Percutaneous Nephrostomy

Anatomy and Physiology

The renal calyces, renal pelvis, ureter, bladder, and urethra form the urinary excretory tract. Embryologic variation of this anatomy is described elsewhere.[4] Due to genetic or other embryological reasons, an individual's kidney or kidneys may have variations in one or all of the factors discussed below, which is why imaging the kidney before the procedure is warranted. This course discussion is limited to native kidney anatomy, although percutaneous nephrostomy can be performed for transplanted kidneys. 

Assuming typical embryological development, the human kidney normally migrates to a final craniocaudal position within the retroperitoneum that is ventrolateral to the T12 and L3 vertebrae. The right kidney is typically 1 or 2 cm lower or inferior to the left kidney. Each kidney is enclosed within its own fascial compartment (the perirenal space, which also contains the adrenal gland). The kidney has some mobility; it moves craniocaudally with respiration and can shift craniad by about 1 cm if a person switches from a supine to a prone position.

The kidneys have their own sagittal plane, which is directed medially toward the body's sagittal plane. Each kidney is typically rotated medially and angled, with its superior pole being more dorsomedial and its lower pole being more ventrolateral. In other words, the kidney's superior poles are "tilted backward" 30 to 50 degrees from the body's coronal plane and "inward" 30 to 50 degrees from the body's sagittal plane. 

The renal collecting system begins at the interface between the renal medulla and the space formed by the renal calyces. At this interface, the terminal orifices of collecting tubules within renal papillae empty urine into 8 to 15 minor calyces. The minor calyces join to form major calyces that, in turn, usually form a single renal pelvis that empties into a single ureter.

The kidney arterial supply is typically a single renal artery that divides into an anterior and posterior branch. Typically, the arteries form a relatively hypovascular plane (a reverse watershed) between the anterior and posterior renal artery distributions. This relatively hypovascular area is usually oriented 20 to 30 degrees laterally from the body's sagittal plane (ie, it lies between the sagittal planes of the body and kidney). Often referred to as "Brodel's line" after medical illustrator Max Brodel, this area has been described by multiple researchers.

The target for percutaneous nephrostomy is an inferior pole minor calyx reached through Brodel's line because this approach theoretically reduces procedure complications compared to other methods. Reaching that target involves navigating a needle into the perirenal retroperitoneal space while avoiding the structures in adjacent spaces, eg, the pleura, subcostal arteries, duodenum, ascending colon, liver (on the right), and descending colon and spleen (on the left). Of these structures, injuries to the pleura and diaphragm are the most common. The pleura typically extends to the lower margin of the tenth to twelfth rib along the paravertebral line. Placement above the pleural attachment can lead to a pleuroperitoneal fistula, pneumothorax, pleural effusion, or impaired diaphragm motion. 

Indications

Percutaneous Nephrostomy Indications

Common indications for percutaneous nephrostomy include:

• Obstructed urinary tract drainage alone, either in a noninfected or infected urinary tract
• Creating an access conduit for inserting tools to treat nephrolithiasis

 Less common indications include:

• Creating an access conduit for inserting other types of tools
• Urinary tract diversion
• Diagnosis of obstruction

Drainage of obstructed urine

Drainage to relieve urinary tract obstruction is the most common indication for percutaneous nephrostomy, accounting for 85% to 90% of all nephrostomy placements.[5] Intrinsic or extrinsic mass effects can cause obstruction. Extrinsic causes include pregnancy, tumors, and loculated fluid collections like cysts, abscesses, or urinomas. Intrinsic causes include stones, strictures, and tumors.

Complete renal function recovery is likely even with complete mechanical collecting system outlet obstruction for a full week. Therefore, acute hydronephrosis-related kidney injury is not a clinical emergency unless the obstruction has already resulted in sepsis or severe electrolyte abnormalities. The longer the duration is beyond 1 week, the lower the eventual glomerular recovery rate. Minimal renal function recovery can be expected after 12 weeks of complete outlet obstruction.[6][7] 

Percutaneous nephrostomy tubes should be inserted in benign or malignant conditions where surgeons with or without oncologists have a plan for resolution once the immediate threat of urinary obstruction has been resolved, because long-term percutaneous nephrostomy carries certain morbidities (Please refer to the Complications section for more information on the adverse effects).

