FUNDAMENTALS OF

UPPER URINARY
TRACT DRAINAGE
Maj. Hafizur Rashid
Content
 PERCUTANEOUS RENAL ACCESS AND DRAINAGE
 Indications
 Anatomic Considerations
 Surgical Technique
 Complications
 RETROGRADE RENAL ACCESS AND DRAINAGE
 Indications
 Surgical Technique
 Stent Varieties
 Stent Tolerance
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Indications

 Indications
 Simple Drainage
 Diagnostic Studies- Whittaker test
 Therapeutic Instillations- Chemotherapeutic agents
 Percutaneous Renal Surgery- upper tract calculi,
urothelial tumors, obstruction, and calyceal
diverticulae and hydrocalyces.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Anatomic Considerations
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Anatomic Considerations
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Anatomic Considerations
 PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Anatomic Considerations

Relation of anterior and posterior calyces to renal parenchyma in Brödel-type kidney

(A) and Hodson-type kidney (B). The optimal site of percutaneous entry from the
posterior aspect of the kidney is into a posterior calyx because the path into the renal
pelvis is fairly straight. If entry is into an anterior calyx (from the posterior aspect of
the kidney), then an acute angulation must be made to enter the renal pelvis, which
may not be possible with rigid instrumentation.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Anatomic Considerations
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Antimicrobial Prophylaxis-
 Recommended agents include first- and second-
generation cephalosporins; aminoglycosides (or
aztreonam in patients with renal insufficiency) plus
either metronidazole or clindamycin;
ampicillin/sulbactam; or a fluoroquinolone
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Management of Anticoagulation
 With hold aspirin, 1 week; warfarin, 1 week;
clopidogrel, 5 days; and NSAIDs, 3 to 5 days.
 Those with preexisting heart disease or at high risk for
heart disease or cerebrovascular disease can continue
this medication safely in the perioperative period.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Diagnostic Imaging
 For simple decompression in the setting of presumed
distal obstruction, preoperative ultrasonography may
suffice.
 For percutaneous nephrolithotomy, the AUA guidelines
on the surgical management of kidney stones
recommends preoperative noncontrast CT for access
and treatment planning
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Patient Positioning- (Prone)

 Prone Position- The prone position affords direct access
into posterior renal calyces.
 Any polar location can also be accessed (upper, mid, or
lower).
 In particular, the upper pole calyx is anatomically closest
to the skin in the prone position and offers ready access to
the proximal ureter and in some cases, the entire collecting
system
 Prone positioning allows bilateral percutaneous procedures
without any repositioning
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Patient Positioning- (Prone)

 access to the airway is more challenging in the prone
position.
 It is also associated with a decrease in cardiac index
 patients with spinal deformity or super morbid obesity
cannot be safely positioned prone.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Patient Positioning- (Supine)

 Ipsilateral side toward the most lateral aspect of the table
and the flank elevated with a bolster or 3-liter bag of
saline underneath the lumbar fossa. The ipsilateral arm is
positioned across the chest, and padding is applied to limit
pressure to the elbow and wrist.
 Benefits of the supine position include easy access to the
airway and optimization of cardiopulmonary function in
patients
 Faster operative times in the setting of percutaneous
nephrolithotomy
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Patient Positioning- (Supine)

 Drawbacks to the supine approach include limited
surface area for renal puncture, difficulty accessing the
upper pole, and lower intrarenal pressures caused by
the downward orientation of the access sheath, which
may impair visualization.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Patient Positioning- Modifications to Prone or

Supine Positioning
 access to the urethra can be facilitated by positioning
the patient with the legs spread in the prone split leg
position or in a modified lithotomy position while in
supine position.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Choice of Calyx for Access

 Patient is prone, then the posterior calyces
 Supine, then the anterior ones are preferred
 Calyceal diverticulum- anterior or posterior
 Access should never be directly through the renal
pelvis,
 Caution should be exercised when puncturing in a
location with atrophic renal parenchyma as sealing of
the tract can be compromised.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Choice of Calyx for Access- Upper Pole Calyx

