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Percutaneous Nephrostomy (PCN)

Percutaneous nephrostomy (PCN) is a minimally invasive, image-guided procedure placing a drainage catheter into the renal collecting system through the skin and renal parenchyma — primarily to decompress an obstructed urinary tract or to gain access for further interventions.[1][2] In use for more than 60 years, it is a cornerstone of interventional radiology and reconstructive urology with technical success > 95% in dilated systems and 80–90% in non-dilated systems.[1][3]

Indications​

  1. Urinary obstruction — the most common indication (malignancy, calculi, strictures, congenital anomalies).[4][2]
  2. Pyonephrosis / infected hydronephrosis — urgent drainage to prevent gram-negative sepsis.
  3. Access for endourologic procedures — PCNL, antegrade ureteral stent (when retrograde fails), balloon dilation of ureteral strictures, antegrade ureteroscopy.
  4. Urinary diversion — traumatic or iatrogenic ureteral leaks / fistulas (post-surgical, radiation-induced).
  5. Antegrade pyelography — to distinguish obstructed from non-obstructed dilation and define anatomy.
  6. Intracollecting-system drug delivery — chemotherapy, antifungals (e.g., fungus balls in neonates).
  7. Post-lithotripsy complications — relief of obstruction from stone fragments after SWL.[5]

Contraindications​

There are no absolute contraindications when PCN is urgently needed.[4] Relative contraindications:

  • Uncorrectable severe coagulopathy.
  • Terminal illness in which the procedure would not alter outcome.
  • Severe metabolic derangements (hyperkalemia, metabolic acidosis) should be corrected pre-procedurally to reduce arrhythmia risk.

Pre-Procedural Workup​

PCN is classified as a high-bleeding-risk procedure by SIR:[6]

  • Labs: INR correct to ≤ 1.5–1.8; platelets transfuse if < 50K; aspirin / anticoagulants per SIR guidance.[6][7]
  • Antibiotic prophylaxis: recommended for all PCN placements. PCN for pyonephrosis or known UTI is contaminated / dirty with ~7% septic-shock risk — agents such as ceftriaxone or ampicillin / sulbactam cover common uropathogens (E. coli, Klebsiella, Proteus, Enterococcus).[8]
  • Imaging review — prior CT or US to assess hydronephrosis grade, anatomy, and obstacles (retrorenal colon, splenomegaly, hepatomegaly).

Technique​

Ultrasound guidance for initial access + fluoroscopy for wire / catheter manipulation:[1][2][4]

  1. Positioning: prone or prone-oblique.
  2. Access site: posterolateral, ideally subcostal (below the 12th rib) and lateral to the paraspinous musculature.[2][9]
  3. Calyceal puncture: a posterior calyx (typically mid or upper pole) — entry through the relatively avascular Brödel's line at a 20–30° posterolateral oblique angle minimizes vascular injury.[2][4][9]
  4. Seldinger technique: 18-G needle → guidewire coiled in renal pelvis → serial tract dilation → self-retaining pigtail catheter (8–12 Fr adults; 5–10 Fr children).[1][4]
  5. Catheter type: external-drainage nephrostomy or internal-external nephroureteral (PCNU) draining through the ureter into the bladder.[1]
  6. Non-dilated systems: more technically demanding (~80–90% success); may require double-puncture, IV contrast, or air/CO₂ distension of the collecting system.[10]

Supracostal access reaches upper-pole calyces but carries pleural-injury risk including pneumothorax and nephropleural fistula.

Success Rates​

SystemTechnical success
Dilated collecting system> 95–100%[1][2][3]
Non-dilated collecting system80–90%[1][3][10]
Complex stone disease (staghorn)≥ 85%[1]
Overall, all comers> 90–97%[11][12][13]

Complications​

Overall complication rate ≤ 10%, with major complications 4–5%.[3][1] SIR quality-improvement thresholds:

ComplicationSIR thresholdNote
Septic shock4% (10% in pyonephrosis)Risk factors: diabetes, renal calculi
Hemorrhage needing transfusion4% (PCN alone)Mild hematuria in ~50% — usually self-limited
Vascular injury requiring embolization / nephrectomy1%Pseudoaneurysm, AV fistula — selective embolization
Bowel injury1%Retrorenal colon most common; often managed conservatively
Pleural (pneumothorax, empyema, hemothorax)1%Higher with supracostal access
Catheter dislodgement3–17%Most common long-term complication; higher in infants and with prolonged dwell
UTI / site infection4–17% / ~2%Asymptomatic bacteriuria is common and should NOT be treated
Urine leak around catheter2–10%—

