Case of the Month January, 2014

Nephrostomy tubes: technique, indications and risks

by Sean Welsh, MD, and Thomas J. Learch, MD

A 62 year old male with history of urothelial carcinoma status post cystoprostatectomy and ileal conduit presented to the emergency department with fevers to 101 at home, chills, and nausea. Patient had decreased PO intake, denied emesis, and had been passing flatus but had no BM since surgery. Patient was noted to have Cr to 2.0, leukocytosis to 16K, hyponatremia, hyperkalemia, hypochloremia, and hypoalbuminemia. UA demonstrated 23 RBCs, >180 WBCs, and 1+ bacteria. Renal ultrasound showed moderate left sided hydronephrosis. Based on the diagnosis of urosepsis presumed related to left renal obstructive uropathy, a loopogram was performed which demonstrated grade 3 vesico-ureteral reflux in the right kidney with no opacification of the left ureter, suggesting a distal obstruction of the left ureter, for which differential considerations would include anastomotic stricture vs. recurrent urothelial malignancy. Subsequently a nephrostomy tube insertion was ordered to decompress the left renal collecting system.

For larger image, please click Nephrostomy tubes

Renal ultrasound demonstrates moderate left-sided hydronephrosis.

For larger image, please click Nephrostomy tubes 2

X-ray loopgram demonstrating reflux into the right ureter, without opacification of the left ureter. The findings suggest distal blockage of the left ureter.

For a larger image, please click Nephrostomy tubes 3

Percutaneous nephrostomy. The needle is positioned in the mid-pole posterior calyx, filled with air. A filter in the inferior vena cava.

For a larger image, please click Nephrostomy tubes 4

A 0.018-inch guidewire has been advanced through the needle into the ureter.

For a larger image, please click Nephrostomy tubes 5

An 8F locking pigtail catheter has been placed in the renal pelvis.

Questions:
1. What is the appropriate insertion site in the kidney for percutaneous nephrostomy tubes?
a. LOWER POLE POSTERIOR CALYX
b. UPPER POLE ANTERIOR CALYX
c. LOWER POLE ANTERIOR CALYX
d. UPPER POLE POSTERIOR CALYX.

Visit our Case of the Month ArchiveNext Page >