Especially when a cause of bilateral urinary tract obstruction is identified, correcting this underlying cause is usually preferable for quality of life instead of opting for long-term bilateral percutaneous nephrostomy tubes, which should be reserved for special cases such as the following:

• Intractable, severe hemorrhagic cystitis
• Failed attempts at or major contraindications to surgical formation of urinary conduits [8][6]

Pyonephrosis, obstructive pyelonephritis, and urosepsis

The most common reason for emergency percutaneous nephrostomy placement is to drain an acutely obstructed and infected urinary tract, also known as pyonephrosis, obstructive pyelonephritis, or urosepsis. This condition has a risk of imminent death. Whether to perform percutaneous nephrostomy alone or also antegrade ureteral stenting depends on multiple factors.[9] Traditionally, percutaneous nephrostomy alone is performed as the initial step to reduce the risk of mechanically inducing bacteria from the infected urinary tract into the bloodstream during stent insertion, which can cause or worsen sepsis even if the patient has already been prescribed antibiotics.

Nephrolithiasis

Percutaneous nephrostomy is the first step in enabling other devices to be inserted to crush, vaporize, and retrieve stone debris (or PCNL), including lasers, ultrasound probes, and baskets. Evidence shows that performing a percutaneous nephrostomy first in a staged manner reduces procedural bleeding and time during the actual treatment phase.[10]

PCNL is often performed after extracorporeal shock wave lithotripsy and in the following settings:

• Staghorn calculi
• Renal pelvis stones >2 cm or other lower pole or ureteral stones >1 cm
• Ureteral stones not amenable to RUA manipulation (eg, due to distal ureteral strictures, tumors, or prior ureteral reimplantation)

In individuals who have a noncurable urinary tract mineral-forming metabolic disease, permanent percutaneous nephrostomy may be used to improve quality of life over the alternative of repeated invasive procedures.

Less common excretory tract diagnostic and interventional situations

Percutaneous nephrostomy serves as a conduit for inserting the following:

• Tools for pyeloplasty or ureteroplasty, including a uretero-enteric anastomosis
• Medications, eg, to treat resistant infections like fungal infections

Urokinase is a proteolytic enzyme that the kidney excretes into the urine. In the setting of damaged urothelium, urokinase promotes persistent tissue injury or bleeding. When chronically inflamed urothelium is present, as with urinary fistula or hemorrhagic cystitis, healing may be accelerated if urine is preferentially rerouted away from the region of inflammation through bilateral percutaneous nephrostomies.[11]

Not all dilated renal calyces or pelvises are due to mechanical obstruction. When noninvasive tests have not provided a reliable diagnosis, particularly in patients with only 1 functioning kidney (eg, patients who have already undergone renal transplant), invasive renal access may be required to differentiate obstruction from other causes of renal failure.

The Whitaker test involves percutaneous renal puncture to measure pressure within the renal pelvis. It may be performed using needle access alone or with renal catheter access. Fluid is infused antegrade while the intrapelvic pressure is measured via a bladder catheter. A gradient pressure of 22 mm of water or more indicates obstruction, while ≤15 mm indicates no obstruction. Pressures between 15 and 22 mm are considered indeterminate or nondiagnostic.[12][13] 

Antegrade contrast injection using percutaneous nephrostomy and conventional fluoroscopy may identify the location and nature of a previously undetected ureteral stricture. However, diuretic renal scintigraphy and multiphase computed tomography (CT) urography are less invasive imaging techniques that have largely replaced the Whitaker test and conventional fluoroscopy, which were more commonly used before the 1980s.

Contraindications

Contraindications for Percutaneous Nephrostomy

Physicians should consider certain patient factors before arranging a percutaneous nephrostomy and, in certain circumstances, delay or avoid the procedure.[5] When a safer therapeutic alternative to percutaneous nephrostomy can be attempted, that serves as a relative contraindication to percutaneous nephrostomy. Other factors in which percutaneous nephrostomy may be contraindicated include: 

Hemorrhage risk

The Society of Interventional Radiology (SIR) classifies percutaneous nephrostomy as a "high-risk" procedure in its 2-tier risk classification of hemorrhage.[14] Prior to 2019, when the SIR employed a 3-tier system for classifying hemorrhagic risk, percutaneous nephrostomy was classified as a level 3 risk.[15] 

For high-risk of hemorrhage procedures, the SIR recommends the following:

• The international normalized ratio is no greater than 1.5.
• The activated partial thromboplastin time is no greater than 1.5 times the hospital's normal standard,
• The platelet count is at least 50,000 cells/cubic  µL
• Delaying the procedure until certain antiplatelet and anticoagulant medications are no longer at therapeutic levels in the blood.

