentally removed or locking pigtail loop (cope loop) (Figs. 1-3). The nephros-
damaged (Figs. 4N-4P). Operators can obtain double wire tomy tube is then secured to the skin with sutures, and left to
access by passing a 6 to 7 French sheath over the original wire gravity bag drainage. Even nephroureteral stents primarily
down the ureter and pass the second wire parallel and adja- placed are set to gravity drainage for at least 24 to 48 hours.
cent to the first wire within the sheath (Fig. 4M). The sheath
is then removed and one of the wires is chosen as the main Post Procedure Imaging
platform of operation, whereas the other is the safety wire/ Immediate post procedure fluoroscopy or ultrasound should
backup wire. be performed to document that the drain is appropriately
Percutaneous nephrostomy 191

situated within the renal pelvis (Figs. 1-3). Contrast is usually Table 3 Complication Rates Following PCN With or Without
injected to obtain the final image and document adequate PCNL
positioning of the tube/drain. Minimal contrast should be Complication PCN PCNL
injected in cases of infected urine/urosepsis. The pigtail/
Mortality rate 0.05%-0.3% pH
cope-loop drain should be well formed (“Coped”) and its Severe bleeding requiring blood 1%-4% 12%-14%
distal tip in contact with the nephrostomy tube shaft. This transfusion &/or intervention
may not always be possible to achieve or confirm with imag- Vascular complications requiring 0.1%-1% pH
ing in decompressed/nonhydronephrotic systems as there is embolization or nephrectomy
not much to form a perfect circular pigtail. Contrast may be Sepsis (septic shock), overall 1%-3%
visualized around the collecting system, and/or tracking Sepsis (septic shock) in 7%-9%a
down the ureter in cases that required multiple initial needle pyonephrosis
passes (Fig. 7). It can also be observed in nephrostomies done Bowel transgression 0.2%
on a decompressed collecting system. This will usually re- Pleural complications 0.1%-0.2% 8%-12%b
(hemothorax, pneumothorax)
solve within 24 hours, and is not a cause for concern. New
filling defects within the collecting system are likely second- PCN, percutaneous nephrostomy; PCNL, percutaneous nephro-
lithotripsy; PH, probably higher.
ary to clots. Special attention should be made by the patient’s aHas been described in up to 25% of cases.
caregivers to watch the output of the drain and monitor vital bIn PCNL of the upper pole. Not overall PCNL pleural complication
signs and hematocrit. rate.
CT angiography is the most suitable initial modality for
evaluating complications related to PCN, particularly in
emergent cases.19,20 It is particularly effective for diagnosing capped to tamponade the bleeding. A surgical/urology con-
postprocedure hemorrhage and can often localize the site of sult should be obtained. Serial hematocrit/hemoglobin
bleeding. Doppler ultrasound, conventional angiography, should be done and blood transfusion should be given ac-
and CT angiography are all appropriate modalities for iden- cordingly to maintain hematocrit levels above 28% to 30%.
tifying arteriovenous fistulas. However, the advantage of con- Continued bleeding requires additional investigation and
ventional arteriography is that concomitant treatment by possible intervention, such as angiography and possible em-
transcatheter embolization can be performed.21 bolization.
Septic shock occurs in less than 4% of patients, but is the
most severe complication of PCN.17,30 Prophylactic antibiotic
Results administration drastically reduces the potential for infectious
The technical success rate for simple PCN is 96% to complications. The overall mortality rate related to PCN is
99%.9,17,22,23 In an obstructed dilated system in native or estimated at 0.04%.5 The incidence of major complications
transplanted kidney the technical success rate is 98%, how- related to PCN combined with nephrolithotripsy (PCNL) is
ever, in a nondilated collecting system and/or in the presence generally higher (Table 3).31 Nevertheless, PCN as well
of complex stones the technical success rate decreases to as PCNL are generally regarded as safe and effective mini-
85%. Similarly, percutaneous lithotripsy has a technical suc- mally invasive options for managing various diseases of the
cess rate of up to 98% for renal stone removal and 88% for urinary track.
ureteral stone removal. Overall, the presence of stones re-
duces the technical and clinical success rates.4,24-26 References
1. Dyer RB, Regan JD, Kavanagh PV, et al: Percutaneous nephrostomy
with extensions of the technique: Step by step. Radiographics 22:503-
Complications 525, 2002
2. Hausegger KA, Portugaller HR: Percutaneous nephrostomy and ante-
Minor and major complications combined generally result in grade ureteral stenting: Technique-indications-complications. Eur Ra-
about 10% of cases; however, minor complications occur in diol 16:2016-2030, 2006
3. Avritscher R, Madoff DC, Ramirez PT, et al: Fistulas of the lower urinary
up to 38%.1,17,23,25,27-30 Minor complications may include
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