Use of locking-loop pigtail nephrostomy catheters

SMALL ANIMALS

in dogs and cats: 20 cases (2004–2009)

Allyson C. Berent, dvm, dacvim; Chick W. Weisse, vmd, dacvs; Kimberly L. Todd; Demetrius H. Bagley, md

Objective—To describe the procedure and clinical usefulness of locking-loop pigtail neph-
rostomy catheter (PNC) placement in dogs and cats.
Design—Retrospective case series.
Animals—16 cats (18 kidneys) and 4 dogs (4 kidneys) that underwent PNC placement.
Procedures—Medical records of patients that underwent PNC placement were reviewed.
The PNCs were placed percutaneously with ultrasonographic and fluoroscopic guidance
or via a ventral midline laparotomy with fluoroscopic guidance. Either a modified Seldinger
technique or a 1-stab trocar introduction technique was used for PNC placement. Preopera-
tive renal pelvic size, postoperative renal pelvic decompression, catheter patency, serum
biochemical changes, and results of microbial culture of urine samples were reviewed.
Length of time the catheter was in place, reason and method for catheter removal, compli-
cations, and clinical outcomes were noted.
Results—Reasons for PNC placement were ureterolithiasis (15 kidneys), ureteral stricture
(3), malignant obstruction (2), and percutaneous nephrolithotomy (2). Seven of 22 catheters
were placed percutaneously, and 15 were placed via a ventral midline laparotomy. Cath-
eters were either size 5F (n = 17) or 6F (5). The PNCs remained indwelling for a median of
7 days (range, 1 to 28 days). Catheter-associated complications included urine leakage (n
= 1) and accidental dislodgement by the patient at home (1). All catheters performed suc-
cessfully by providing temporary urine diversion and drainage for successful renal pelvis
decompression.
Conclusions and Clinical Relevance—Placement of locking-loop PNCs was safe, effec-
tive, and well tolerated in dogs and cats for temporary urine diversion to achieve renal pelvis
decompression. (J Am Vet Med Assoc 2012;241:348–357)

A ureteral obstruction is a serious clinical problem in

dogs and cats and can occur secondary to ureteroli-
thiasis, neoplasia, ureteral stricture or stenosis, iatrogenic
ureteral ligation, and postsurgical trauma or edema.1–9 Hy-
dronephrosis typically occurs following ureteral obstruc-
tion and can result in increased intrarenal hydrostatic
pressure, decreased ipsilateral kidney function,10–13 and
potentially life-threatening azotemia, particularly when
contralateral renal function is impaired. In cases of par-
tial ureteral obstruction, some patients can be managed
medically with supportive care until a ureterolith passes,1,8
whereas others may require more aggressive management
for stabilization. The use of a nephrostomy catheter may
aid in stabilization and help to avoid permanent renal
damage prior to a more prolonged anesthetic procedure
for definitive treatment.2,4,14 If medical management of a
ureteral obstruction fails, decompression of the renal pel-
vis becomes imperative to preserve renal function ipsilat-
erally until definitive treatment is provided.
The physiologic response to a ureteral obstruction is
complex. Studies in clinically normal dogs have shown
that ureteral pressures increase immediately following
From the Department of Diagnostic Imaging and Interventional
Radiology, The Animal Medical Center, 510 E 62nd St, New York, NY
10065 (Berent, Weisse); Matthew J. Ryan Veterinary Hospital, School
of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
19104 (Todd); and the Department of Urology, Jefferson Medical Col-
lege, Thomas Jefferson University, Philadelphia, PA 19107 (Bagley).
Address correspondence to Dr. Berent (Allyson.Berent@amcny.org).
CHF
Abbreviations
Congestive heart failure
PCNL Percutaneous nephrolithotomy
PNC Pigtail nephrostomy catheter
TCC Transitional cell carcinoma
obstruction.10 This increase in pressure due to ureteral
obstruction is transmitted to the entire nephron, and a
decrease in glomerular filtration rate subsequently oc-
curs.15 The contralateral kidney will have an increase
in its glomerular filtration rate in response if there is
renal reserve for a compensatory hypertrophic mecha-
nism. This may not be the case in patients with preexist-
ing chronic kidney disease, seen in > 50% of dogs and
83% of cats with calculi-induced ureteral obstructions.1,7
The longer the ureter remains obstructed, the greater
the potential for progressive irreversible damage. In ex-
perimentally induced ureteral obstruction in dogs, it has
been found that after 7 and 14 days of complete ureteral
obstruction, the glomerular filtration rate is permanently
diminished by 35% and 54%, respectively.10–13,15,16
Traditional methods of renal pelvis decompres-
sion include various surgical options (ureterotomy,
ureteral reimplantation, and ureteronephrectomy), de-
pending on the cause and location of the ureteral ob-
struction.2,7,8 For severely debilitated patients in which
more prolonged surgical procedures should be avoided,
hemodialysis and nephrostomy catheter placement are