For example, the SIR does not recommend delaying percutaneous nephrostomy after prophylactic dose enoxaparin has been administered, but does recommend delaying percutaneous nephrostomy for 24 hours after an enoxaparin therapeutic dose (unless a reason to deviate from this safety measure is identified).

Sepsis risk

The SIR recommends that preprocedure antibiotics be administered at least 1 hour before the procedure if an infected collecting system is suspected, which is frequently the case when a request for percutaneous nephrostomy is made.[16] The bacteria to empirically treat include:

• Gram-negative Escherichia coli, Proteus, and Klebsiella
• Gram-positive Enterococcus
• Pseudomonas is a gram-negative rod with beta-lactamase that often makes it resistant to early-generation penicillin and cephalosporins

Usually, anaerobic coverage is not needed. The SIR lists 4 first-line antibiotic regimens, all of which contain a cephalosporin or penicillin, but do not all provide coverage for Pseudomonas. The American Urological Association's Best Practice Policy recommends using the following:

• A first or second-generation cephalosporin (which do not cover Pseudomonas)
• Clindamycin
• Gentamycin and metronidazole [17] 

Renal pelvis urine cultures have been shown to be more sensitive and useful than bladder urine cultures in predicting urosepsis.[18][19] Several clinical studies have demonstrated a benefit of 1 week of antibiotic treatment before PCNL, even when the initial urine culture is negative.[20][21]

Risk of renal failure and  associated sequelae

Metabolic acidosis and hyperkalemia are known complications of kidney injury that can destabilize cardiac myocytes and cause a life-threatening arrhythmia. If such abnormalities are discovered, then an electrocardiogram should be performed. If the clinical features of hyperkalemia (eg, nonspecific weakness, fatigue, and dyspnea) or arrhythmia (palpitations or chest pain) are not present, emergent treatment for hyperkalemia is not necessarily needed; however, it should still be considered if the serum potassium value is greater than 5.5 mEq/L. With a potassium level greater than 7 mEq/L, hemodialysis should be performed before attempting percutaneous nephrostomy.

Anatomic risks

Percutaneous nephrostomy needle placement should not be determined until the imaging modality or modalities used for needle guidance confirm the optimal route and approach for the planned procedure. Ultrasound, x-ray, fluoroscopy, or CT can be used in isolation or in combination for procedural planning. Regardless of which of these modalities is used, preplanning should confirm the following:

• The expected skin-to-selected-renal calyx distance
• Any aberrant anatomy, eg, a horseshoe kidney or scoliosis, which can cause the kidney and its hypovascular region to lie in an unusual location
• The colon, lung, liver, and spleen are not in the line of puncture (approximately 5% of patients have a retrorenal colon when placed prone [22], which is more common in thin patients, and the colon region nearest the kidney typically contains gas when in the prone position) [8]

Attempting percutaneous nephrostomy when no clear target has been identified can result in the following:

• Unnecessary and unsuccessful punctures
• Greater risk of complications
• Poorly placed puncture routes that limit the success of future interventions like PCNL

Therefore, when a clear target (eg, in a nondilated calyceal system) or needle path has not been determined, clinicians should discuss alternative strategies to make the target area easier to access, increase the chance of percutaneous nephrostomy technical success, and improve overall safety. These strategies include:

• Administering contrast (Please refer to the Technique or Treatment section for more information)
• Temporarily delaying the procedure if the calyces may increase in size with hydration alone

Anesthesia and overall morbidity risk

Patients typically undergo percutaneous nephrostomy in an uncomfortable position (prone) and are already in pain from their condition at the beginning of the procedure. The passage of instruments through the lumbar musculature is a generally painful experience. Lacing the entire percutaneous nephrostomy tract with anesthetic (eg, 20 mL 0.25% bupivacaine) has been shown to reduce postoperative pain and requests for opioids but has not yet been shown to reduce intraprocedure sedative doses.[23]

High sedative dosages may be required to enable patients to tolerate percutaneous nephrostomy. Often, percutaneous nephrostomy is requested in patients who have the following factors:

• Comorbidities of the cardiovascular and respiratory systems
• Risk factors for needing an advanced airway (eg, sleep apnea or short neck)
• A definite risk of septic or hemorrhagic shock (ie, need for hypotension and second-line antibiotic management)
• Underlying metabolic abnormalities and their associated risks

Therefore, a hospital's safety policy should have a low threshold for requiring that an anesthesiologist or similarly experienced practitioner be present during the procedure.[24] Some hospitals require the presence of an anesthesiologist when the American Society of Anesthesiology's risk of sedation score is 4 (designated as the presence of a condition that is "a constant threat to life") or higher. Calling a code team who is unfamiliar with the patient to attempt advanced cardiac life support, especially in a patient whose kidney has been freshly punctured without the possibility of applying immediate hemostasis, is better prevented than needed. 

