**5. Complications**

Complications following simple nephrostomy tube drainage are minor with a rate approaching 4%. (LeRoy, 1996). The common complications are hemorrhage, infection, improper catheter placement, nephrostomy tube dislodging after initial proper placement, nephrocutaneous fistula, stone formation and post-obstructive diuresis. Initial hematuria is common, but should be cleared in 24 – 48 hours post operatively.

Small subcapsular hematoma is found about 3% of cases, a complication that is usually resolved without sequelae. Bleeding from iatrogenic arteriovenous-caliceal fistulas occurs in less than 2% and can be managed with angioembolization. (Fig. 21, 22) Pulmary

Preoperative and postoperative angioembolization of arteriovenous fistula follow percutaneous nephrolithotomy.

Fig. 21. Arteriovenous fistula at middle part of kidney.

Fig. 22. Disappear of fistula after angioembolization.

Modern Surgical Treatments of Urinary Tract Obstruction 279

Fig. 25. Kinking of tube follow long term nephrostomy tube placement.

**6. Percutaneas nephrostomy placement in special situations** 

prone position, the site of access is relatively median often at paraspinous area.

Due to abnormal anatomy of patients with renal anomalies such as horseshoe kidney; in

In supine position, the percutanous access can be achieved through extraperitoneal approach under ultrasound guidance. The puncture site start at medial to the anterior superior iliac crest. Occasionally, CT guidance is needed especially when there is bowel

Access nephrostomy tube to pelvic kidney is challenging due to significant complications such as bleeding and urine extravasation. This technique requires combined transabdominal

Access to the pediatric kidney is more complex than the adult kidney in terms of fluid management and the appropriate size of the nephrostomy tube. Long term stabilization the

Percutaneous nephrostomy is performed for temporary or permanent supravesicle urinary diversion. The successful outcome without complication is the goal of this procedure and this requires careful preoperative planning and proper techniques. The guidance system for urinary tract intervention are fluoroscopic guidance, real-time ultrasonography and CT

**6.1 Renal anomalies** 

**6.2 Transplanted kidney** 

**6.3 Pelvic kidney** 

**6.4 Pediatric kidney** 

**7. Summary** 

loops between anterior abdominal wall and kidney.

laparoscopic and transurethral retrograde access creation.

nephrostomy tube in children is often difficult.

complication is found in endourologic procedure via upper pole access. Patients with significant hydrothorax usually need intercostal drainage. (Lojanapiwat & Prasopsuk, 2006). (Fig. 23, 24) Other minor complications are small perforations with collection, malfunction of nephrostomy tube, persistence nephrocutaneous fistula and sepsis in patients with infected urine. (de la Rosette et al., 2011) (Fig. 25)

Fig. 23, 24. Hydrothorax: Immediate post-operative and post intercostal tube drainage chest x-ray of patient following upper pole percutaneous nephrolithotomy.

Patients who develop postobstructive diuresis (POD > 3 liters per day or > 200 ml/hr for 12 to 24 hours) following urinary diversion should be treated with intravenous fluid of 0.45 percent NaCI at a two hourly rate equal to one half the previous two hours urine output. (Gulmi et al., 1998)

Nephrostomy tube dislodgement from the skin can be undertaken even when carefully fixed to the skin with silk suture. Zhou and colleges reported a new technique to reinforce the nephrostomy tube in 48 patients by using 2 cm long rubber drainage tube as the outer tube to encase the nephrostomy tube and suturing the longitudinal cutting edges together with the skin suture. This technique can significantly decrease the dislodgement incidence of nephrostomy tube. (Zhou et al., 2011)

Prevention of nephrocutaneous fistula, a nephrostogram should show radio-opaque contrast medium passing freely down the ureter into the bladder. Clamping the catheter should be done before removing the catheter and should cause no pain and no leakage around the catheter.

Foreign-body calculi at nephrostomy tube can occur after long term placement. Dalton et al reviewed the inducement of foreign-body calculi in laboratory animals as 1) Stone may develop on foreign bodies in absence or presence of infection, 2) Urea-splitting organisms enhance the formation of foreign-body stones, 3) Diuresis and urinary acidification inhibits foreign-body stone formation. Iatrogenic foreign body stones lead to a significant proportion of this urologic problem such as ureteral catheters or nephrostomy tubes. (Dalton et al., 1975).

Fig. 25. Kinking of tube follow long term nephrostomy tube placement.