348 Scientific Reports JAVMA, Vol 241, No. 3, August 1, 2012

often quicker alternatives to traditional definitive sur-
gical correction. Advantages of a nephrostomy catheter
placement, compared with intermittent hemodialysis
or surgical correction, include commercial availability
of the catheter, minimization of anesthesia-associated
patient morbidity, ability to provide rapid renal pelvic
decompression, assess ipsilateral urine production and
ureteral patency, and determine whether adequate renal
function ultimately remains, thus giving justification for
a more definitive subsequent ureteral intervention.7–20,a
Nephrostomy catheters may also potentially be helpful
following intervention as a surgical site is healing (after
ureterotomy) or in patients awaiting transfer to facilities
capable of providing a more definitive procedure.
There is a paucity of literature on the use of neph-
rostomy catheters in clinical veterinary patients,2,8,19–23,b
and to the authors’ knowledge, no case series exists de-
scribing technique or outcome in small animal medi-
cine. One report21 describes the case of a feline patient
that had 5F red rubber catheters placed for treatment of
bilateral ureteral ligations during ovariohysterectomy.
One of the catheters dislodged within 10 hours after
placement, and the other became obstructed. In a ret-
rospective study2 of ureteral obstructions in cats, the
highest morbidity rate occurred in patients with neph-
rostomy catheters where urine leakage was a common
complication. Complications related to nephrostomy
catheters were seen in 46% of patients and included
urine leakage, poor drainage, and catheter dislodge-
ment. To the authors’ knowledge, all other reports8,20
are review articles that describe placement of a Foley
catheter, red rubber catheter, or a large (15 to 18F) fe-
nestrated latex catheter across both poles of the kidney
for drainage. Complications, including urine leakage,
dislodgement, infection, and hemorrhage, are frequent-
ly reported when such catheters are used.2,8
In human urology, percutaneous placement of
nephrostomy catheters was first described in 1955.24
Since that time, the type of catheter considered stan-
dard of care, the safest, and most effective is the lock-
ing-loop PNC.24–26 In people, these catheters can be left
in place long term, provided careful maintenance and
routine catheter exchanges are performed. The overall
major and minor complication rates associated with
PNCs in people are 3% to 8% and 3% to 25%, respec-
tively, with complications including hematuria, infec-
tion, dislodgement, pneumothorax or hemothorax, in-
testinal injury, septicemia, and urine leakage.26,27 The
purpose of the study reported here was to describe the
clinical use and outcome of PNC placement in dogs and
cats for various problems and to describe the technique
of placing a locking-loop PNC by either a percutaneous
approach or via a ventral midline laparotomy.
Materials and Methods
Selection of cases—Medical records from the Matthew
J. Ryan Veterinary Hospital of the University of Penn-
sylvania and The Animal Medical Center were reviewed
for any patient that had a locking-loop PNC placed by
1 of 2 authors (ACB or CWW) from 2004 to 2009. Pa-
tients were included if a procedural report with the final
outcome after PNC use was available for review. The
reason for PNC placement and technique were extract-
JAVMA, Vol 241, No. 3, August 1, 2012 Scientific Reports 349
ed from the medical record, along with patient informa-
tion, including signalment, history, and laboratory data
SMALL ANIMALS
(CBC, serum biochemical profile, preoperative urinaly-
sis and microbiological data, and coagulation profiles).
Findings of preprocedural imaging (radiography and
abdominal ultrasonography) were evaluated. Informa-
tion on renal pelvic size determined in a transverse
dimension via ultrasonography was obtained from the
medical records. Postprocedural data, including renal
pelvis size, catheter patency, results of microbial cul-
tures of urine samples, PNC indwelling time, other
urinary diversion mechanisms applied, and reason for
catheter removal, were obtained. All complications cit-
ed in the medical record were noted.
Procedure—Each patient was placed under general
anesthesia by use of various protocols. After surgery, all
patients were administered analgesics for the first 24
hours and then as needed on the basis of clinical signs.
Percutaneous approach—Each patient was placed
in lateral recumbency with the affected kidney in the
up position. Antimicrobials (cefazolin) were given (22
mg/kg [10 mg/lb], IV, at induction and q 2 h during the
procedure) if patients were not currently being treat-
ed with antimicrobials. The area over the kidney was
clipped of hair and aseptically prepared. A small stab
incision was made in the skin for catheter penetration.
Catheter placement was performed by use of either the
modified Seldinger technique or a 1-stab trocar intro-
duction technique.
Modified Seldinger technique—Ultrasound guid-
ance was used to perform pyelocentesis with an over-the-
needle standard IV catheter or renal access needlec (dog,
18 gauge; cat, 22 gauge). Once the tip of the catheter
was in the renal pelvis, the stylette was removed and an
extension set and 3-way stopcock were attached to the
catheter. Urine was drained and an equal amount of di-
luted contrast solutiond (50% contrast: 50% sterile saline
[0.9% NaCl]) was infused into the renal pelvis to perform
a pyelogram. Urine was submitted for microbial culture
and antimicrobial susceptibility profiling. Under fluoro-
scopic guidance,e an angle-tipped hydrophilic guidewiref
(dog, 0.035-inch-diameter wire; cat, 0.018-inch-diame-
ter wire) was advanced through the catheter and coiled
inside the renal pelvis. The catheter was removed over
the wire, and the PNC (cat, 5Fg; dog, 6Fh) was advanced
through the skin, into the renal parenchyma, and into
the renal pelvis. For this process, the hollow cannula in-
side the PNC remained secure to keep the catheter rigid
during renal penetration. Once the tip of the PNC was
inside the renal pelvis, the cannula was immobilized as
the catheter was advanced over the guidewire to form its
loop. Once the loop of the pigtail was completely within
the renal pelvis, the loop of the catheter was locked in
place by pulling on the locking string at the catheter hub
(Figures 1 and 2) and the string was carefully locked and
secured. The cannula was removed from the catheter.
The catheter was secured to the body wall by means of a
purse-string and Chinese finger trap suture pattern and
a second butterfly suture along the shaft of the catheter
to the body wall. A sterile urine collection system was
attached to the catheter for gravity drainage. A secure
abdominal bandage was placed.
SMALL ANIMALS