Patient preference

Informed consent for percutaneous nephrostomy requires a discussion of the procedure's nature, risks, benefits, and alternatives to preserve the patient's right to autonomy.[25][26] During this discussion, the patient should be informed of issues to expect in the weeks to months following the procedure. Even without immediate procedure-related complications, the new foreign body (a percutaneous nephrostomy tube or stent) will require maintenance for the duration it remains in the body, which usually involves prolonged nursing or family medical support and limitations on lifestyle functionality. A patient's unwillingness to accept these factors or other proposed aspects of percutaneous nephrostomy constitutes a contraindication to the procedure.

Equipment

Percutaneous nephrostomy requires a needle long enough to reach the renal collecting system. Some physicians prefer an 18-gauge needle to a smaller needle because 18-gauge needles typically track straighter, pass more easily through soft tissue, are better visualized using ultrasound, and do not need further dilation to pass a 0.035-inch guide wire. No increase in significant bleeding complications was noted between 18-gauge and 21-gauge needles when used for percutaneous nephrostomy access.[27] However, some physicians prefer using a 21-gauge needle until they have confirmation of successfully reaching the collecting system to try to reduce bleeding complications from unsuccessful initial puncture attempts.

Most percutaneous nephrostomy procedures conclude with a catheter left in the body. A typical modern model of percutaneous nephrostomy catheter has a distal end that can be retracted into a loop (forming a "pigtail") having a larger diameter than the ureter or catheter tract itself, by pulling on a suture that extends from the tube's distal end to its proximal end. The pigtail can be locked in place, a maneuver designed to prevent catheter motion, either antegrade or retrograde, and it can be released at the desired time for tube exchange. Nevertheless, to prevent inadvertent tube dislodgement before the next scheduled tube replacement, care should be taken when dressing the wound to anchor the tube to the skin surface with sutures, bandages, or a nitinol anchoring device. 

Some percutaneous nephrostomy tube models are designed to connect to proprietary drainage bags, which are specific to the company that manufactures the percutaneous nephrostomy tube. Percutaneous nephrostomy tubes from different manufacturers have special safety features. Some models have break-away connectors at the hubs so that the percutaneous nephrostomy tube itself will not be affected if the drainage tubing is tugged on. Others have expandable balloons that can be used to tamponade the renal cortex to reduce procedure-related hemorrhage. However, such models have not yet been shown, by a randomized trial, to result in a statistically significant reduction in the need for postprocedure blood transfusion.[28]

Percutaneous nephrostomy procedures and equipment have many variations, which may include:

• Guidewires
• "Directional" catheters having an angled tip to redirect guidewires
• Tools to dilate the tissue tract (plastic dilators or a tissue plasty balloon)
• X-ray contrast
• Sheaths or other catheters that serve as transitional aids to insert the final percutaneous nephrostomy catheter or NUS

Conventional fluoroscopy and ultrasound enable faster decision-making and lower radiation exposure compared to CT for image guidance. A common method combines ultrasound and C-arm fluoroscopy due to the following considerations:

• Ultrasound allows superior visualization over fluoroscopy for soft tissues, including the kidney, along the entire needle path to the intended renal calyx.
• C-arm fluoroscopy can allow superior visualization over ultrasound for guidewires, bones, lungs, and possibly the colon.

Technique or Treatment

The entry point selected for needle insertion should target a posterior calyx through Brodel's line to minimize bleeding. Accessing the renal pelvis or infundibulum directly increases the risk of a vascular injury.

From a mediolateral perspective, the following vascular risks are present:

• If too medial a site is chosen, the needle will pass through thicker paraspinal muscles. These muscles can kink the percutaneous nephrostomy tube, making the patient's back motion, or even just supine body positioning, painful. 
• If too lateral a site is chosen, the chance of trauma to the colon, liver, or spleen is increased.

