A nephrostomy tube is a pigtail drain inserted under fluoroscopic, ultrasonographic or CT (computed tomography) guidance, with a local anaesthetic, usually by an interventional radiologist. The procedure involves the passing of a needle and guidewire, followed by a pigtail drain, through the skin, subcutaneous tissue, muscle layers and renal parenchyma into the renal pelvis (McDougal et al. [143]). The drain is attached to a drainage bag (Figure 6.16) and the system is secured to the skin with a suture and in many cases a drain fixation dressing.

The percutaneous nephrostomy diverts urine away from the ureter and bladder into an externalized drainage bag (Hohenfellner and Santucci [100]). The nephrostomy can be unilateral, with a tube and drainage bag on one side and the other kidney continuing to drain through the ureter into the bladder. Alternatively, bilateral tubes may be inserted, with a tube and drainage bag on each side and with minimal urine draining through the ureters into the bladder.

In most cases a nephrostomy is temporary and will be removed when the obstruction has resolved, when the obstruction can be bypassed with an internalized ureteric stent or when the therapeutic intervention has been completed. Rarely, a nephrostomy is a permanent or semi‐permanent solution; this is the case when bypassing the obstruction is not possible or when it is inadvisable.

Externalized ureteric stents are used following the formation of an ileal conduit or a continent urinary diversion. Stents are inserted into each kidney, and these then drain into the urostomy pouch or are externalized cutaneously or rectally and drain directly into a bag. These maintain the patency of the ureters following surgery and ensure that the kidneys are able to drain; they also act to protect the anastomosis (Geng et al. [84]). Urine drains both through and around the ureteric stent. In the context of urinary diversion, stents usually remain in situ for 7–14 days depending on patient factors such as previous radiotherapy.

The nurse looking after the patient must have an understanding of the principles, anatomy and indications for a nephrostomy tube. All staff managing a patient with a nephrostomy tube should be appropriately trained and working within their scope of practice (NMC [178]). If formal competencies are required at the place of employment, these must be met prior to managing the patient's care.

Removal of the nephrostomy tube should be performed by a trained member of staff and under the instruction of the medical and/or surgical team (see Procedure guideline 6.14: Nephrostomy tube: removal of locking pigtail drainage system). If there is a stent in situ, the nephrostomy tube should be removed under radiological guidance to avoid misplacement of the ureteric stent.

Following formation of the ileal conduit or continent urinary diversion, ureteric stents should be removed by a trained nurse or member of the surgical team as guided by the consultant surgeon.

For a long‐term nephrostomy, the patient and/or carer should be taught to change both the drain site dressing and the drainage bag on a regular basis. If self‐care and independence are not possible, the patient should be referred to the community nursing team.

The recommended dressing is one that supports the nephrostomy tube to prevent accidental tugging and also secures the tube to the patient's skin. There are several drain‐specific types available, including the Drain‐Guard, Drain‐Fix and OPSITE Post‐Op Visible drain dressings. When selecting the dressing, it is important to consider the comfort factor for the patient as the exit site is directly on the patient's back and therefore can present discomfort when lying down or sitting against a chair. When such dressings are unavailable or unobtainable, many teams choose to dress the nephrostomy with a simple gauze‐and‐tape method. If the gauze‐and‐tape method is used, it is essential to make sure the nephrostomy tube is sutured in position.

To perform the dressing change or drainage bag change, the patient will need to be sitting upright on a stool, couch or a bed with their back facing towards you. The dressing change and drain removal are best performed from behind, so preparing the patient well and good communication are essential (NMC [178]). If the patient is unable to sit upright, then positioning the patient on their side in a bed is an alternative with the patient's back facing towards you.

After initial nephrostomy insertion, if the kidney has been obstructed, the patient may enter a phase of diuresis. This is characterized by high‐volume outputs from the nephrostomy tube (polyuria). Close monitoring of the patient's fluid balance and vital signs is required. The patient's fluid intake (intravenous or oral) should closely match the output. A closely monitored and adjusted fluid balance will prevent deterioration in the patient's condition associated with rapid fluid loss (Hsu et al. [102], Jairath et al. [107]).

The patient is at risk of pyelonephritis (inflammation of the kidney, usually due to infection) from the foreign body puncturing the kidney (Hsu et al. [102]). The patient should be monitored for signs of infection or sepsis, such as loin pain, elevated temperature, fever or chills, purulent urine output or deterioration in their vital signs. A urine specimen should be taken when infection is suspected. In such cases, medical advice should be sought and the patient treated accordingly. Ensuring the drain site remains clean and dry is essential to prevent infection, and flushing of the nephrostomy tube should only be done when patency of the tube is compromised. Drainage bags should be changed every 5–7 days. Ensure good hand hygiene when handling the drain and exit site and when emptying the drainage bag. Nephrostomy tubes should be routinely changed every 3 months.

The nephrostomy bag should be emptied when it becomes three‐quarters full (see Procedure guideline 6.9: Urinary catheter bag: emptying). Where appropriate, the patient or carer should be taught how to do this. Note that many hospital‐supplied nephrostomy drainage bags are not widely available in the community setting and are also not comfortable as body‐worn products. An example of a comfortable body‐worn system is shown in Figure 6.17.

All patients being discharged out of hospital with a nephrostomy should be referred to the community nursing team for support and assistance when required. They must also be discharged with information on when and how to obtain clinical supplies such as dressings and bags. The patient must also have a written follow‐up plan of review and/or a planned date for their tube to be changed. Some manufacturers produce a ‘nephrostomy passport’, which is a very useful patient‐held tool for recording and monitoring this information.