**3.2.7 Techniques**

Follow the preparation of skin: under the ultrasonic or fluoroscopic imaging, once the pelvocalical system is clearly visible, the skin is anesthetized with one percent xylocaine or 0.25 percent bupivicaine. Xylocaine is injected into the skin, subcutaneous tissue, muscle, perinephric space and renal capsule with a small cutaneous incision. Using a needle 2 system, a 18-gauge needle is introduced toward the desired site in the renal pelvis at the more lateral point which is usually along the posterior axillary line. This can be followed and monitored by real-time ultrasound or fluoroscopy. Under fluoroscopic guidance, visualization of desired calyx is demonstrated by injection of air and contrast media. In prone position, air usually floats up to posterior calices that it is the marker for the puncture. (Fig. 16)

Fig. 16. Fluoroscopic imaging: air usually floats up to posterior calices in prone position that it is the marker for the puncture.

When the needle tip enters the collecting system, urine can be aspirated from the needle after the needle stylet is removed. A soft J-tipped guidewire is inserted into the needle and advanced across the caliceal infundibulum to renal pelvis. The choice of guidewires depends on the indication of nephrostomy placement. A Bentson guidewires is commonly used due to a floppy tip and coil atraumatically in collecting system.

Follow the preparation of skin: under the ultrasonic or fluoroscopic imaging, once the pelvocalical system is clearly visible, the skin is anesthetized with one percent xylocaine or 0.25 percent bupivicaine. Xylocaine is injected into the skin, subcutaneous tissue, muscle, perinephric space and renal capsule with a small cutaneous incision. Using a needle 2 system, a 18-gauge needle is introduced toward the desired site in the renal pelvis at the more lateral point which is usually along the posterior axillary line. This can be followed and monitored by real-time ultrasound or fluoroscopy. Under fluoroscopic guidance, visualization of desired calyx is demonstrated by injection of air and contrast media. In prone position, air usually floats up to posterior calices that it is the marker for the puncture.

Fig. 16. Fluoroscopic imaging: air usually floats up to posterior calices in prone position that

When the needle tip enters the collecting system, urine can be aspirated from the needle after the needle stylet is removed. A soft J-tipped guidewire is inserted into the needle and advanced across the caliceal infundibulum to renal pelvis. The choice of guidewires depends on the indication of nephrostomy placement. A Bentson guidewires is commonly

used due to a floppy tip and coil atraumatically in collecting system.

**3.2.6.3 The causes of access failure** 

it is the marker for the puncture.

**3.2.7 Techniques** 

(Fig. 16)





In special situations, such as an impacted stone in the collecting system, the manipulation often requires small angled-tip catheters and hydrophilic coated wires. Then the needle is removed, and progressively larger dilators are introduced over the guidewire to dilate the access tract to facilitate the placement of soft nephrostomy tube. The size of tract dilatation depends on the goal of percutaneous access. If the goal is to provide external urinary drainage, serial dilators are inserted over the guidewire to dilate the tract to a sufficient size for the nephrostomy tube. The 8 or 10 Fr nephrostomy tube is introduced over the guidewire and optimal position is monitored by ultrasound or fluoroscopy.

The most reliable evidence for the proper placement of the nephrostomy tube can be demonstrated by nephrostogram under fluoroscopic imaging. The guidewire is withdrawn and the nephrostomy tube is secured with skin to prevent dislodging the catheter. The catheter is connected to a urine bag for drainage. (Fig. 17-20) For permanant nephrostomy tube placement, the tract can be further dilated and a regular Foley's catheter can be used.

Fig. 17. Ultrasonic probe for guidance the nephrostomy tube placement.

Fig. 18. Dilators over the guidewire.

Modern Surgical Treatments of Urinary Tract Obstruction 277

Overall success rate of uncomplicated nephrostomy tube placement is over 97% with less success in patients who required percutaneous tract for subsequent endourologic interventions. Factors which affect the success rate of nephrostomy tube placement during endourologic operation are stone burden, degree of hydronephrosis, history of previous open nephrolithotomy, and experience of surgeon. As same as other urologic procedure, a training simulator for ultrasound-guided percutaneous nephrostomy insertion is needed for a safe, non-threatening environment, without risk to patients. Commercial and a gelatin phantoms are available. Skill is required prior to undertaking procedures in patients. (Rock et al., 2010)

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

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

Fig. 22. Disappear of fistula after

angioembolization.


**4. Results**

**5. Complications** 

percutaneous nephrolithotomy.

of kidney.

Fig. 21. Arteriovenous fistula at middle part



common, but should be cleared in 24 – 48 hours post operatively.

Fig. 19. 8 Fr nephostomy catheter inserted through the guidewire.

Fig. 20. The nephrostomy tube is secured with skin.

Further endourologic procedures that will follow temporary nephrostomy tube placement are percutaneous nephrolithotomy for removal of renal and upper ureteral calculi, endopyelotomy for ureteropelvic junction obstruction and infundibulotomy for infundibular stenosis. Percutaneous nephrolithotomy is effective and safe in patients with complex conditions such as underlying medical conditions and previous open nephrolithotomy. (Lojanapiwat, 2006).

Following these procedures, most patients need a larger nephrostomy tube for adequate drainage and tamponing the bleeding point from the nephrostomy tract. Recently tubeless percutaneous nephrolithotomy has been performed in uncomplicated cases with no significant bleeding, no significant extravasation, no distal obstruction and no secondary nephroscopy required. (Lojanapiwat et al., 2001) (Table 5)


276 Chronic Kidney Disease

Fig. 19. 8 Fr nephostomy catheter inserted through the guidewire.

Fig. 20. The nephrostomy tube is secured with skin.

nephroscopy required. (Lojanapiwat et al., 2001) (Table 5)

nephrolithotomy. (Lojanapiwat, 2006).

Further endourologic procedures that will follow temporary nephrostomy tube placement are percutaneous nephrolithotomy for removal of renal and upper ureteral calculi, endopyelotomy for ureteropelvic junction obstruction and infundibulotomy for infundibular stenosis. Percutaneous nephrolithotomy is effective and safe in patients with complex conditions such as underlying medical conditions and previous open

Following these procedures, most patients need a larger nephrostomy tube for adequate drainage and tamponing the bleeding point from the nephrostomy tract. Recently tubeless percutaneous nephrolithotomy has been performed in uncomplicated cases with no significant bleeding, no significant extravasation, no distal obstruction and no secondary


Table 5. Criteria for tubeless percutaneous nephrolithotomy.