From a craniocaudal perspective, the following should be considered:

• The access route should remain entirely below the 12th rib to minimize pleural and diaphragmatic trauma.
• When subsequent insertions of tools after percutaneous nephrostomy are not anticipated, the entry point selected for needle insertion should be an inferior pole calyx.
• When subsequent insertions of tools are anticipated, the angle needed for inserting those rigid tools should be considered in advance. If a radiologist places the initial percutaneous nephrostomy and a urologist performs the subsequent PCNL, then the planned approach should be discussed. Urologists may prefer upper pole access for treating stones that have a staghorn configuration, are in the ureter, or are even in the lower pole. 

If using C-arm fluoroscopy alone for initial calyx puncture, then:

• Radiographic contrast can be administered to visualize the renal calyces fluoroscopically. Typically, contrast is administered intravenously, but it can be injected:
• Retrograde if the ureter has already been catheterized via RUA or
• antegrade after an initial percutaneously inserted needle successfully pierces the excretory tract. 
• Either a 1-stick or 2-stick technique can be used.
• In the 2-stick technique, the first needle puncture is used solely to opacify the collecting system with contrast, enabling target planning for the subsequent or final needle stick. 
• Since the first stick is just for opacification, a small needle can be used and targeted directly at the renal pelvis. 
• Room air or carbon dioxide can be injected to help visualize the posterior calyces because gas preferentially fills them in prone patients.[8]
• In either technique, the final needle is aligned parallel to the orientation of the x-ray beam, looking "down the barrel" of the needle, toward the target calyx or stone (if present). The x-ray image intensifier and receiver are positioned perpendicular to the needle to assess its depth, typically when the calyx or stone is observed to move with needle movement on the down-the-barrel view.

Once evidence of successful entry into the collecting system is indicated by urine aspiration, a guidewire is inserted to access (ie, "achieve stable purchase") ideally in the ureter, but sometimes, out of necessity, a different calyx or the renal pelvis. A directional catheter with an angled tip may be used to redirect the guidewire. Once the guidewire position is established, the tract for the eventual percutaneous nephrostomy tube must be dilated using sequential plastic dilators or a tissue plasty balloon. An 8 French tube often suffices for successful drainage during initial punctures; it can be upsized during subsequent procedures if needed.

Positioning the tube drainage holes entirely within the renal collecting system, to collect urine, and not in the renal parenchyma itself, in contact with the renal vasculature, is crucial. 

Complications

The SIR has published complication rates for percutaneous nephrostomy. The rate of major complications is around 2% to 10%. Major complications include:

• Sepsis [29][30][31]
• Hemorrhage, including subcapsular hematoma and pseudoaneurysm [29][30][32][31]
• Pneumothorax [29][30][32]
• Puncture of adjacent organs [31][33][34]
• Urine leak/urinoma
• Death

Transgression of arterioles during percutaneous nephrostomy is to be expected. The percutaneous nephrostomy tube usually tamponades the hemorrhage, and successful coagulation typically occurs within 2 to 3 days. Bleeding through the catheter can occur if a catheter side hole is left in communication with a renal vessel or if a pseudoaneurysm develops. Minor, temporary bleeding occurs after percutaneous nephrostomy placement in approximately 95% of cases. Significant bleeding requiring transfusion has been reported in 1% to 4% of patients, while small retroperitoneal hematomas have been reported to occur in 13%.[5]

Percutaneous nephrostomy provides a conduit for bacteria to enter the urinary tract from an external source. Although percutaneous nephrostomy may be performed to treat the obstruction that is the cause of sepsis, percutaneous nephrostomy itself may also cause sepsis. 

Percutaneous nephrostomy tubes become clogged with encrustations, typically calcium phosphate, if they are not exchanged promptly. Catheter flushing can help an acute obstruction temporarily, but even routine flushing does not stop encrustation. Good oral or IV hydration may reduce the encrustation rate. In pregnancy, percutaneous nephrostomy catheters should be changed every 4 to 6 weeks. Routine changes occur every 2 to 3 months for most patients.

Percutaneous nephrostomy tubes create a chronic soft tissue wound. This can result in chronic pain and recurrent bouts of cellulitis. Guidelines for caring for ostomy wounds are available.[35]

Management of Bleeding from Percutaneous Nephrostomy in Hemodynamically Stable Patients

If arterial hemorrhage is evident (eg, bright red pulsatile blood coming out of the tube), the patient should undergo emergent digital subtraction angiography (DSA)-guided arterial embolization.

