03 / Urology · percutaneous
Percutaneous nephrostomy
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.
On the tray for this operation
Test yourself on the tray
Stage
1 / 4
Imaging and planning the track
Under ultrasound (with or without fluoroscopy), a posterior calyx is chosen and a track planned below the pleural reflection.
Watch for: Pleural transgression → pneumothorax or urinothorax · Colonic injury with a retrorenal colon
Why are we operating?
Percutaneous nephrostomy drains an obstructed kidney from above: a needle passed through the flank into the collecting system, a wire, a dilated tract and a pigtail catheter, all under imaging and local anaesthesia. Its defining emergency is the obstructed infected kidney, where the tube is the treatment for sepsis, and its elegance is that the sickest patients, who least tolerate an anaesthetic, are exactly the ones it serves best.
Pulls toward surgery
Gives the team pause
Shared foundations
What the surgeon is thinking
Imaging and planning the track
Why a posterior calyx, and what is Brodel's line?
The kidney's posterolateral aspect carries a relatively avascular plane between the anterior and posterior arterial divisions: a puncture through a posterior calyx along that corridor crosses the least parenchymal blood supply and enters the system end-on. Ultrasound picks the calyx; the geometry does the haemostasis.
Puncture and wire
Why puncture through the kidney at all, rather than straight into the pelvis?
The parenchymal tract is the seal: the renal pelvis is thin-walled and retroperitoneal, and a direct pelvic puncture leaks urine and blood with nothing to close around the catheter. A transparenchymal route through the calyx lets the kidney itself grip the tube.
Track dilation and tube placement
What is the wire's job in the exchange?
The wire is the tract's guardian: once coiled in the collecting system, everything else (dilators, then the pigtail catheter) travels over it, and losing wire access in a bleeding, infected tract is the procedure's classic self-inflicted disaster. The pigtail's coil is the retention mechanism, formed and confirmed under imaging.
Aftercare and the definitive plan
Why is 'decompress, do not explore' the septic kidney's rule?
Manipulation in an infected, pressurised system showers organisms into the circulation: in urosepsis the procedure ends when urine flows, with contrast studies and stone work deferred. The first specimen goes to culture, and the definitive stone plan waits for a cooled patient.
Decision points
The pyonephrosis is drained and the patient defervesces. When is the stone treated?
Interval treatment after full recovery
The standard arc: culture-guided antibiotics, days to weeks of recovery, then definitive stone surgery with the nephrostomy as ready-made access if percutaneous.
Early same-admission treatment
For the fully recovered, low-burden case in units with capacity: still never in the same sitting as the septic drainage.
Drain now, define later, treat definitively third: instrumenting an infected system spreads what the tube just contained. The nephrostomy is a bridge with a named far bank, and the discharge letter must say who owns the crossing.
Frank blood runs from the new nephrostomy in recovery.
Observe, clamp trial, transfuse as needed
Some haematuria is universal and settles: a transparenchymal tract bleeds briefly by design.
CT angiography and embolisation
For persistent or pulsatile bleeding or haemodynamic cost: the pseudoaneurysm or AV fistula in the tract is interventional radiology's to close.
The tract crosses vascular parenchyma, so bleeding has a spectrum with a pathway attached: expected pink, watchable red, and the persistent bleed that earns angiography. Knowing which tier you are watching is the aftercare.
Leaving the OR
The handoff
- Procedure
- Left percutaneous nephrostomy for obstructed infected kidney (7 mm ureteric stone)
- Drainage
- Purulent urine under pressure, sent to culture; pigtail coiled and secured
- Sepsis
- Antibiotics running; lactate falling post-decompression
- Watch for
- Tube output hourly (a stopped tube is an urgent call), haematuria tier, fever trajectory
A fictional educational patient, handed over the way real ones are.
The postoperative course
- First hoursDefervescence is the procedure's report card: the pressure problem is solved, and the tube's patency is now the treatment being protected.
- Day 1-2Culture-guided antibiotics; the tube dressed, fixed and taught to the patient: it stays until the stone plan replaces it.
- Days to weeksDefinitive stone management scheduled: ureteroscopy, lithotripsy or percutaneous surgery through the established tract.
- RemovalThe nephrostomy comes out when antegrade drainage is proven unnecessary: an unobstructed system, a treated stone, and a tract that closes itself within days.
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