 Most versatile access
 The renal pelvis, proximal ureter, lower pole, and in
some cases, interpolar calyces can be accessed with a
combination of rigid and flexible instruments
 This site often requires supracostal (above the 12th rib)
access leading to an increased risk for pleural morbidity.
 Nonetheless, if entry directly above the 12th rib (11th
intercostal space) provides the best access to the optimal
calyx, then the benefit generally exceeds the risk.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Choice of Calyx for Access- Interpolar Calyx

 Least versatile
 Nearly impossible to navigate a rigid instrument into
the upper or lower pole calyces
 Reserved only for procedures limited to the interpolar
region.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Choice of Calyx for Access- Lower Pole Calyx

 Ready access to the majority ofthe kidney while
essentially eliminating the possibility of
pulmonarymorbidity with upper-pole access.
 With the use of a flexible scope, access to most calyces
can be achieved.
 Iliac crest may limit upward deflection of the rigid
scope.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Image Guidance for Puncture

 Fluoroscopic-Guided Access
 Retrograde ureteral catheter- plain and contrast
Pyelogram- “air pyelogram”
 “Eye-of-the-needle”
 “Triangulation”
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 “Blind” Access
 The lumbar notch, also known as the superior lumbar
triangle or Grynfeltt lumbar triangle
 Insert a needle 3 to 4 cm deep into the notch at a 30-
degree cephalad angle to enter the collecting system.
 Another blind approach to the collecting system is to
insert a needle directly perpendicular to the body
surface 1 to 1.5 cm lateral to the L1 vertebral body,
which will lead directly to the renal pelvis if anatomy
is normal.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Access Needles
 Seldinger technique
 21-gauge needle through which is passed a 0.018-inch
guidewire or an 18-gauge needle through which is
passed a standard 0.035-inch guidewire.
 Guidewires
 The safest initial 0.035, polytetrafluoroethylene (PTFE)-
coated J-wire or C-wire.
 The curved tip makes the guidewire unlikely to perforate out
of the collecting system.
 Floppy-tip PTFE-coated guidewire or a hydrophilic guidewire
Can pass to ureter easily
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Tract Dilation
 The goal of dilation for percutaneous renal surgery is
to place a 30-Fr inner-diameter/34-Fr outer-diameter
plastic access sheath.
 Sequential rigid metal dilators, introduced by Alken
 After passing the first rod, each successive metal rod is
passed sequentially over the former until the desired
tract is achieved, up to a 30-Fr rod over which is
passed a 30/34-Fr plastic sheath.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Tract dilatation
 Progressive semirigid plastic dilation sets, often
referred to as “Amplatz” dilators,
 The advantages of the semirigid plastic dilation system
are that trauma to the collecting system is theoretically
less likely than with the rigid metal dilators
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique

 Postprocedural Drainage
 Balloon Catheters- Foley and Council catheters
 Cope Catheter
 Malecot Catheter.
 Nephroureteral Stent.
 Circle Catheter.
 No Drainage Tube
 This can be considered in selected patients with low-
volume stones, atraumatic single access, and no
hemorrhage, perforation, or obstruction
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Surgical Technique
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Acute Hemorrhage
 Larger caliber of the percutaneous tract
 Increased manipulation, Prolonged operative time
 Patient characteristic
 Multiple access sites, Supracostal access
 Tract dilation with methods other than balloon dilation,
 Renal pelvic perforation
 Best management is to insert and occlude a
nephrostomy tube, apply pressure to the incision,
and let the collecting system clot off.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Acute Hemorrhage
 Intraoperative hemorrhage from an injured vein or artery within the
collecting system mandates cessation of the procedure if vision is lost
 If venous, then placing a nephrostomy tube and letting the collecting
system clot off is effective.
 inserting a Council catheter as a nephrostomy tube, with the balloon
inflated slowly at the site where contrast material enters into the
venous system until repeated nephrostography reveals no more
extravasation of contrast material
 Gelatin matrix hemostatic sealant is injected into the tract
 A small arterial injury can sometimes be addressed with fulguration
under direct vision, but if this is not successful and bleeding does not
cease with pressure, or in cases of significant arterial hemorrhage,
then selective angioembolization will likely be required
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Delayed Hemorrhage
 Delayed hemorrhage is usually caused by
arteriovenous fistulas or arterial pseudoaneurysms,
with the latter being more common
 Any report of bright-red blood in the urine or
nephrostomy tube after surgery should raise clinical
suspicion for either of these entities
 Both arteriovenous fistulae and pseudoaneurysms are
treated with selective angioembolization, which is
usually effective
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Collecting System Injury

