Should any special precautions be undertaken when performing a neprostomy for a presume infected system?
In addition to the usual patient preparation one should ensure: 1. Prior antibiotics have been administered 2. Inject the minimal contrast requires to ellucidate the collection system following puncture ( large volumes and aggressive injection can worsen the sepsis) 3. Collect the initial puncture urine sample for microbiological analysis.
I've punctured the collecting system, and nothing is coming out freely from the needle. What next?
In an obstructed system with merely urine within, one would expect free flow of urine from the puncture needle to confirm correct position. With a pyonephrosis, often nothing will immediately, if at all, come out freely. Ensure one uses a small syringe ( 5ml ) to actively aspirate. This will often yield pus, before performing a nephrostomgram prior to wire insertion.
Control film: large proximal ureteric calculus.
Nephrostogram: Hydronephrosis due to almost complete obstruction from the ureteric calculus.
8F nephrostomy tube in the renal pelvis.