Nephrostomy and Upper Tract Drainage
Upper tract drainage relieves an obstructed kidney by either a retrograde ureteric stent or an antegrade percutaneous nephrostomy — and the central skill is choosing the right route and acting urgently when there is infection.
The big picture
When the upper tract is obstructed, urine (and any infection) is trapped above the blockage. Two drainage routes exist: a retrograde JJ ureteric stent (placed cystoscopically from below) or an antegrade percutaneous nephrostomy (a tube placed through the flank directly into the collecting system).
Infected + obstructed = drain now (stent or nephrostomy), antibiotics, and definitive treatment later — never operate definitively on an infected obstructed kidney.
Red flags
Emergency — decompress immediately, antibiotics, resuscitate; do not operate definitively.
Check the drain is correctly placed and patent.
All renal function is at stake — drain early.
Symptom sorter
From below, cystoscopically.
Diagnostic algorithm
Each step answers one question. Tap to expand.
Treatment ladder
Decompress the obstructed kidney by the most appropriate route; treat infection and resuscitate; defer definitive treatment until stable.
Complications
- Pyonephrosis/sepsis, renal loss if undrained
- Nephrostomy: bleeding, malposition, dislodgement
- Stent: symptoms, migration, encrustation, failure to relieve a tight obstruction
- Choose nephrostomy when stent likely to fail or pus is present
- Confirm drain position/patency if sepsis persists
- Reposition/replace malfunctioning drains
- Manage post-obstructive diuresis
Summary tables
Stent vs nephrostomy
| Feature | JJ stent | Nephrostomy |
|---|---|---|
| Route | Retrograde (cystoscopic) | Antegrade (percutaneous) |
| Best for | Feasible retrograde access | Pus, impassable obstruction, stent failure |
| Drainage | Internal | External bag |
| Bonus | No external tube | Antegrade access for later procedures |
Memory hooks
Infected + obstructed = drain now.
Two routes: stent (below) or nephrostomy (flank).
Pus or impassable obstruction → nephrostomy.
Decompress first, treat the cause later.
Expect post-obstructive diuresis.
Board traps
Septic patient with an obstructing stone taken for ureteroscopy instead of decompression.
Ongoing sepsis after 'drainage' — the tube is blocked or malpositioned.
Choosing a stent when there is frank pus (favour nephrostomy).
Clinical cases
A septic patient has fever, flank pain and an obstructing ureteric stone with hydronephrosis and pus on imaging.
What is the immediate management?