Figure 1—Photographs of a locking-loop PNC. A—The distal end of the

catheter over the hollow metal stylette and a guidewire; notice the multiple
fenestrations and locking string. B—After the metal stylette and guidewire
are withdrawn, notice the pigtail shape forming. C—The string is being
locked, creating a tight curl in the distal end of the catheter. D—Notice the
string at the top of the catheter near the hub that is pulled to lock the distal
pigtail (panel C) in place.

350 Scientific Reports JAVMA, Vol 241, No. 3, August 1, 2012

 SMALL ANIMALS
Figure 2—Fluoroscopic images during percutaneous nephrostomy
catheter placement in a cat via the modified Seldinger technique.
Please note sterile leaded gloves are worn by the clinician for radia-
tion protection. A—A renal access needle is inside the renal pelvis
after renal puncture via ultrasound guidance. The needle is being
held with a hemostat during an antegrade ureteropyelogram docu-
menting renal pelvic and proximal ureteral dilation. B—A guidewire
is coiled inside the renal pelvis through the renal access needle.
C—The PNC is advanced over the guidewire with the stiff hollow
stylette in place. D—The catheter is advanced off the stylette to
form a curl inside the renal pelvis as the guidewire is removed. E—
The lock is formed by pulling the locking-string mechanism tightly,
curling the pigtail inside the renal pelvis.

One-stab trocar induction technique—The 1-stab

trocar introduction technique was performed with the
sharp stylette through the hollow cannula in the PNC.
Via ultrasonographic or fluoroscopic guidance, the
locking-loop PNC with the hollow trocar and sharp
stylette (Figure 1) was directly advanced through the
body wall and punctured through the greater curvature
of the kidney and into the renal pelvis, being careful to
avoid the ureteropelvic junction. The sharp stylette was
removed once the catheter was seen inside the renal

JAVMA, Vol 241, No. 3, August 1, 2012 Scientific Reports 351

 pelvis, and urine was drained through the hollow can- was seen to uncurl. The PNC was carefully removed
nula. The hollow cannula was injected with contrast over the guidewire, with fluoroscopic guidance to en-
SMALL ANIMALS

material by means of fluoroscopic guidance to ensure
proper location. The loop was advanced off the hol-
low cannula into the pelvis, and the string was slowly
pulled to help form the loop inside the renal pelvis and
lock the pigtail. Once a full loop was made, the hollow
cannula was withdrawn. The catheter was secured to
the body wall as described.
Ventral midline laparotomy—Because of the na-
ture of the smaller, more mobile kidneys of feline pa-
tients, placement via a ventral midline laparotomy was
typically performed (n = 15/18 feline kidneys). Either
the modified Seldinger technique or the 1-stab trocar
introduction technique was performed via intraopera-
tive fluoroscopy during surgery. Once in place, locked,
and secured, the hub of the PNC was passed through
the body wall by means of a combination of sharp and
blunt dissection to exteriorize the catheter. A nephro-
pexy was performed to secure the kidney to the body
wall prior to closure with 4 deep box sutures of 3-0 or
4-0 polydioxanone suture material. The abdomen was
closed routinely, and the catheter was secured to the
outside of the body wall as described. The catheter was
tested with contrast material prior to closure to ensure
no leakage was seen.
sure any associated ureteral stent was not entrapped
and the curl was straightening without resistance. Af-
terward, the remaining locking string was identified to
be sure it did not remain in the insertion site and an
abdominal wrap was applied for 12 to 24 hours.
Follow-up—Microbial culture of urine samples
from the nephrostomy bag was typically performed 3
days after PNC placement or prior to tube removal if that
was < 3 days. If the PNC remained in > 3 days, microbial
culture of urine samples was recommended at 7 days and
every 2 weeks until the catheter was removed. Micro-
bial culture of urine samples obtained through the PNC
was typically performed at the time of PNC removal and
via cystocentesis 2 weeks later. Renal pelvis dimensions
were measured via abdominal ultrasonography to obtain
a transverse diameter prior to catheter removal in most
patients. The serum BUN, creatinine, sodium, and potas-
sium concentrations were monitored daily during hos-
pitalization and weekly if patients were discharged from
the hospital with their PNC in place. The outcome of
each patient was recorded.
Results

