SARELGAURMD
Interventional Radiologist
Urologic Procedures:
Nephrostomy Tube Check and Possible Removal :
to do this, inject contrast through 20 cc syringe through existing nephrostomy (usally placed after PCNL) to see if drains into bladder
if drains into bladder, remove catheter by cutting and then yank
if doesn't drain into bladder, try to characterize where the obstruction is. ultimately, likely will have to call urology and ask what to do
options are, leave nephrostomy, place nephroureteral, or place internal double j stent
how to place Nephroureteral Stent:
this is long stent from kidney to bladder
first have to get wire access to bladder
cut existingnephrostomy
advance glidewire and make sure gain a good position within collecting system, then remove cut and remove nephrostomy
then advance 4 F Berenstein over wire
consider magging up on monitor, goal is to advance the glide wire into the renal pelvis and down ureter. goal is to get to the bladder
have to steer with the berenstein catheter.
sometimes can just wedge the catheter into the renal pelvis and then advance the wire. kinda have to futz around a bit
once wire is in the bladder, advance berenstein catheter to the bladder
then take out wire and place amplatz wire. why amptalz is more sturdy and better for advancing / placing the final catheter
advance nephroureteral stent catheter over amptaz. coil distal tip in bladder by removing the wire and internal stifferner
have to be careful forming proximal pigtail. have to look at the marker thing and remove wire and internal stifferner to form coil int he renal pelvis. remember to pull the strings as well.
Neph tube changes:
some patients have routine changes 6-8 weeks with indwelling nephrostomy
if not changed, tube will crust up and become difficult to remove
simple procedure, shoot contrast through tube
cut tube
insert short amplatz
remove tube
place new tube
tee off tube on stiffner and wire
coil into renal pelvis
inject contrast and save
suck out contrast and save
^ test cath location, and ability to decompress calyces
NT Changes Tricks:
Crusty tubes suck
make it hard to advance wire
try glidewire as it may escape through a sidehole
if no dice, consider placing 8 french vascular sheath and pulling catheter out, may be painful so consider deep lidocaine infusion
how to check nephroureteral stent
different from nephrostomy as cannot infuse into stent
they are usually placed after PCNL by urologists and are different from our stents, have tapering french size
goal is to remove catheter over wire, and advance vascular sheath into kidney collecting system to check patency
prep and drape region
give lidocaine for anesthesis
obtain scout image
cut catheter and run long bentson wire into bladder
once see wire in bladder, remove catheter over wire using pinch and pull
advance 6F vascular sheath into collecting system, remove dilator
infuse dilute contrast through sidearm and image under fluoro
try to demonstrate either patency or obstruction and at what level
consider options:
if patent, remove all instruments and place DSD. instruct patient re. leakage
if not patent, consider level of obstruction
consider calling urology
consider replacing new nephroureteral stent, placing double J, placing nephrostomy
How to place Double J stents
Usually for ureteral obs usually requested by Urology for specific purpose
Get access to a mid or lower pole calyx identical to PCN, either two stick or US guided one stick using uresil or greb kit
Want to get long amplatz into bladder
If have difficulty passing into bladder, can use 4F berenstein to help guide wire into bladder through obs
Save position of wire using berenstein so you can use wire to measure the catheter length (24-26 cm)
Once internal double J on table, set up using inner stiffner and pusher catheter. Make sure the suture at proximal end is not tangled
Obtain amplatz wire access to bladder
Slide catheter including pusher catheter and stiffner over amplatz
Remove inner stiffener and wire to form distal pigtail within bladder
Forming proximal pigtail in renal pelvis is slightly more challenging
If need a bailout access to the collecting system, consider placing 8F sheath over wire
Have to remove wire and use pusher catheter to form prox pigtail into renal pelvis
Can use the external sutures to pull back pigtail if formed too distal in ureter
To remove that suture, cut and pull on one end
Oftentimes pulling the suture out can retract the pigtail
Pull the suture uses quick jerks or use a cut piece of catheter to hold the double J in place while you pull suture
Place sterile dressing and case complete
AM Method:
things you need to convert from nephrostomy to double j
150 bentson
150 glidewire
65 glidecath- berenstein
8-9F vascular sheath with sidearm
150 amplatz
double J stent with stiffener and pusher cath
after cut nephrostomy, advance bentson into collecting system
want to pass wire down ureter past a presumed obstruction (stone, stricture, or tumor)
can use glidecath to help push, and glidewire to pass obs
once have glidecath in bladder, advance benston, use to measure, then place amplatz to bladder
forming pigtails of double J is difficult
distal is easy, remove wire and stiffener
to form proximal, remove wire slowly to form loop
can tug catheter with string prior to removal
use the 8F sheath to save access to the collecting system
--
how to remove double J stent and place NUS at damn time
was req by urology
usu setting is failed urologic stent exchange of DJS
perofrm nephrstomy to gain access
will use safety wire technique
use a 8 or 9F sheath
advance sheath into collecting system
advance additional wire down into bladder, might need to use angled catheter
to snare out the DJS
use a snare device of any type
twirl the snare to engage the DJS
remove the DJS, remember when using snare to keep very tight backtension on the snare wire
now to place NUS
advance 10F catheter over wire and form loops in the bladder and renal pelvis
done
2 stick technique:
stick pelvis
then use back and forth angulations to target lower pole posterior calyx
use air nephrostogram techinque
to crros a ureteral stricture:
use a STIFF angled glide
use a 7F sheath - more pushability
use a angled cath - kumpe
if it the kumpe wont track use a GLIDEcobra or a GLIDEkumpe
---
MJM PCN Placement Two Stick Nice method
stick down on renal pelvis using 22G Chiba
once able to opacificy system, use 18G Chiba for access
MJM prefers to upsize 22G chiba to inner stylet of Jeff Set and opacify with contarst
then add 10 cc of air to outline posterior calyx
these can be hard to see
rotate tube back and forth to identify posterior calyx, which may project as a round faint circle of contrast rarefaction
target using 18G chiba
use one plane for target mode and opposite oblique for progress mode
advance needle until in kidney, may feel the pop
use stiff angled glide to probe needle
do gentle probing and eventually while retracting needle, will feel wire slide nicely into collecting system
then place nephrostomy standard style, MJM prefers 8.5 F flexima BosSci catheter
Remember the concept of safety wires when doing urologic or biliary intervention
load 7 or 8F sheath, advance 018 nitrex wire through, pull sheath off, remove 018 wire, advance sheath back over 035 wire
can help if you somehow lose access- a MJM trick
PCNL access
some of the most difficult cases because of lack of dilataion of the collecting system
tips use a needle guide
use a 21G needle
make sure the wire sails
if it doesn't sail, its prolly peri-ureteral
also be careful with 018 glidewire.
its a nice wire but you can shear the tip off easily
did this around 11/2017 because thought was intraluminal but wasn't**
be careful out there
dont shear wires
of note i've seen of the best make mistakes: renal artery pseudo post PCN placement
sheath injury peds limb loss
gtube gastric perf and sepsis
etc
failed birds nest, trauamitc removal
urinoma post renal ablation
ureter transection post ablation
death post BRTO
lots of things
keep it in perspective
--
how to place NU stent de novo
stik a calyx
get in the 6F trans sheath
through that, 4 or 5F angled glide cath with glide wire
negogiate to bladder
switch out for amplatz
can measure using bentson first
then place device 8F x 22, 24, or 26 cm Nu stent
sometimes device wont track well and can use stiffer wire