Nephrostomy - is a term used to describe a passageway maintained by a tube, stent, or catheter that perforates the skin, passes through

the body wall and renal parenchyma, and terminates in the renal pelvis or a calyx. -The nephrostomy has multiple functions but is used most frequently to provide urinary drainage when the ureter is obstructed and retrograde access is inadvisable or impossible. - A nephrostomy can also be used to gain access to the upper urinary tract for various antegrade endourologic procedures, such as intracorporeal lithotripsy, chemical stone dissolution, antegrade radiologic studies of the ureter, and double-J stent placement. Nephrostomy has several other functions, including the following:

To remove or dissolve renal calculi To obtain direct access to the upper urinary tract for various endourologic procedures To diagnose ureteral obstruction, filling defects, and anomalies via antegrade radiography To deliver chemotherapeutic agents to the renal collecting system To provide prophylaxis after resection for local chemotherapy in patients with tumors of the renal pelvis

PROCEDURE Nephrostomy involves creating an opening into the kidney to maintain temporary or permanent urinary drainage. The collecting system of the kidney is punctured percutaneously with a needle under fluoroscopic, ultrasonographic, or CT guidance. The needle is passed through the skin, subcutaneous tissue, external and internal muscle layers, and the renal parenchyma to reach the collecting system. When the needle has entered the renal collecting system, a guidewire is passed through the needle into the kidney and possibly down the ureter. Over the guidewire, various dilators can be used to establish and enlarge the nephrostomy tract, which is then maintained by a tube. Alternatively, a nephrostomy tube can be placed during open surgery. In this procedure, a tube is placed into the renal pelvis, perforating the renal parenchyma and puncturing the flank musculature,

subcutaneous tissues, and skin to create a direct passage between the renal collecting system and the external environment. Anesthetic agents can be more hazardous in patients with overt renal shock. Therefore, performing the nephrostomy under local anesthesia is especially important when the procedure is potentially lifesaving.

Indications Percutaneous nephrostomy is occasionally essential, if not lifesaving, in the treatment of acute or chronic upper urinary tract obstruction. It is the first step in obtaining antegrade access to the kidney for various procedures. Specific indications for percutaneous nephrostomy include the following:

Acute or chronic upper urinary tract obstruction in which access to the kidney is impossible from the lower urinary tract because of stones, infections, tumors, or anatomic anomalies, especially when a double-J stent cannot be placed through the ureter because of above-mentioned circumstances When a patient's creatinine level is rising above the reference range and the urine cannot be drained through the ureter Renal pelvis disorders (eg, UPJ obstruction, horseshoe kidneys, ureter duplex, ureter fissures, double renal collecting systems) Hydronephrosis in renal transplant allografts: When dilatation of the renal pelvis affects kidney function to the extent that double-J stent placement is difficult or impossible, percutaneous nephrostomy may be an easier option. Treatment of staghorn calculi and large or lower-pole kidney stones (when a percutaneous nephrolithotomy [PCN] is likely to be followed because of the stone burden and an extracorporeal shockwave lithotripsy [ESWL] is less likely to be successful) Contraindications to ESWL (ie, size of patient): Most ESWL units have a weight limit of 140 kg (approximately 300 lb). Body habitus that prevents ESWL (eg, contractures): Disabled patients occasionally cannot be positioned on an ESWL unit in a prone or supine position.

Stones or tumors associated with distal obstruction or a foreign body that cannot be removed through the ureter When rapid dilation of the nephrostomy tract is required (eg, when access is needed instantly for operative procedures within the renal collecting system [for stone removal or tumor ablation]) Prolonged sequential dilatation: Gradually increasing the catheter size may be necessary when a nephrostomy tube is placed permanently for urine drainage in patients in whom a retrograde access to the kidney is impossible (eg, advanced metastatic tumors, loss of the total ureter, patients with a palliative nephrostomy tube whose cases are inoperable).

Contraindications

Bleeding diathesis (eg, hemophilia, thrombocytopenia) and uncontrolled hypertension Anticoagulant use (eg, aspirin [relative contraindication], heparin, warfarin)

Preoperative Management 1. Functional Assessment should be performed. 2. Bowel preparation is performed to prevent fecal contamination during surgery and potential complication of infection. 3. Adequate hydration is ensured. How to I care for the nephrostomy tube? Keep the skin around the nephrostomy tube clean. To prevent infection, a sterile dressing should be placed over the site where the tube leaves your body. . The location of the nephrostomy tube may make it difficult for you to reach. You may need help from another person to do the dressing change and flushing. The way you care for a newly inserted tube is different than the care you use once the site has healed.

 For the first 2 weeks after nephrostomy tube placement, the sterile gauze dressing should be changed once a day. If you prefer to use sterile transparent dressing, it should be changed every 3 days. After the first 2 weeks, the dressing should be changed at least twice a week (for example, every Monday and Thursday). You must change your dressing if it is wet.