Postprocedural management—All hospitalized Clinical data—Twenty-two PNCs were placed (16

patients had a closed urine collection system attached
to the PNC. This was made of a sterile fluid line and a
sterile empty fluid bag (dog, 1,000 mL; cat, 100 mL).
The system was drained, and urine was quantified ev-
ery 2 hours in a sterile manner by use of alcohol swabs
and a sterile needle and syringe. All catheters and urine
collection lines were cleaned with chlorhexidine scrub
6 times daily to prevent bacterial colonization of the
catheter near the insertion site, and the abdominal
wrap was changed and tube exit site evaluated every 24
hours during the time patients were hospitalized.
PNC removal—The PNCs were removed under
fluoroscopic guidance. The proximal portion of the
catheter was aseptically scrubbed. The entire catheter
was cut 5 to 10 cm from the insertion site, releasing
the locking string mechanism. By use of a sterile tech-
nique, an appropriately sized guidewire (5F catheter,
0.018-inch-diameter wire; 6F catheter, 0.035-inch-
diameter wire) was advanced through the cut end of
the catheter, and under fluoroscopic guidance, the loop
cats [18 kidneys] and 4 dogs [4 kidneys]; Table 1). Me-
dian body weight of dogs and cats combined was 4.5 kg
(9.9 lb) and ranged from 2.5 to 33 kg (5.5 to 72.6 lb);
median age was 9 years (range, 2 to 14 years). There were
11 domestic shorthair cats (6 castrated males; 5 spayed
females), 3 domestic longhair cats (3 spayed females), 1
castrated male Siamese, and 1 spayed female Bengal cat.
There was 1 castrated male Shetland Sheepdog, 1 castrat-
ed male Lhasa Apso, 1 spayed female French Bulldog, and
1 spayed female Spitz. One cat had a peritoneal dialysis
catheter in place because of persistent ureteral obstruction
after a ureterotomy had been performed at a referring fa-
cility. One cat with ureterolithiasis was uninephric as a re-
sult of previously being a renal transplant donor. Reasons
for PNC placement included ureterolithiasis (15 feline
kidneys), ureteral stricture (3 feline kidneys), malignant
ureteral obstruction (2 canine kidneys), and following a
PCNL for nephrostomy access-tract closure during neph-
ropexy development (2 canine kidneys).
Eighteen of 20 patients had azotemia prior to PNC
placement. Median preprocedural serum creatinine con-

Table 1—Pre- and postprocedure data in dogs (n = 4) and cats (16) with percutaneous locking-loop PNC
placement.

Variable Canine kidneys (n = 4) Feline kidneys (n = 18) Overall (n = 22)

Pre-PNC renal pelvis size (mm) 14 (4.2–34) 13 (5.24–25) 13 (4.2–34)
Post-PNC renal pelvis size (mm) 1.75 (1.0–2.4)* 2 (2.1–4)† 2 (1–4)
Pre-PNC serum creatinine (mg/dL) 2.0 (1.1–8.4) 7.25 (3.0–15)‡ 7.4 (1.1–15)
Post-PNC serum creatinine (mg/dL) 1.75 (1.1–4.4) 2.5 (1.5–7.2)§ 2.5 (1.1–7.2)
Time indwelling (d) 14 (5–28) 8 (0.25–27) 7 (0.25–28)
Complications Dislodgement at home (n = 1) Urine leakage (n = 1) Not applicable

Data are median (range).

*Value represents data for 3 dogs. †Value represents data for 13 cats. ‡Value represents data for 16 cats.
§Value represents data for 15 cats.
There were 22 PNCs placed overall, in 16 cats and 4 dogs. Two cats had bilateral PNC placement.

