Percutaneous Nephrostomy (PCN)
A PCN drains the renal collecting system through a catheter exiting the flank. It provides decompression, access for subsequent intervention or diversion from a urinary leak. It is distinct from a PCNU, which also traverses the ureter, and an internal double-J stent.[1][2]
Choosing Drainage
Sepsis with an obstructing stone requires urgent decompression and immediate antibiotics. EAU 2026 supports either PCN or a ureteral stent; choose according to anatomy, clinical stability, access and available expertise. Definitive stone treatment waits until sepsis is controlled. Resuscitation and correction of dangerous electrolyte or coagulation abnormalities proceed alongside the drainage plan rather than creating an automatic delay.[1][3]
Other uses include benign or malignant obstruction, ureteral injury/leak, and access for antegrade stenting or endourology. Hydronephrosis alone does not determine the need for drainage. In advanced malignancy, discuss symptom relief, renal recovery, possible cancer treatment, tube burden and the patient's goals.[1][2]
A 2024 review of 18 comparative studies/1,228 patients with malignant obstruction found less procedure/intervention failure with PCN, but less displacement, shorter procedure time and shorter stay with retrograde stents. It did not establish one universally superior option. Studies of antegrade versus retrograde stent placement answer a different question from PCN versus stent drainage.[4]
Planning and Safe Access
| Check | Purpose |
|---|---|
| Imaging and route | Review collecting-system anatomy, kidney position, intervening bowel, pleura and vessels; altered anatomy or a nondilated system may require a different imaging approach. |
| Bleeding risk | Check blood count, coagulation and antithrombotics; agree correction/interruption with the procedural team, balancing urgency and thrombosis risk. |
| Infection | Obtain relevant cultures and distinguish treatment of an infected obstructed system from procedural prophylaxis. |
| Catheter and future plan | Choose caliber, retention mechanism and calyceal access for drainage contents and possible later antegrade intervention. |
These planning decisions are addressed in CIRSE's 2026 standards of practice; these are technical practice standards rather than a systematic clinical guideline.[1]
Use image-guided access through an appropriate calyx and verify intraluminal wire and catheter position. Posterior calyceal access can reduce vascular injury, but no fixed angle or upper-pole preference fits every kidney. Supracostal access has pleural risks. In an infected system, avoid unnecessary manipulation and pressurized distension.[1]
Drug choice depends on local susceptibility, prior cultures, allergy and renal function. Ceftriaxone does not provide reliable Enterococcus coverage; it should not be described as covering every listed uropathogen. Use the UTI antibiotic, perioperative prophylaxis and antithrombotic workflow companions for agent and interruption decisions.[5]
Complications That Change Management
- Obstruction, kinking or displacement: new low output, flank pain, leakage or rising creatinine requires reassessment. Do not assume pericatheter leakage means the tube is draining adequately.
- Infection or sepsis: assess the patient and tube function, culture appropriately, begin treatment and arrange source control when needed.
- Bleeding: mild early hematuria can occur. Persistent, recurrent or heavy bleeding, hemodynamic change or falling hemoglobin warrants investigation for vascular injury; selective embolization may be needed.
- Bowel or pleural injury: obtain urgent specialist assessment and imaging. Catheter removal, repositioning or retention depends on the injury and drainage needs; blind withdrawal is not a universal solution.
- Dislodgement: contact the drainage service urgently. Tract age and anatomy determine whether image-guided recannulation is possible; a fixed “7–10 days means mature” rule is unsafe.[1][6]
Published complication frequencies vary with indication and population. Quality-improvement action thresholds are not the same as an observed complication rate or an individual patient's risk.[1]
Ongoing Care and Exchange
Secure the catheter without traction, keep the prescribed drainage arrangement functioning, and teach the patient to recognize leakage, reduced output, fever and displacement. Monitor fluid balance after relief of obstruction because post-obstructive diuresis may require replacement and electrolyte monitoring. Flushing should follow the prescribed device/service plan; resistance or pain should prompt reassessment rather than force.[1][6]
Set an individualized exchange date. CIRSE 2026 describes an initial 6–8-week interval, extendable to 8–12 weeks if encrustation is not a problem; some patients need earlier changes. Pregnancy increases encrustation risk and commonly requires shorter intervals. Product instructions, catheter performance and clinical circumstances take precedence over a universal 3-month rule. Exchange does not sterilize a chronically colonized urinary tract.[1][3]
Asymptomatic bacteriuria is common, not inevitable, and does not usually require antibiotics solely because a tube is present. Pregnancy and planned endourologic procedures involving mucosal trauma are important exceptions to a blanket “never treat” statement; device manipulation also requires its own procedural assessment.[6][7]
A PCN may be temporarily capped in a planned trial when internal drainage is being assessed, including after ureteral stent placement. Give explicit instructions about symptoms that require reconnecting drainage and contacting the team. Removal requires evidence that drainage or diversion is no longer needed; do not equate a cap trial with proof of native ureteral healing.[1]
Special Situations
- Pregnancy: coordinate obstetric and urologic care and minimize radiation. Both PCN and stenting remain drainage options; ureteroscopy is another option in selected patients.[3]
- Children: use age-appropriate equipment and pediatric expertise; adult catheter sizes and outcome estimates do not transfer automatically.[1]
- Suspected upper-tract urothelial malignancy: include the tumor and access route in drainage planning; urgent decompression and subsequent oncologic management require coordinated decisions.[1]
See also Nephropleural Fistula and Renal Anatomy.
References
1. Ryan AG, Irvine I, Bardgett H, et al. CIRSE Standards of Practice on Nephrostomy and Ureteric Stent Placement and Exchange. Cardiovasc Intervent Radiol. 2026;49:464–479. doi:10.1007/s00270-025-04328-9
2. 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
3. European Association of Urology. EAU Guidelines on Urolithiasis, 2026. Sections on sepsis, ureteroscopy, stenting and pregnancy.
4. 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
5. Baxter Healthcare. Ceftriaxone injection: prescribing information. Microbiology section, updated October 7, 2024. DailyMed.
6. 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
7. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by IDSA. Clin Infect Dis. 2019;68:e83–e110. doi:10.1093/cid/ciy1121