While initially developed as emergent procedure for the relief of urinary obstruction, the use of percutaneous nephrostomy (PCN) has expanded beyond urinary diversion to a variety of other diagnostic procedures and therapeutic interventions. Patients with nephrostomy catheters may present to the emergency department days after placement, with complications relating either to the procedure or to the device itself. Other patients may present with complications related to the long-term use of nephrostomy catheters.
The indications for use of percutaneous nephrostomy include supravesicular obstruction or urine leak, adjunctive therapy for ESWL, or percutaneous ultrasonic lithotripsy. PCN is also used in cases of ureteral strictures, or for nephroscopy or antegrade ureteroscopy, often in conjunction with ureteral stents, as well as in cases of patients who have contraindications to surgical interventions. PCN may be indicated in cases where patients have failed ureteral stenting to relieve obstruction, especially in cases involving malignancy, or in cases of pyonephrosis, where the drainage from the kidney may be too viscous to be adequately drained by ureteral stent. Patients with urinary tract fistulas or other injuries may occasionally have PCN for postprocedure urinary diversion while the fistula closes or injury heals.
Complications in patients who have had percutaneous nephrostomy include hemorrhage, hematuria, infection (including septicemia), urinoma, obstruction, or catheter dislodgment. Complications requiring specific treatment or prolonged hospitalization occur in 4 to 8 percent of PCNs. Although patients can have other serious complications from PCN, including pneumothorax, bowel perforation, and liver or splenic injuries, these complications tend to be detected in the postoperative period and are rarely seen by emergency physicians. Hemorrhage tends to be more likely and more severe in patients with a coagulopathy. If a patient has sufficient bleeding to produce clots large enough to obstruct the nephrostomy catheter, then gentle intermittent irrigation with normal saline can be attempted to maintain the catheter's lumen until the bleeding either slows or clears. Hemorrhage—including pelvocalyceal and retroperitoneal hemorrhage—may also occur in the days following PCN. Although the large majority of patients with clinically significant hemorrhage will be recognized in the period during or shortly after PCN, patients with a history of recent percutaneous nephrostomy should trigger a higher level of suspicion. Hematuria, either transient or persistent, occurs commonly (especially after stone extraction) and is not a cause for alarm, provided that the patient is hemodynamically stable, the hematocrit is stable, and that urinary drainage is maintained. If any of the latter criteria are not met, then an arterial injury should be considered. If significant hemorrhage occurs, then aggressive blood transfusion/fluid resuscitation should be followed with urologic consultation, as the patient may require transcatheter embolization or further surgical procedures.
One to 2 percent of patients having PCN to treat pyonephrosis develop septicemia from release of bacteria or endotoxin from the renal parenchyma or collecting system into the blood. These patients can also develop perinephric abscesses. Therefore, patients with indwelling nephrostomy catheters who present to the emergency department with fever, pain, or other signs of systemic illness should have further evaluation, including urologic consultation.
Patients also may present with persistent urine leak from the nephrostomy site: up to 2 percent of patients have more than 1 week of such urinary drainage from the flank. These patients should have urologic consultation and, after treatment by ureteral catheter insertion or continued nephrostomy drainage, usually recover fully. Urinomas are a relatively infrequent complication and may be managed by ensuring that there is adequate drainage from the nephrostomy catheter. Observation and a possible second percutaneous catheter may be inserted by an urologist or a radiologist. In cases of catheter obstruction, the catheter can be intermittently irrigated with normal saline. If this does not resolve the obstruction, then an urologist should see the patient. If the catheter has become dislodged, in most cases a new puncture must be performed. If the catheter has been left indwelling for many weeks, then the renal parenchymal portion of the nephrostomy tract may be negotiated with either a guidewire or a new catheter, with varying rates of success. Any attempt at recannulation should be carried out by an urologist or a radiologist.
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