352 Scientific Reports JAVMA, Vol 241, No. 3, August 1, 2012

centration was 7.4 mg/dL (range, 1.1 to 15 mg/dL; cat
reference range, 0.8 to 1.9 mg/dL; dog reference range,
0.4 to 1.8 mg/dL), median BUN concentration was 75
mg/dL (range, 31 to > 240 mg/dL; cat reference range,
15 to 34 mg/dL; dog reference range, 7 to 27 mg/dL),
and median potassium concentration was 4.8 mEq/L
(range, 3.2 to 6.5 mEq/L; cat reference range, 3.4 to 5.6
mEq/L; dog reference range, 3.6 to 5.5 mEq/L). Eight
of 20 patients had microorganisms cultured from urine
samples obtained via cystocentesis (n = 7) or urethral
catheterization (1) prior to PNC placement; each was
given appropriate antimicrobials at least 48 hours prior
to the procedure. Ten patients had a coagulation profile
obtained; all results were within reference ranges.
Imaging—All patients had diagnostic abdominal
ultrasonography performed prior to PNC placement.
As determined on the basis of transverse renal imaging,
the renal pelvic dimension had a median diameter of
13 mm (range, 4.2 to 34 mm). Abdominal radiography
confirmed ureterolithiasis in 15 patients (14 cats and
1 dog) and nephrolithiasis in 18 patients (16 cats and
2 dogs). Two cats had bilateral ureteral obstructions.
One cat was uninephric with associated ureterolithia-
sis. Two dogs had a trigonal mass obstructing the ureter
at the ureterovesicular junction.
Procedures—In 18 feline kidneys, 3 had PNC
placement via a percutaneous approach (modified Seld-
inger technique) and 15 had PNC placement via a ven-
tral midline laparotomy (modified Seldinger technique
[n = 13] and 1-stab trocar introduction technique [2]).
Eleven cats had PNCs placed in the left kidney, 3 had
PNCs placed in the right kidney, and 2 cats had PNCs
placed bilaterally. All 3 cases of percutaneous PNC
placement in kidneys of cats were left sided. Of 18 fe-
line kidneys, 17 had a 5F PNC placed and 1 had a 6F
PNC placed. In the 4 canine kidneys, PNC placement
was performed on the right kidney percutaneously by
means of the modified Seldinger technique and a 6F
catheter in all cases.
The PNC was placed during the primary treatment
of ureteral obstruction in 13 of 22 (59%) kidneys and for
azotemia stabilization and renal pelvis decompression
prior to definitive treatment of the ureteral obstruction
in 9 (41%) kidneys (all of which were feline kidneys).
Nephrostomy catheters were placed intraoperatively
during the primary treatment if there was concern of
postoperative urine leakage to allow for renal pelvis
decompression. This resulted in most patients having
> 1 drainage mechanism (PNC and primary treatment
technique [ureterotomy or ureteral stent placement]).
Placement of a PNC typically occurs during the
primary treatment procedure when immediate patency
is uncertain or temporary urine leakage is anticipated,
regardless of the method of correction (traditional sur-
gery or stent). In this group of patients, a PNC was used
to prevent urine leakage after ureterotomy or ureteral
stent placement (n = 8), to maintain renal pelvis de-
compression and prevent urine leakage when a renal
pelvis rupture was discovered (likely due to the com-
plete ureteral obstruction; 2), to drain and flush an ob-
structive pyelonephritis due to TCC (1), and as a stan-
dard procedure after a PCNL to prevent urine leakage
JAVMA, Vol 241, No. 3, August 1, 2012 Scientific Reports 353
after a large sheath is placed in the kidney percutane-
SMALL ANIMALS
ously for intracorporeal nephrolithotripsy (2).
The median time for PNC placement prior to de-
finitive correction of the ureteral obstruction (n = 9)
was 40 minutes (range, 35 to 75 minutes); 2 PNC
placements were bilateral and represented the longest
procedure times in this group. For those that had the
catheter placed intraoperatively during ureteral stent
placement, ureterotomy, or PCNL, the procedure time
was not possible to discern from the medical records
because the exact time of PNC placement was not re-
corded. Nineteen of 20 patients had a urine sample sub-
mitted for microbial culture at the time of the pyelocen-
tesis during PNC placement; only 1 of the 19 patients
had microorganisms cultured from urine samples.
Complications—One feline patient had evidence
of urine leakage into the subcutaneous space 3 days
after PNC placement without associated uroabdomen.
This was corrected by catheter exchange and purse-
string suture at the subcutaneous exit site. During the
catheter exchange, the indwelling double pigtail ure-
teral stent, which was placed for permanent fixation at
the time of PNC placement, was accidentally entrapped
by the pigtail loop of the PNC and the stent was with-
drawn through the renal parenchyma. This complica-
tion required a small cystotomy.
A second patient was discharged from the hospital
with the PNC after a ureteral stent was placed for TCC
as a result of an associated renal pelvis rupture. Because
of owner concerns, hospitalization was not considered
an option for this patient. Five days after placement,
the catheter was accidentally dislodged in the crate at
home. The catheter remained intact (locking loop still
curled), and there was no known complication asso-
ciated with this event (no evidence of abdominal or
subcutaneous effusion or bleeding). The ureteral stent
remained in place, maintaining urinary tract patency
with this patient surviving this episode. Finally, 1 pa-
tient required 2 attempts at renal pelvis access to im-
prove the angle for the locking loop to curl. Complica-
tions related to the PNC in all 3 patients resolved.
Postoperative clinical data—Improvement in renal
function on the basis of creatinine concentrations was
documented within 12 to 72 hours after PNC place-
ment in 16 of 17 patients that were alive after surgery
(3 of 20 patients not included because of death during
anesthetic recovery [1 patient] or death because of CHF
[2] within 72 hours). Some degree of postprocedural
azotemia remained in 9 of 17 patients that were previ-
ously azotemic, with a median creatinine concentration
of 2.5 mg/dL (range, 1.1 to 7.2 mg/dL), compared with
7.4 mg/dL prior to PNC placement.
