Indications
- Urinary obstruction — hydronephrosis with renal impairment
- Pyonephrosis — infected, obstructed collecting system
- Access for nephrolithotomy — PCNL tract creation
- Urine diversion — ureteral injury, fistula
- Antegrade stent placement — failed retrograde approach
- Pressure-flow studies — Whitaker test
- Chemolysis — struvite stone dissolution
- Caliceal access — for nephroscopy procedures
Key Technical Points
Prone positioning with ipsilateral arm extended. Posterior lower pole calyx targeted — avoids major vessels and provides a straight working channel. US guidance for initial puncture, fluoroscopy for wire and tube placement.
- Posterior lower pole calyx — preferred access point
- Prone or prone-oblique positioning
- US-guided initial puncture — 18G or 22G access needle
- Seldinger technique — wire, dilators, locking pigtail
- 8–10 Fr locking pigtail nephrostomy catheter
- Brödel's avascular plane — posterior access, reduces bleeding
- Fluoroscopic confirmation — contrast injection in collecting system
- Nephrostogram — prior to exchange to check tube position
Full PCN Procedure Playbook
Technique, troubleshooting difficult access, tube exchange, and post-procedure management
Complications
- Hemorrhage — 1–4% requiring transfusion
- Sepsis — pyonephrosis patients, pre-treat antibiotics
- Pneumothorax — upper pole access crosses pleura
- Colon injury — rare, retrorenal colon on CT
- Tube dislodgement — secure well, consider nephropexy
- Urinoma — if tube drains into retroperitoneum
- AV fistula — delayed hematuria, Doppler diagnosis
- Failed access — hydronephrosis not present, alternative approach