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  5. Nephrostomy Troubleshooting

Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

Nephrostomy Troubleshooting

  • A nephrostomy is a tube that drains urine from the renal collecting system externally to the outside world via the skin.
  • They are inserted for ureteric obstruction that causes hydronephrosis which unresolved can lead to renal failure, infection or sepsis, and intractable pain.
  • Read more in Common operations “Upper Tract Operations – Stone procedures” - HERE
  • Nephrostomies may be associated with multiple complications – both immediately post-procedure and during its long-term care.
    • It is key that the output of a nephrostomy is documented clearly and separately from other sources of urine output (e.g. per urethra, urostomy and/or from another nephrostomy).
Nephrostomy tube — external drainage bag and kidney cross-section showing pigtail in renal pelvis

What to do if Nephrostomy not draining?

This is a common presentation that often requires input from the on call urology SHO.

Common reasons why a nephrostomy may not be draining include:

  • Blockage within the tube (e.g. due to sediment or bleeding)
  • Displacement
  • Issues with external tube – kinked, bag not attached, leaking bag
  • Non-functioning kidney
  • Incorrect output recording

The cause of why a nephrostomy has stopped draining may be unclear after an initial assessment – you need to flush the nephrostomy to know.

Interpret your flushing similar to a cannula flush! – it is easy to know when cannula is not working = same with nephrostomy

How to flush a Nephrostomy?

Equipment Required

  • Sterile gloves
  • Alcohol (chlorhexidine) wipes x2
  • 5-10mL 0.9% saline
  • 5 or 10mL syringe (ideally with Luer lock)
  • New nephrostomy bag

Procedure

This is an ANTT procedure (like cannula flush).

  • Explain the procedure to the patient and gain consent
  • Wash hands + gather equipment + draw up 5-10mL 0.9% NaCl into syringe
  • Disconnect and discard the old nephrostomy drainage bag
  • Clean the drainage connector thoroughly with an alcohol wipe
  • Attach the syringe and gently instil 5- 10mL saline
    • Stop if resistance is met or leakage from the tubing occurs
    • Gentle aspiration of the tube may help to dislodge the blockage
    • DON’T use excessive force - may cause bleeding, pyelorenal backflow and sepsis
  • Disconnect syringe, allow urine to flow out of the tube and attach a new sterile collection bag
  • Ensure the tube is secured and not taut
  • Monitor output

Video demonstration: https://www.royalmarsden.nhs.uk/welcome-patient-procedures-portal/nephrostomy-care

Post-Procedure & Safety Netting

  • Record your procedure
  • Instruct patient to seek medical attention if:
    • The nephrostomy tube stops draining or falls out
    • Increased pain
    • Leaking from nephrostomy site
    • Fresh blood is seen coming from the tube
    • Feeling unwell, suspicion of urinary or site infection

Nephrostomy still not flushing?

  • Discuss with SpR/consultant to book a nephrostogram +/- exchange with IR team

Nephrostomy flushing well but still not draining?

  • Consider alternate causes to actual tubing issue.
  • Consider imaging to check nephrostomy position and any tract issues

⚠ Important!

If patient has blocked nephrostomy + fever/rigors/flank pain → consider obstructed infected system treat this immediately and escalate to Urology SpR

 

Nephrostomy fell out?

  • Book nephrostomy re-insertion with IR
  • Discuss with SpR/consultant admission vs expedited outpatient re-insertion
  • Patient will need to be ready for procedure
    • Stop anticoagulation as per usual advice prior surgery (eg. withhold Apixaban 48hrs, Clopidogrel 7 days)
    • Check renal function + clotting + have a fresh Group & Save
    • Speak with IR team to arrange a date & time
 

Take home message

  • ✓1. Have no output → flush nephrostomy
  • ✓2. Fell out → need re-insertion via IR
  • ✓3. Have blood in bag → flush nephrostomy + discuss with Urology SpR
  • ✓4. Blocked nephrostomy + fever/unwell/flank pain consider infected obstructed kidney and sepsis

References

  • Lister S, Hofland J, Grafton H and Wilson C. (2021). The Royal Marsden Manual of Clinical Nursing Procedures. 10th ed. West Sussex, England: John Wiley & Sons.