There was evidence of gross hematuria from the
PNC kidney in 14 of 19 patients, all of which resolved
within 12 to 36 hours (1 of 20 patients not included
because of death during anesthetic recovery). No signs
of pain at the nephrostomy site were recorded after the
first 24 hours for 18 of these 19 patients. One patient
that had persistent signs of discomfort at the PNC site
was the patient with urine leakage into the subcutane-
ous space. There was no mention of discharge from the
PNC exit site in any case, including the one with urine
 leakage. Urine output from the PNC ranged from 2.3 to
35 mL/kg/h (1.04 to 15.9 mL/lb/h).
SMALL ANIMALS
The median renal pelvis diameter after PNC place-
ment was 2 mm (range, 1 to 4 mm) on the basis of ultra-
sonography. The catheters were left indwelling in patients
a median of 7 days (range, 1 to 28 days), depending on the
reason and mechanism of placement. For the patients that
had a nephropexy performed, the catheter remained in
place for a median of 5 days (range, 1 to 21 days). For the
patients that had the catheter placed percutaneously, the
median indwelling time was 21 days (range, 5 to 28 days)
to allow a nephropexy to form. Twelve cats had a transure-
thral catheter placed at the time of PNC placement to help
monitor urine output from the contralateral kidney due to
the presence of oliguria or anuria preoperatively.
Five patients (3 dogs and 2 cats) were discharged
from the hospital with the PNC. Two cats were dis-
charged to the local veterinarian with the PNC draining
to determine whether renal function improved prior to
considering definitive treatment (1 stricture and 1 mul-
tiple calculi in the kidneys and ureters). In the authors’
opinion, a serum creatinine concentration of < 4 mg/dL
was the aim. Two dogs had their catheters capped off
and wrapped because the PNCs were only in place fol-
lowing the PCNL for nephropexy formation. One dog
had the catheter draining at home; this was the cath-
eter that was accidentally dislodged 5 days after surgery
while the dog was running with a patent indwelling
ureteral stent. This patient had a renal pelvis rupture
from the obstruction, so constant drainage was desired,
but hospitalization was declined.
Six of 17 patients had microorganisms cultured
from urine samples within 2 weeks after PNC place-
ment (median, 7 days; range, 3 to 14 days). Fifteen of
17 patients had microbial cultures of urine samples ob-
tained from the PNC prior to removal, and 2 of 17 from
a cystocentesis after catheter removal. Of the 6 patients
with microorganisms cultured from urine samples, 4
had urine samples obtained from the PNC collection
system at the time of removal and 2 from a cystocen-
tesis 3 and 10 days after PNC removal. Of the isolates,
3 were Escherichia coli, 2 were Enterococcus spp, and
1 was a combination of E coli and Enterococcus spp.
All positive samples had a growth of > 100,000 colony
forming units. Five isolates were multidrug resistant.
All E coli isolates were susceptible to amikacin and
imipenem, and all Enterococcus spp were susceptible to
amikacin, chloramphenicol, nitrofurantoin, and van-
comycin. One E coli isolate had a broad susceptibility
pattern. Twelve cats had a transurethral catheter placed
at the time of PNC placement; 5 were of the 6 patients
that had microorganisms cultured from urine samples
obtained after PNC.
Follow-up—Fifteen of 20 patients were discharged
from the hospital. No known cause of death was direct-
ly related to the placement or presence of a PNC. One
patient died during recovery under anesthesia. This was
likely associated with the ruptured kidney found at the
time of surgery. Four patients died (n = 2) or were euth-
anized (2) because of nonresponsive CHF after surgery
(3 to 7 days after catheter placement). All 4 of these
patients had a severe postobstructive diuresis requiring
high-volume fluid replacement (7 to 25 mL/kg/h [3.2 to
354 Scientific Reports JAVMA, Vol 241, No. 3, August 1, 2012
11.4 mL/lb/h]), and all of these patients had improve-
ment in their serum creatinine concentrations immedi-
ately after PNC placement prior to death (median, 1.5
mg/dL; range, 1.3 to 2.9 mg/dL), compared with before
(median, 11 mg/dL; range, 5.1 to 15 mg/dL). A diagno-
sis of CHF was made on the basis of some combination
of the following: thoracic radiography (pleural effusion
[n = 3], pulmonary edema [3], and enlarged pulmonary
veins [4]) and echocardiographic findings (enlarged
right and left atrium [4]), elevated central venous pres-
sures (4), and weight gain (4).
Most patients had improvement in their azotemia.
The 1 patient that did not improve in the first few days
was discharged without PNC complication; renal func-
tion never improved, and euthanasia was performed 42
days after PNC placement.
The definitive procedure included a ureteral stent
placement in 16 ureters (with or without a ureterotomy
or ureteral reimplantation) and a ureterotomy alone in
1. One patient had a ureterotomy performed, and a PNC
was placed at the same time. This patient developed
urine leakage and re-obstruction at the ureterotomy site
when the PNC was capped off. Antegrade pyelography
confirmed obstruction to flow at the previous stone site
with leakage of contrast material. This was suspected
to be due to a postsurgical stricture, edema, or a stone-
induced stricture. A ureteral stent was placed 7 days
after the ureterotomy. Two patients that had a PCNL
performed did not require further treatment once the
nephrostomy site was healed and the nephrolith was
successfully removed. All PNCs that were electively
removed (n = 15) were removed under fluoroscopic
guidance over an appropriately sized guidewire. This
was performed without complication in all except the
patient that developed urine leakage and required cath-
eter exchange. The remaining catheters were removed
as a result of dislodgment (n = 1) or removed at the
time of death (6).
Discussion
The present study supports the use of a locking-
loop PNC in canine and feline patients and documents
that PNCs are associated with few serious complica-