If hemorrhage is suspected but not immediately apparent (as indicated by persistent hematuria, a declining hemoglobin level, or an unfavorable trend in vital signs), then CT angiography (CTA) can be considered a first-line diagnostic tool. When there is strong clinical suspicion of bleeding in the absence of hemorrhage seen on CTA, then percutaneous tractography should be performed. If initial imaging shows no vessels opacified with contrast or if the drainage catheter side holes are found to lie outside the kidney, then the catheter should be repositioned and the tractogram repeated. If tractography opacifies a vein, then the catheter should be upsized to tamponade the vein, and time should be allowed to see if the intervention is effective. If tractography opacifies an artery, then the catheter should still be upsized to tamponade the artery. However, if blood can still be aspirated after this maneuver, then DSA-guided embolization of the renal artery branch involved should be performed urgently.

If pyelonephritis is confirmed based on clinical and radiologic findings (usually contrast-enhanced CT), standard measures should be used for treating pyelonephritis in individuals without a percutaneous nephrostomy, including urine culture and broad-spectrum antibiotics followed by tailored antibiotics. Once appropriate antibiotics have been administered, the nephrostomy tube should be changed within 4 days.[36]

Management of Acute Percutaneous Nephrostomy Complications in Hemodynamically Unstable Patients

In the setting of bleeding, a decision must be made regarding whether the patient should undergo surgery, angiography, or both (if angiography can be performed in the operating room). Intravenous fluids and oxygen should be administered, and vasopressors should be considered.

In the setting of septic shock, broad-spectrum antibiotics and ICU admission should be considered.[37]

Clinical Significance

The technical success rate for percutaneous nephrostomy with dilated calyces without stones has been reported to be as high as 95%.[38] However, success in nondilated systems is lower, at around 80%, even in the hands of experienced operators.[31][39][40][41] A randomized trial found no difference in clinical outcomes between RUSI and percutaneous nephrostomy in the treatment of patients with ureteral stones and pyelonephritis.[42]

Percutaneous nephrostomy has benefits over other therapeutic options in some circumstances, including:

• Compared to operative renal access: Percutaneous nephrostomy is a less invasive way to relieve pain and has less expected morbidity (ie, is less likely to result in injury to abdominal organs, muscles, and nephrons).
• Compared to medication alone: Percutaneous nephrostomy can improve the likelihood of successfully treating an infected and obstructed urinary tract.
• Compared to RUA or RUSI alone: Percutaneous nephrostomy can allow for a larger conduit to improve urinary drainage and access to stones or tumors for subsequent endoureteral therapies. Whereas RUA usually uses an 8 Fr caliber or smaller tools, standard PCNL tools may be up to 26 Fr.[43]
• Compared to AUSI alone: Percutaneous nephrostomy can accomplish the clinical goal of collecting system access and decompression without resulting in chronic ureterospasm or bladder spasm.

Enhancing Healthcare Team Outcomes

Effective management of percutaneous nephrolithotomy demands a collaborative, interprofessional approach to ensure patient-centered care, optimal outcomes, and patient safety.[44] Physicians—including urologists, radiologists, anesthesiologists, hospitalists, and intensivists—must engage in shared decision-making to determine the appropriateness of percutaneous nephrostomy, especially when patient survival is limited and less invasive interventions may be more ethical. Additional ethical considerations for this recommendation have been previously reviewed.[25][26] Interprofessional communication is critical in discussing procedural indications, risk stratification, and postoperative management. When these teams collaborate effectively, they uphold safety standards and align treatment with patient goals, minimizing harm and maximizing therapeutic benefit.

Advanced practitioners, nurses, pharmacists, and other health professionals each play vital roles in care coordination and patient education. A nurse navigator often facilitates periprocedural education, monitors for complications, and coordinates follow-up care, which directly reduces avoidable emergency visits. Patients who underwent education before undergoing percutaneous nephrostomy and again at the first catheter exchange are half as likely to seek unnecessary urgent care.[45] Pharmacists ensure appropriate antimicrobial stewardship and pain management strategies, while nurses monitor catheter function and signs of infection.

Regular, open communication among all team members supports the development of comprehensive care plans and ethical decision-making. This coordinated approach not only improves patient outcomes but also enhances team performance by ensuring all professionals contribute their expertise toward a unified care strategy.