1. Nephrostomy Dr Christopher Watts Consultant Radiologist Salisbury District Hospital

2. Talk Overview Indications & Contraindications Patient preparation Consent Kit Techniques – dilated and non dilated kidney Complications

3. Indications Relief of Urinary Obstruction Urosepsis or possible infection Acute Renal failure Urinary Diversion Haemorrhagic cystitis Trauma or iatrogenic ureteral injury Inflammatory or malignant urinary fistula Access for endourological procedure Dilating or stenting ureteral stricture Biopsy or treatment of urothelial lesions Foreign body retrieval

6. Contraindications Absolute ? None… Relative Dying patient Uncorrectable severe coagulopathy / bleeding diathesis Severe hyperkalaemia and/or metabolic acidosis Pregnancy

7. Who should do it? When should it be done? IR or Urologists? Part of RCR specialty IR training Not just a drainage…. During the day Possibly during the night Single kidney Sepsis

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

9. Patient Preparation Bloods….. Bleeding Risk Assessment Evidence of coagulopathy Is the patient on warfarin FBC – plts >50 x 10 9 INR - <1.5 Hyperkalaemia K >6.5 – call your medic / anesthetist. Can the patient be dialysed?

10. 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

11. 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

12. Consent and Complications Major (<5%) Septic Shock 1-3% ( <10% if pyonephrosis) Haemorrhage 1-4% Bowel Transgression <1% Pleural Complications <1%

13. SIR classification 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

14. Success Rates Obstructed Dilated system without stones 95-98% Non-dilated collecting system80-85%

15. 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

16. Bleeding Renal artery divides into anterior an posterior branches Posterior branch supplies 30% of the kidney Brodel’s Line divides the area between the anterior and posterior division RELATIVELY AVASCULAR

17. Other anatomical considerations BOWEL LUNG

18. 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

19. The Procedure For dilated collecting systems US puncture For Non Dilated collecting systems Not straightforward. ‘Hybrid IVU’ Frusemide CT

20. Kit Angiocath 16gu Kellet Needle -19gu

21. Access Kits

23. 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

24. Single Stick Technique

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

28. Post Procedural Care Bed Rest for 4hours Obs – Bp/Pulse 30min for 4 hrs Temperature

29. The Non Dilated System

30. Single stick v Double Stick

32. 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 -

33. 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

34. CT guided

36. Complications

37. References Hausegger Percutaneous nephrostomy and antegrade ureteral stenting: technique— indications—complications.. Eur Radiol (2006) 16: 2016–2030 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 non- dilated pelvicaliceal system. J Clin Ultrasound. 1998 Mar- Apr;26(3):177-9. Quality Improvement Guidelines for Percutaneous Nephrostomy J Vasc Interv Radiol 2003; 14:S277–S281 (SIR website)