tions. When complications occur, they can be det-
rimental. Timely and effective renal pelvis decom-
pression in patients with ureteral obstructions can
ultimately preserve remaining renal function.10–13,16 If
definitive treatment is possible (eg, via ureterotomy,
ureteral reimplantation, ureteral stenting, or ureteral
bypass)2,19,b,i and the patient is stable enough to handle
a longer anesthesia period, then definitive correction
is recommended over the placement of a PNC alone,
in the authors’ experience. Unfortunately, in many cir-
cumstances, because of patient instability or procedural
circumstance, temporary drainage is considered neces-
sary either prior to or during definitive treatment.
The most common reason for PNC placement in
the present study was renal decompression second-
ary to ureterolithiasis in cats. Another potential use of
PNCs was to provide scaffolding for the formation of
a nephropexy after an intracorporeal PCNL in dogs.
Nephrostomy catheters are rarely considered neces-
sary if there is a patent ureter following an appropri-
ate intervention. After ureteral surgery, the ureter can
become edematous and primary closure of the ureter
can be technically difficult, resulting in either luminal
occlusion or urine leakage. If urine leakage or contin-
ued obstruction exists, it can be life-threatening but is
often temporary, as the postoperative edema and swell-
ing resolves. When this occurs, having a nephrostomy
catheter for drainage as the surgical site heals can be
beneficial, as was the case in 4 cats of this report. Pa-
tency was documented on a ureteropyelogram through
the PNC prior to removal. Because of the concern for
the inability to provide appropriate drainage, a PNC
was used for severe obstructive pyelonephritis. This di-
agnosis was made on the basis of purulent material and
a positive microbial culture of urine samples removed
from the renal pelvis during the pyelocentesis. Having
a catheter in the renal pelvis for drainage and flushing
may be necessary if the infected material is too thick
to passively drain through the ureter or ureteral stent.
In 1 patient with an obstructive ureteral TCC, there
was concurrent severe pyelonephritis and the material
was thick and inspissated in nature. A PNC was placed
to provide adequate drainage. The PNC was removed
once the urine was grossly normal.
In the present study, improvement in renal func-
tion on the basis of serum creatinine concentrations
was documented in 16 of 17 patients within the first
3 days (12 to 72 hours) after PNC placement. Medi-
an serum creatinine concentration was 2.5 mg/dL af-
ter PNC placement, compared with 7.4 mg/dL before
placement. Patients that received a PNC were typically
more unstable (ie, higher serum creatinine and potas-
sium concentrations or severely hypotensive under an-
esthesia) than most patients that were able to withstand
a definitive treatment. With the placement of a PNC
before definitive treatment, renal stabilization is pos-
sible prior to more prolonged anesthesia, which could
be a safer alternative for certain patients. One patient
had worsening of serum BUN and creatinine concen-
trations immediately after PNC placement, which took
> 1 month to return to baseline. Although results of
postmortem examination were not available, it might
be speculated that the decrease in renal function was
secondary to the anesthetic event or directly related
to PNC placement. The latter was considered unlikely
because this procedure is typically considered to cause
minimal renal damage.24–26
Catheter placement was associated with short
procedure times in the present study. Unfortunately,
documentation of the exact duration of catheter place-
ment was not available in the anesthesia record when
the catheters were placed during another definitive
procedure, which included most cases. The longest
procedure time for PNC placement was 75 minutes in
a patient that had bilateral PNCs placed via a ventral
midline laparotomy prior to any intervention. The me-
dian procedure time was 37.5 minutes for unilateral
PNC placement. This would suggest that the placement
of PNCs either percutaneously or via a ventral midline
laparotomy can be quicker than the procedures associ-
ated with more definitive treatment.
The loop of the PNC is approximately 10 to 12 mm
for the 5F catheter and 15 mm for the 6F catheter, mak-
JAVMA, Vol 241, No. 3, August 1, 2012 Scientific Reports 355
ing placement more difficult in a small renal pelvis.
SMALL ANIMALS
Seven patients had a renal pelvis < 10 mm in diame-
ter, and in these cases, catheters were technically more
challenging to place so that the loop was appropriately
placed inside the renal pelvis. On the basis of experi-
ence, the authors suggest placement of PNCs via a ven-
tral midline laparotomy in cats and patients with a renal
pelvis < 10 mm in diameter. Most cats have very mobile
kidneys, and safely placing the PNC without manu-
ally securing the kidney makes percutaneous place-
ment more difficult. The authors prefer the modified
Seldinger technique over the 1-stab trocar introduction
technique whenever possible.
Previously reported complications for nephrosto-
my catheters include hemorrhage, urine leakage, pneu-
mothorax, dislodgement, and infection.2,8,20,21,27 Al-
though complications are possible with PNC, they are
minimized by careful placement, securing techniques,
the locking-string mechanism, and careful catheter
management. To prevent urine leakage, it is important
to ensure all of the fenestrations in the loop are situ-
ated within the renal pelvis prior to locking the string.
This can be done by testing the catheter location within
the renal pelvis via pyelography. Also, in the authors’
opinion, a nephropexy in feline patients ensures more
stability because feline kidneys are very mobile, com-
pared with those of dogs or humans. Numerous secu-
rity sutures around the catheter to the skin can prevent
catheter movement, and a secure abdominal wrap may
prevent contamination and dislodgement. Other po-
tential complications include creating a pneumothorax
during puncture, renal hemorrhage during nephropexy
