What is a percutaneous nephrostomy (PCN)?

The ureter is a narrow tube that drains urine from the kidney to the bladder. If the drainage of infected urine is blocked due to a stone, blood clot, diabetic papilla or fungal ball; then the patient has a propensity to go into septic shock & surgical intervention may become mandatory. Prior to a definitive intervention, the patient needs to be stabilized by relieving the blockage. For this a fine plastic tube is put through the skin, into the kidney, under general / local anesthesia. This tube allows deobstruction of the system & drains the urine from the kidney into a collecting bag, outside the body. This procedure is called a percutaneous (meaning through the skin) nephrostomy (a tube put into the kidney through a small hole). An iatrogenic injury or a diagnostic study may also merit placing a PCN.

 

Why the need for a PCN?

PCN is done to relieve the kidney of it’s blockage which may lead to irreversible damages. It can also be done as a diagnostic (to diagnose the proximal extent of the narrowing in the ureter) or therapeutic modality (in case ofsteinstrasse – collection of multiple stone fragments in the ureter post ESWL or to place a double J stent in case it is not passable from below)

 

Who has made the decision?

The Urologist makes the decision reviewing the clinical condition of the patient. However the patient & the family have the option of discussing & deciding alternate treatment options if any with their urologist before consenting for the procedure.

 

How do I prepare for percutaneous nephrostomy?

You need to get admitted in the hospital. You will have to be fasting for six hours prior to the procedure. You may receive a sedative to relieve anxiety, & an antibiotic shot after test dose prior to the procedure.

Inform any allergies that are known to you. If you have a past history of reaction to intravenous contrast medium (the dye used for kidney x-rays and CT scans), then you MUST also tell your doctor about this.

 

What happens during the procedure of PCN?

The patient is placed supine or prone as per the urologist preference with an intravenous cannula for medicines as required. The procedure can be performed under general or local anesthesia as is deemed fit. PCN is carried under strict aseptic precautions. The urologist uses the x-ray equipment or the ultrasound to decide on the point for inserting the PCN catheter usually in the patients back. Then the skin will be anesthetized with local anesthesia, and a fine needle inserted into the kidney.

A guide wire is then placed into the kidney through the needle. The tract is dilated & PCN placed over the wire into the pelvicalyceal system. This catheter is then fixed to the skin and attached to a drainage bag.

 

Does it pain?

It may pain but any pain you have should be controlled with painkillers. If the procedure is done under local anesthesia, it stings initially but after a minute or two the tissues become numb. The patient may be aware of touch sensation however it does not pain. If the procedure does become painful, do inform the doctor so that you can be given more pain killers. Usually PCN once placed does not hurt at all.

 

How long will it take?

Every patient is different, and it is not possible to predict the length of the procedure. However it may be over in 20 minutes or occasionally it may take longer than 90 minutes. One must expect to be in the urology O.T for about 1-2 hours altogether.

 

What happens in postoperative recovery?

The patient is kept under observation for 3-4 hours being regularly monitored for pulse & blood pressure. The patient is expected to be in bed rest for 4-6 hours till complete recovery. The drainage catheter stays in place in your body and will be attached to a collection bag. The patient carries on with daily life with catheter in place.

Caution: One should not make sudden jerky movements & ensure there is no pull on the catheter lest it gets displaced. The bag & tube should move freely with you at all times. The bag needs to be emptied every 2 hourly so that it does not become too heavy & gets accidentally pulled out. Make sure to get the amount of urine measured each time if asked by the urologist. At all times be careful so that you do not pull out the tube. Accidentally pulling out the tube may need a repeat PCN.

 

How long will the catheter stay in, and what happens next?

This question has a very patient specific answer for which you need to discuss with your Urologist. It may only be kept for a short duration till stones of steinstrasse postESWL pass or may be needed for longer durations as per the disease process. Removing the catheter does not hurt.

 

Are there any risks or complications?

Percutaneous nephrostomy is a safe procedure, but as with any surgery there are risks involved.

The biggest problem at times may be inability to place the PCN in the kidney. Such a situation may require some alternate treatment including expediting the definitive procedure at times. Slight bleeding from the kidney is common. Rarely bleeding maybe severe requiring a surgical operation or angiography SOS embolisation (a minimally invasive radiological procedure) to stop it.

Rarely leakage of urine from the kidney may result in collection of urine in the retroperitoneum requiring drainage by another tube placement. PCN is normally safe and will result in improvement in your medical condition. This is only a summary of the procedure for your basic understanding. Make sure all your queries stand answered & benefits & side effects understood , before you sign the consent form.