Nephrostomy - Dr Christopher Watts

7/21/2019 Nephrostomy - Dr Christopher Watts

http://slidepdf.com/reader/full/nephrostomy-dr-christopher-watts 1/39

NephrostomyAris Caesariano

Fitriliani

Lind Octaviani Irawan

Meta Sakina



Pengertian

Tindakan bedah menggunakan tube, stent, atau

kateter melalui insisi kulit, masuk ke parenkim

ginjal dan berakhir di bagian pelvis renalis atau

kaliks

Jenis nefrostomi

• Nefrostomi terbuka

• Nefrostomi perkutan



Overview

Indikasi dan kontraindikasi

Prosedur

Teknik – dilated and non dilated kidney

Komplikasi





Kontraindikasi

1. Bleeding diathesis (misal coagulopathy tidak terkontrol).

2. Hiperkalemia berat (>7 mEq/L); koreksi dengan

hemodialisisi

3. Pasien tidak kooperatif



Prosedur

1. Preprosedural

Inform consent

Pemeriksaan laboratorium lengkap

Pemenuhan cairan yang adekuat

Antibiotik profilaksis

Pasien puasa 4-8 jam sebelum prosedur



• 2. Alat

• Atas: kateter malecot

• Bawah : kateter pigtail





Patient Preparation

Bloods…..

Bleeding Risk Assessment

Evidence of coagulopathy

Is the patient on warfarin

FBC – plts >50 x 109

INR - <1.5

Hyperkalaemia

K >6.5 – call your medic / anesthetist. Canthe patient be dialysed?



http://localhost/Users/CW/Documents/Radiology/Talks/Nephtostomy%20Talk%20Basic%20Interventional%20Training/pelvic%20extravasation.jpg

http://localhost/Users/CW/Documents/Radiology/Talks/Nephtostomy%20Talk%20Basic%20Interventional%20Training/pelvic%20extravasation.jpg



The referral

Speak to your urologist

Get a detailed overview of

the problem and the

patient’s current state ofhealth

Discuss the urgency of the

case

Review relevant imaging

Is there another way?



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



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



Complications

Major (<5%)

Septic Shock1-3% ( <10% if

pyonephrosis)

Haemorrhage

1-4%

Bowel Transgression

<1%

Pleural Complications

<1%



MINOR

A no therapy or consequence

B nominal therapy, no consequence, overnight admission forobservation only

MAJOR

C therapy , minor hospitalisation <48 hrs

D major therapy, increased care, prolonged hospitalisation>48hours

E permanent adverse sequelae

F death



Success Rates

Obstructed Dilated system without stones 95-98%

Non-dilated collecting system 80-85%



Where to Puncture?

Considerations:

• Anatomy – Where am I least likely tocause significant complications

•Bleeding

•Perforation

•Pneumothorax

•Next intervention

•Simple nephrostomy

•Ureteral intervention

•Patient comfort



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 andposterior division

RELATIVELY AVASCULAR



Other anatomical

considerationsBOWEL

LUNG



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



The Procedure

For dilated collecting systems

US puncture

For Non Dilated collecting systems

Not straightforward.

‘Hybrid IVU’

Frusemide

CT



Kit Angiocath 16gu

Kellet Needle -19gu



Access Kits



Access Kits



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



Single Stick Technique



The Procedure

Performed Prone

Check with US access is

suitable

TIPS

Pillow under the abdomen

Semi prone – kidney to

puncture uppermost

QuickTime™ and a

decompressor are needed to see this picture.



QuickTime™ and a

H.264 decompressor are needed t o see this picture.



QuickTime™ and a

JVT/AVC Coding decompressor are needed to see this picture.



Post Procedural Care

Bed Rest for 4hours

Obs – Bp/Pulse 30min for 4 hrs

Temperature



The Non Dilated System



Single stick v Double

Stick





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 thecalyces

Eg 40mg IV -



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



CT guided



C li ti



Complications

R f



References

Hausegger Percutaneous nephrostomy and antegrade ureteralstenting: technique

— indications

—complications.. Eur Radiol

(2006) 16: 2016–2030

Patel & Hussain Percutaneous Nephrostomy of non-dilated renalcollecting systems with fluoroscopic guidance: Techniques andResults.. Radiology 2004; 233:226-233

Barbaric et al. Percutaneous nephrostomy: placement under CTand 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 JVasc Interv Radiol 2003; 14:S277–S281 (SIR website)