Creation of a nephrostomy

Creation of a nephrostomy

Indications for surgery

What is a nephrostomy?
Performing a nephrostomy, also known as a nephrocutaneous fistula, is a procedure performed for therapeutic reasons, most often for the purpose of discharging residual urine from the kidney, or for diagnostic purposes, e.g. in the case of hydronephrosis with unclear aetiology. The nephrostomy is performed by means of surgery or using a puncture kit to puncture the kidney through the skin and insert a catheter.

Causes and infications for a nephrostomy
A nephrostomy is performed for a number of reasons, the most important one being to ensure patency and free urinary outflow from the kidneys in the case of ureteral obstruction. Indications:

• cancer infiltrating the ureter, including bladder cancer, cervical cancer, ovarian cancer, prostate cancer, colorectal cancer:
Most tumours grow over time, sometimes giving metastasis to distant parts of the body. Those located in the abdominal or pelvic cavity, e.g. ovarian or colon cancer, are theoretically not associated with the urinary tract, however, they may also have a negative effect on the urine flow from the kidney. When they are located near the ureters, they can compress them from the outside, causing obstruction and impeding free flow of urine.

• stone in the renal pelvis or ureter:
Stone is a hard, compact mass that can form in the kidneys, gallbladder or bladder. Stones most often arise when minerals or acid salts contained in the urine crystallise. Most stones are excreted from the body during urination, but sometimes they can get stuck in the ureter, block normal flow of urine and cause its retention in the kidney and the occurrence of disease symptoms. Due to their size, some stones are unable to pass through the ureter and undergo spontaneous excretion. In this case, surgical intervention may be necessary – to remove residual stones and to ensure the free flow of urine to the bladder.

• post-inflammatory or post tuberculosis ureteral stricture:
Inflammation and post-inflammatory healing process as well as tuberculosis-related lesions are responsible for the excessive production of connective tissue, which in some cases may cause complete overgrowth and closure of the ureteral lumen, leading to obstruction of urinary flow.

• ureter constriction after irradiation of the pelvic organs:
In the initial period of radiotherapy, as a result of the blood vessel wall damage caused by ionising radiation, ureter hyperaemia and oedema of the surrounding tissues occur. In more than half of patients, the ureter is compressed and their lumen is narrowed, which results in transient ureteral obstruction and urine retention. After the completion of radiotherapy, or sometimes during its course, obstructive vasculitis may occur, involving the replacement of the vascular epithelium with fibrous tissue. The fibrotic process also affects periureteric tissues. The result of the described processes may be a partial or complete obstruction of the ureters, which may be accompanied by fistulas.

• post-traumatic and postoperative damage to the ureters:
Injuries of the urinary tract most often occur as a result of traffic accidents, a kick or impact with a blunt tool in the lumbar region, a stab wound or gunshot wound. Sometimes ureter damage is caused by iatrogenic injury, i.e. resulting from actions of a medical professional, mainly an incorrect diagnosis made by a physician or a mistake while performing a surgical procedure.

A nephrostomy is also performed for the following reasons:
• prevention, after the resection of renal pelvis tumour;
• direct administration of medication to the excretory system – most often antibiotics;
• diagnostics, e.g. in the case of hydronephrosis of uncertain aetiology, drainage of a renal cyst or abscess.

Hydronephrosis occurs in a situation when the kidney produces the correct amount of urine but there is an obstruction in its outflow pathway, e.g. a tumour, ureteral stone or mass compressing the urinary tract from the outside. In such a case, the urine retains in the kidney, damaging its structure and impairing its function. In order to maintain normal functioning of the kidney, the obstruction must be removed quickly or urinary diversion must be created. The latter solution is provided by percutaneous nephrostomy.

The course of surgery

What does a nephrostomy procedure involve?
A nephrostomy procedure is performed by a urologist in sterile hospital conditions. The doctor evaluates the anatomical structure of the kidney using imaging techniques, such as an X-ray or ultrasound. The procedure is performed under local anaesthesia, the patient is lying on the side or the stomach to expose the punctured organ. Using a special needle, under ultrasound guidance, the urologist punctures the renal calyx and pelvis system (the kidney pulp is not affected) and introduces a nephrostomy tube which is specially contoured – its renal end is curled and resembles a pig’s tail. The catheter is designed to keep the drain inside the kidney calyx and pelvis system for a long time and to protect it from spontaneous ejection. The end of the drain has numerous openings, which facilitate urinary diversion from the kidneys. The nephrostomy tube is sewn at its skin outlet to increase stability.

It is located on the side of the body and connected to a special urine collection bag. The bag is usually worn under clothing, attached to the patient’s thigh or calf.

How long is a nephrostomy for?
The duration of a nephrostomy depends on the individual patient’s case. In the event that the urethral obstruction disappears due to successful cancer treatment, it may be possible to remove the nephrostomy. In some cases, it is possible to set up special stents to by-pass the ureteral obstruction. If the procedure of stent placement is successful, it will be possible to remove the nephrostomy. In patients in whom cancer treatment or stent placement is not possible, the nephrostomy is usually permanent. Each case is individual and the above issues should be thoroughly discussed with the doctor.

After surgery

The risk of complications following a nephrostomy procedure
The risk of complications due to a nephrostomy procedure is relatively low. Occasionally, infections, haemorrhage or kidney leakage may occur. Your health will be closely monitored in the hospital to immediately prevent any possible complications.

Nephrostomy after the procedure
After returning home, the nephrostomy should not be an obstacle to free movement and leading a normal lifestyle. In the initial period after the procedure, performing some daily activities (bending down, climbing stairs etc.) may cause discomfort. Finding a comfortable sleeping position can also be a problem. Over time, however, all the inconvenience associated with nephrostomy should resolve. The fear associated with living with a nephrostomy is natural, but it can be easily resolved thanks to the support and help of family and friends. It is important to observe simple rules:

• change urine collection bags as often as your doctor or nurse recommend
• always wash your hands before and after changing the bag or dressing,
• contact your doctor immediately if your urine contains blood, has a cloudy texture or a strong odour, or when you experience pain associated with urinary excretion. These may be symptoms of a urinary tract infection that will require the use of antibiotics,
• drink lots of liquids to minimise the possibility of infection – at least 2 litres per day of, preferably, still water,
• contact your doctor or nurse if your skin around the drain is painful, red or swollen. These can be symptoms of an infection requiring immediate medical attention,
• contact your doctor or nurse immediately if the drain comes out of the body or if the urine stops flowing out of the drain or if there is a spontaneous release of the suture that secures the drain in the right position.
If you suspect that something bad is happening with your nephrostomy, contact your doctor or nurse immediately.