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Nephrostomy — why, how and what to look out for

Department of Radiology, St George's Hospital and Medical School, London, UK

• Nephrostomy or ureteric stents are equally efficacious in randomized trials.
  
• Obstructed infected kidneys need to be drained as early as possible.
  
• Combined ultrasound and fluoroscopic guidance is most commonly used, but ultrasound, fluoroscopic or CT guidance alone can be used.
  
• The accepted threshold for haemorrhage after nephrostomy insertion is 4% or less, but only 1% or less should require embolization.
  

Percutaneous nephrostomy is a skill that is attainable by all radiologists, but technical variations can be employed specific to each case. Imaging guidance for nephrostomy may include ultrasound, fluoroscopy, computed tomography (CT) or any combination of these modalities. An understanding of the appropriate indications, relevant anatomy and required laboratory investigations, in combination with a basic knowledge of sedation and analgesia, is vital. Familiarity with the available equipment and how to use it is also fundamental to achieving a safe and successful outcome. Nephrostomy insertion does not finish upon connection of the drainage bag. It remains the responsibility of the operator to recognize potential complications and their appropriate management. This article outlines the practical aspects of nephrostomy. By covering issues relating to special cases, such as the pregnant patient and the transplant kidney, it should also be of interest to those radiologists already familiar with the basics of the technique.