OR / Prep · Urology · percutaneous
You’re scrubbing into
Percutaneous nephrostomy
Why are we operating?
A tube through the flank into a blocked, infected kidney: the urological equivalent of draining an abscess, and the operation that turns sepsis around overnight.
Indication: Obstructed infected kidney (pyonephrosis), the urological emergency; obstruction with failing renal function.
Read the imaging first
Practice before you scrub
The kidney under pressure
Colicky loin-to-groin pain, now rigors and a temperature of 38.9. Renal ultrasound. (Fictional educational case.)
- Hydronephrosis says obstructed; the fever beside it says drain tonight, by stent or nephrostomy, whichever the hospital can mobilise fastest.
- Definitive stone surgery waits for a cooled, cultured, recovered patient: never the same sitting as the septic drainage.
The operation in 4 steps
01Imaging and planning the track
Under ultrasound (with or without fluoroscopy), a posterior calyx is chosen and a track planned below the pleural reflection.
Why: The posterior calyx approach passes through the kidney's least vascular plane; planning below the twelfth rib keeps the needle out of the pleura, and the colon's position is checked before anything advances.
02Puncture and wire
A fine needle enters the target calyx; urine (or pus) confirms position, and a guidewire is coiled in the collecting system.
Why: Everything that follows rides this wire, so its position is confirmed before the track is enlarged. The first aspirate is the diagnosis: cloudy urine converts suspicion of pyonephrosis into fact and is sent for culture.
03Track dilation and tube placement
The track is dilated over the wire and a pigtail nephrostomy advanced and coiled in the renal pelvis, then secured.
Why: The pigtail's coil is its anchor; free drainage of infected urine is the operation's entire objective, and minimal manipulation in an infected system is the rule, because every extra pass bacteraemias the patient.
04Aftercare and the definitive plan
Output monitored, cultures chase the organism, and the obstructing cause is treated electively once sepsis has resolved.
Why: The nephrostomy is a bridge, not a destination: the stone or stricture that caused this is booked for definitive treatment when the patient can afford it, and post-obstructive diuresis is watched for meanwhile.
Anatomy you need
The kidney and its collecting system from behind, the way the needle approaches through the posterior calyx.
What can go wrong
Watch it done
Percutaneous nephrostomy
The interventional radiology teaching: posterior calyx puncture, wire, dilatation and the pigtail.
Source: IR Education · Watch on YouTubeYour nephrostomy or nephroureteral drain
Caring for the tube afterwards: flushing, the bag, and when to call.
Source: Cleveland Clinic · Watch on YouTube
Conceptual teaching for learners preparing to observe and assist under supervision, not operative instructions. Five minutes from now you should know why this operation exists, what its shape is, and which structures it is designed not to injure.