 Tears in the infundibulum are not uncommon-
conservative- distal drainage is maintained
 Ureteral injuries are rare- heal over a ureteral stent
 Renal pelvic perforation- Collapse of a previously
distended renal pelvis- insert a nephroureteral stent or
a nephrostomy tube plus an internal ureteral stent to
optimize drainage, and then wait 2 to 7 days before
nephrostography and tube removal, depending on the
severity of the injury.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Visceral Injury
 colon, duodenum, jejunum, spleen, liver, and biliary system-
exceedingly rare.
 Left colon is injured twice as often as the right colon, and the
majority of colon injuries involve access to the lower pole
 Pleural Injury
 Hydrothorax, and occasionally pneumothorax, is a risk for
percutaneous access to the upper urinary tract–collecting
system.
 Supracostal access is the main risk factor; access below the
12th rib rarely results in hydrothorax or pneumothorax
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Metabolic and Physiologic Complications

 Intravascular hemolysis of irrigation fluid
 Hyponatremia and other electrolyte abnormalities
 A large amount of saline extravasation can lead to
clinically significant respiratory distress or cardiac
failure caused by volume overload.
 Venous gas embolism is a rare but potentially fatal
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Postoperative Fever and Sepsis

 15% to 30% of patients have a fever, usually due to
SIRS
 Most patients with fever after percutaneous
nephrolithotomy, assuming appropriate antimicrobial
prophylaxis, do not have infection, responds well.
 If pus is aspirated upon initial percutaneous entry to
the upper urinary tract, the safest measure is to abort
the procedure and leave a nephrostomy tube for
drainage.
PERCUTANEOUS RENAL ACCESS AND DRAINAGE- Complications

 Neuromusculoskeletal Complications
 Prone positioning
 Excessive pressure
 Maintain adequate padding and careful manipulation
 Venous Thromboembolism
 Collecting System Obstruction
 Loss of Renal Function
 When there is renal loss after percutaneous renal surgery, it
usually is a result of disastrous vascular injury or the
angioembolization used to treat hemorrhage
RETROGRADE RENAL ACCESS AND
DRAINAGE- Indications

 Indications
 The indications for retrograde renal drainage are vast,
and roughly parallel those for percutaneous renal
drainage.
RETROGRADE RENAL ACCESS AND
DRAINAGE-Surgical Technique

 Pre-requisite
 Urinalysis
 Antibiotics
 Anaesthesia
 Position
 Cystoscopy
RETROGRADE RENAL ACCESS AND
DRAINAGE-Surgical Technique

 Guidewire Placement
 In most cases, a straight, open-ended ureteral catheter,
typically 5 or 6 Fr, is used to stabilize and introduce a
working guidewire.
 Angled tip or torque stabilized angiographic catheter in
difficulties
 straight or curved tips
 PTFE, hydrophilic coated nitinol, or hybrid wires
composed of a hydrophilic nitinol tip and PTFE body.
RETROGRADE RENAL ACCESS AND
DRAINAGE-Surgical Technique

 Stent Placement
 The ureteral stent should be passed in a coaxial fashion
over the working wire and into the renal collecting
system.
 Pusher- direct vision- cystoscopy- Fluroscopy
RETROGRADE RENAL ACCESS AND
DRAINAGE-Surgical Technique
RETROGRADE RENAL ACCESS AND
DRAINAGE- Stent Varieties
RETROGRADE RENAL ACCESS AND
DRAINAGE- Stent Varieties

 Stent Tolerance
 Symptoms associated with ureteral stents are often
quite bothersome to patients
 The validated ureteral stent symptom questionnaire
(USSQ), addressed patient quality of life, is composed
urinary symptoms, pain, general health, work
performance, sexual function, and additional problems
 No significant difference is established on the length,
material, loop count of the stent.
Conclusion