References: [1][3][14][15]

Management​

  • Bleeding — transient hematuria is nearly universal; persistent or significant bleeding → arteriography for pseudoaneurysm / AV fistula → selective embolization. Balloon-tract tamponade can temporize active hemorrhage.[16][9]
  • Infection / sepsis — broad-spectrum antibiotics; avoid over-distension of the collecting system intraprocedurally to minimize sepsis risk.
  • Dislodgement — urgent replacement, especially if nephrostomy-dependent. Mature tracts (> 7–10 d) often allow over-the-tract replacement; otherwise re-access.
  • Bowel transgression — ensure adequate urinary drainage, withdraw catheter into the colon as a percutaneous colostomy drain, allow tract to mature, antibiotics.[9]

Post-Procedure Care & Maintenance​

  • Monitor vital signs, urine output, and hematuria in the immediate post-procedure period.[16]
  • Catheter to gravity drainage bag. Patient / caregiver education: site cleanliness, catheter securement, output monitoring.[4][16]
  • Routine exchange every ~3 months to reduce colonization, biofilm, and infection.[4]
  • Asymptomatic bacteriuria is universal from biofilm and should not be treated in well-appearing patients.[16][8]
  • Selected low-risk patients (no active infection, adequate renal function, no major comorbidity) can undergo PCN as an outpatient procedure with same-day discharge.[1][4]

PCN vs Retrograde Ureteral Stenting​

SettingFindingReference
Malignant ureteral obstruction (Ahmad meta, 18 studies, n = 1,228)PCN had lower procedure-failure rate than RUS (p < 0.05)[17]
MUO antegrade vs retrograde stent (Kim 2022)Antegrade (via PCN) technical success 98.4% vs 47.4% retrograde — particularly with UO invasion, extrinsic compression, or near-UVJ obstruction[18]
Acute obstructive uropathy meta-analysisBoth effective; no difference in septic parameters, QoL, or failure. PCN: lower post-procedure hematuria / dysuria; longer hospitalization[19]
QoL preferenceBoth negatively affect QoL; most patients who have had both prefer internal stents over external nephrostomy tubes[20]

Advantages Over Internal Stent​

  • Larger bore — better flow of pus or debris.
  • Immediate decompression in septic obstruction.
  • Accessible for exchange, irrigation, nephrostogram.
  • No cystoscopy required — can be placed in the septic, bed-bound patient.

Special Populations​

  • Pregnancy — ultrasound guidance alone is preferred to minimize fetal radiation (ALARA); limited fluoroscopy only if necessary.[5][11]
  • Pediatrics — smaller catheter sizes (5–10 Fr), meticulous securement, gravity drainage (not vacuum). Upper-pole calyx access often preferred for direct ureter access.[4]
  • Malignancy patients — higher complication rates; dislodgement is the most common long-term issue. Risk factors include diabetes, low BMI, chemotherapy, and longer follow-up.[15]

Tract Tumor Seeding​

Rare but documented in upper-tract urothelial carcinoma — relative consideration when planning PCN for known UTUC; alternative drainage (RUS) may be preferred.

See also: Double-J Stent, Nephroureteral Stent, Metal / Long-Term Ureteral Stents, Nephropleural Fistula, The Kidneys.

References​

1. Scheidt MJ, Hohenwalter EJ, Pinchot JW, et al. ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction. Journal of the American College of Radiology. 2020;17(5S):S281-S292. doi:10.1016/j.jacr.2020.01.039

2. Dyer RB, Regan JD, Kavanagh PV, et al. Percutaneous Nephrostomy With Extensions of the Technique: Step by Step. RadioGraphics. 2002;22(3):503-525. doi:10.1148/radiographics.22.3.g02ma19503

3. Hausegger KA, Portugaller HR. Percutaneous Nephrostomy and Antegrade Ureteral Stenting: Technique — Indications — Complications. European Radiology. 2006;16(9):2016-2030. doi:10.1007/s00330-005-0136-7

4. Cahill AM, Annam A, Baskin KM, et al. Society of Interventional Radiology Quality Improvement Standards for Percutaneous Nephrostomy in the Pediatric Population. Journal of Vascular and Interventional Radiology. 2021;32(1):146-149. doi:10.1016/j.jvir.2020.07.029

