J Korean Soc Radiol.  2019 Jul;80(4):613-630. 10.3348/jksr.2019.80.4.613.

A Comprehensive Review of Percutaneous Nephrostomy and Suprapubic Cystostomy

• Jo SH
• Lee SM
• Shim JJ
• Choi HC
• Na JB
• Shin HS
• Park MJ
• Cho SB
• Park SE
• Jang JH

• KMID: 2457442
• DOI: http://doi.org/10.3348/jksr.2019.80.4.613

Abstract

Percutaneous nephrostomy is widely used for the diagnosis and treatment of various urinary tract diseases, such as ureteral fistula, stenosis, and percutaneous nephrolithotomy, and the relief of urinary obstruction. Suprapubic cystostomy is also known as a good method for bladder drainage in patients with lower urinary tract obstruction or injury and neurogenic bladder. Despite the frequent use of these procedures, reports in the literature are insufficient for an interventional radiologist to understand the procedures easily and thoroughly. In this article, the indication, anatomy, placement, and postoperative management of percutaneous nephrostomy and suprapubic cystostomy have been described, explaining that the procedures are safe and effective.

MeSH Terms

Constriction, Pathologic
Cystostomy*
Diagnosis
Drainage
Fistula
Humans
Kidney
Methods
Nephrostomy, Percutaneous*
Ureter
Urinary Bladder
Urinary Bladder, Neurogenic
Urinary Tract
Urologic Diseases

Figure

• 

  Fig. 1 Vascular anatomy of the kidney in the coronal plane. 1 = renal artery, 2 = superior segmental artery, 3 = anterior superior segmental artery, 4 = anterior inferior segmental artery, 5 = inferior segmental artery, 6 = posterior branch of the renal artery, 7 = interlobar arteries, 8 = arcuate artery, 9 = ureteric branch of the renal artery

• 

  Fig. 2 Schematic anatomy of the kidney in the axial plane. The arrow indicates a needle within the posterior calyx along the plane of the Brodel's bloodless line. 1 = posterior division of the renal artery, 2 = anterior division of the renal artery, 3 = renal pelvis, 4 = Brodel's bloodless line, 5 = interlobar arteries, 6 = arcuate artery, 7 = interlobular arteries, 8 = fornix, 9 = minor calyx

• 

  Fig. 3 Comparison of PCN performed through the inferior calyx and middle calyx. A. A needle was percutaneously introduced in the inferior calyx (arrowheads). Under fluorosopy, PCN performed through the inferior calyx placing the catheter at a sharp angle to the urete. B. If a subsequent ureteral stent is needed, it is better to puncture the middle calyx (arrowheads). In the PCN performed through the middle calyx, an obtuse angle is formed between the catheter and the ureter, reducing resistance during the ureteral stent placement. PCN = percutaneous nephrostomy

• 

  Fig. 4 A 41-year-old woman presenting with fever and flank pain. A. Contrast-enhanced CT shows pelvocalyceal dilatation with an internal air bubble (arrowhead), which suggests emphysematous pyelonephritis in the right kidney. Percutaneous nephrostomy was performed (not shown). B. Massive hematuria occurred immediately after the procedure. Right renal arteriogram shows a direct fistula between the inferior segmental artery (arrow) and inferior renal calyx (arrowhead). C. After embolization using microcoils (arrow), no further bleeding is seen on the right renal arteriogram. During the procedure, the microcoil migrated into the calyx (arrowhead).

• 

  Fig. 5 An 80-year-old woman with bladder cancer replacing the drain catheter due to marked decrease of urination. A. Fluoroscopic image of the prone patient. A small amount of contrast media was injected through the catheter, but the 0.035-inch guidewire could not pass, as the catheter was clogged. Therefore, after inserting the guidewire (arrowheads) to the side of catheter, it could be advanced along the outer surface of the catheter. B. The existing catheter was removed, and a new catheter was inserted over the guidewire.

• 

  Fig. 6 A 53-year-old man with a double-J stent for ureteral stricture after kidney transplantation. At the follow-up, the patient presented with elevated serum creatinine. A. Percutaneous nephrostomy was performed for the transplanted kidney in the left lower abdomen. Under fluoroscopy, the catheter (arrow) was inserted via the anterosuperior calyx of the transplanted kidney. Arrowheads indicate a double-J ureteral stent. B. Two days after the procedure, the patient complained of abdominal pain, and free air was noted on the abdominal plain film (not shown). Contrast-enhanced CT shows that the catheter (arrowhead) penetrates the descending colon (arrow). Subsequently, the patient underwent primary repair for colon perforation.

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  Fig. 7 Percutaneous nephrostomy using the double-stick technique in a patient with a non-dilated renal collecting system. A. Fluoroscopic image after ultrasound-guided needle (22G) placement in the dilated pelvis of the right kidney. A small volume of urine was aspirated and an equivalent amount of diluted contrast was gently injected in the left renal collecting system. B. After opacifying the renal calyces and identifying the posterior calyx (arrowhead), a 21G second needle (arrow) was inserted toward the posterior calyx under fluoroscopic guidance. C. A 0.018-inch guidewire is inserted through the second needle. Once the wire was in the appropriate position, the first puncture needle was removed. D. After inserting a percutaneous access system (Neff, Cook, Bloomington, IN, USA) over the 0.018-inch guidewire, a 0.035-inch guidewire, dilators (arrow), and an 8.5-Fr pigtail catheter were subsequently inserted. Small hematomas are seen in the renal pelvis and calyces (arrowheads).

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  Fig. 8 Caudal view of the pelvis and anterior abdominal wall. Circle indicates the preferred puncture site. 1 = inferior epigastric artery, 2 = rectus abdominis muscle, 3 = bladder, 4 = space of Retzius, 5 = external iliac artery, 6 = reflected peritoneum

• 

  Fig. 9 A 59-year-old man presenting with urinary retention due to neurogenic bladder. A. Fluoroscopic image in a supine patient. A 21G needle was percutaneously inserted 2–3 cm above the pubic symphysis under ultrasound guidance. If bladder is not fully inflated, diluted contrast media should be injected through the indwelling transurethral catheter or a puncture needle. B. A 0.018-inch guidewire was inserted through the access needle (arrowheads). The needle was exchanged over the wire for the percutaneous access system (Neff, Cook, Bloomington, IN, USA), and the inner metal cannula was removed (not shown). C. A 0.035-inch guidewire was advanced into the bladder, and serial dilatation of the tract was performed over the wire. D. A 8.5-Fr pigtail catheter was subsequently inserted over the wire, and a small amount of contrast media was injected to confirm that the catheter was in an appropriate position.

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