5. Mueller PR, vanSonnenberg E. Interventional Radiology in the Chest and Abdomen. The New England Journal of Medicine. 1990;322(19):1364-1374. doi:10.1056/NEJM199005103221906

6. Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions — Part II: Recommendations. Journal of Vascular and Interventional Radiology. 2019;30(8):1168-1184.e1. doi:10.1016/j.jvir.2019.04.017

7. Culkin DJ, Exaire EJ, Green D, et al. Anticoagulation and Antiplatelet Therapy in Urological Practice: ICUD / AUA Review Paper. The Journal of Urology. 2014;192(4):1026-1034. doi:10.1016/j.juro.2014.04.103

8. Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis During Vascular and IR Procedures: A SIR Practice Parameter Update. Journal of Vascular and Interventional Radiology. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007

9. Zagoria RJ, Dyer RB. Do's and Don't's of Percutaneous Nephrostomy. Academic Radiology. 1999;6(6):370-377. doi:10.1016/s1076-6332(99)80233-5

10. Patel U, Hussain FF. Percutaneous Nephrostomy of Nondilated Renal Collecting Systems With Fluoroscopic Guidance: Technique and Results. Radiology. 2004;233(1):226-233. doi:10.1148/radiol.2331031342

11. Montvilas P, Solvig J, Johansen TE. Single-Centre Review of Radiologically Guided Percutaneous Nephrostomy Using "Mixed" Technique: Success and Complication Rates. European Journal of Radiology. 2011;80(2):553-558. doi:10.1016/j.ejrad.2011.01.109

12. Degirmenci T, Gunlusoy B, Kozacioglu Z, et al. Utilization of a Modified Clavien Classification System in Reporting Complications After Ultrasound-Guided Percutaneous Nephrostomy Tube Placement. Urology. 2013;81(6):1161-1167. doi:10.1016/j.urology.2013.02.038

13. Rana AM, Zaidi Z, El-Khalid S. Single-Center Review of Fluoroscopy-Guided Percutaneous Nephrostomy Performed by Urologic Surgeons. Journal of Endourology. 2007;21(7):688-691. doi:10.1089/end.2006.0281

14. Sim LS, Tan BS, Yip SK, et al. Single Centre Review of Radiologically-Guided Percutaneous Nephrostomies: A Report of 273 Procedures. Annals of the Academy of Medicine, Singapore. 2002;31(1):76-80.

15. Alma E, Ercil H, Vuruskan E, et al. Long-Term Follow-Up Results and Complications in Cancer Patients With Persistent Nephrostomy Due to Malignant Ureteral Obstruction. Supportive Care in Cancer. 2020;28(11):5581-5588. doi:10.1007/s00520-020-05662-z

16. Yoo MJ, Bridwell RE, Inman BL, Henderson JD, Long B. Approach to Nephrostomy Tubes in the Emergency Department. The American Journal of Emergency Medicine. 2021;50:592-596. doi:10.1016/j.ajem.2021.09.034

17. Ahmad MU, Siddiqui S, Ashraf FA, et al. Retrograde Ureteral Stents Versus Percutaneous Nephrostomy in the Management of Malignant Ureteral Obstruction: A Systematic Review and Meta-Analysis. Urology. 2024;192:158-167. doi:10.1016/j.urology.2024.05.042

18. Kim HJ, Yoon CJ, Lee S, et al. Comparison Between Antegrade Versus Retrograde Ureteral Stent Placement for Malignant Ureteral Obstruction. Journal of Vascular and Interventional Radiology. 2022;33(10):1199-1206. doi:10.1016/j.jvir.2022.06.024

19. Zul Khairul Azwadi I, Norhayati MN, Abdullah MS. Percutaneous Nephrostomy Versus Retrograde Ureteral Stenting for Acute Upper Obstructive Uropathy: A Systematic Review and Meta-Analysis. Scientific Reports. 2021;11(1):6613. doi:10.1038/s41598-021-86136-y

20. Shvero A, Haifler M, Mahmud H, et al. Quality of Life With Tandem Ureteral Stents Compared to Percutaneous Nephrostomy for Malignant Ureteral Obstruction. Supportive Care in Cancer. 2022;30(11):9541-9548. doi:10.1007/s00520-022-07354-2