or catheter insertion, and penetrating the catheter wall
with securing sutures. Such complications did not oc-
cur in the present study but are certainly possible. It is
also important when removing a PNC to monitor the
loop carefully by means of fluoroscopy. This will allow
one to ensure that removal is appropriate and the curl
is unlocked prior to removal. If there is a double pig-
tail ureteral stent present and the pigtail of the stent is
within the renal pelvis, then the loops of the PNC and
the stent can entrap, as in 1 case described in the pres-
ent report. Allowing patients to be managed at home
with their nephrostomy catheters could increase the
risk of an adverse event, such as dislodgement. This did
not seem to be an issue in those PNCs that were cov-
ered and capped under an abdominal wrap for several
weeks after PCNL, although there were few cases that
were discharged with their catheters (5 of 20 cases).
One patient had evidence of renal rupture due to
a complete ureteral obstruction prior to PNC place-
ment. The PNC seemed to initially decompress the re-
nal pelvis and control the hemorrhage; however, upon
anesthetic recovery, this patient seemed to have another
acute bleeding episode and, despite aggressive resusci-
tation, ultimately died. Unfortunately, a postmortem
examination was not permitted by the owner; the sus-
pected cause of deterioration was persistent renal hem-
orrhage. The possibility that the PNC was associated
with further hemorrhage cannot be ruled out.
Eight of 20 patients in the present study had evi-
dence of a urinary tract infection prior to PNC place-
ment, and all were treated with appropriate antimicro-
 bials for at least 48 hours prior to the procedure. Six pa-
SMALL ANIMALS
tients had microorganisms cultured from urine samples
after PNC placement, only half of which (n = 3) had
positive microbial culture results prior to PNC place-
ment. Only 1 of 3 had the same isolate identified before
and after PNC placement. One patient with a subclini-
cal Enterococcus infection was unable to be cleared of
the infection, living an additional 16 months without
signs of a lower urinary tract infection. Infections were
found only in patients that had a PNC indwelling for
> 5 days, and none were seen in patients that had the
catheters removed sooner. Twelve of 19 patients had an
indwelling transurethral catheter after surgery; most
of the patients with positive microbial culture results
of after PNC placement were those with an indwelling
transurethral catheter (5 of 6 patients). Which exter-
nalized catheter was responsible for the urinary infec-
tion is not clear, and one might expect the urethral
catheter would be more responsible because it is easily
contaminated by fecal matter, which is consistent with
the literature.28–30 The shorter the duration that a trans-
urethral catheter remains indwelling, the lower the risk
of urinary tract infections, with a recommendation of
< 3 days.28–30 One might speculate the same to be true
for PNCs. The authors’ current recommendation is to
avoid transurethral catheterization if possible in any
patient; however, if necessary, removal of any catheter
at the earliest possible time is suggested, and maintain-
ing clean technique with a closed collection system in
all catheter manipulation is important.
After surgery, 1 patient had signs of discomfort that
persisted at the PNC site after 24 hours. This was the
same patient that had urine leaking into the subcutane-
ous space. Careful attention should be paid to patients
that have overt signs of pain and subcutaneous bruis-
ing beyond standard laparotomy-associated discomfort
after surgery. Diagnostic imaging with contrast material
for urine leakage is highly recommended.
There is no clear evidence of how long a PNC
should remain indwelling for a seal to form and pre-
vent urine leakage. On the basis of recommendations
for other viscous organs (stomach after percutaneous
endoscopic gastrostomy catheter placement and uri-
nary bladder after cystostomy catheter placement), 3 to
6 weeks should be adequate for a fibrous seal to form.
The authors recommend the catheters remain indwell-
ing until either the obstruction is relieved (if a concur-
rent surgical nephropexy was performed) or a catheter-
induced nephropexy is formed.
One study31 evaluated clinically normal dogs in
which a nephrostomy catheter was placed after a ure-
teral obstruction (via an artificial stone) was created
at the ureteropelvic junction. In that study, more dogs
with a PNC passed the artificial calculi, compared with
dogs without a PNC. This suggests that patients may
spontaneously pass calculi after nephrostomy catheter
placement, and in theory, this may be another poten-
tial benefit of renal pelvic drainage prior to a definitive
treatment. Decompression of the renal collection sys-
tem may allow for ureteral relaxation and stone passage
without the need for further intervention.
In the present study, no known cause of death was
directly related to the placement or presence of the
356 Scientific Reports JAVMA, Vol 241, No. 3, August 1, 2012
PNC. Interestingly, 4 patients died of or were eutha-
nized because of presumable CHF that was nonrespon-
sive to aggressive medical management. Unfortunately,
this can occur, particularly in cats requiring high rates
of fluid administration IV. These rates are often neces-
sary to prevent hypovolemia and subsequent hypoten-
sion and severe dehydration in cats that have severe
postobstructive diuresis and excessive fluid losses.
There were not enough patients that had this occur in
the present study to make generalizations, but it does
seem that the patients that developed CHF were those
that received the highest fluid rates (typically on the ba-
sis of high urine output), had the highest preoperative
creatinine concentrations (median, 11 mg/dL), and had
a dramatic and fast decrease in the degree of azotemia
within 36 hours. This finding requires further investiga-
tion for markers and predictors of CHF, and care should be
taken with fluid therapy during postobstructive diuresis.
The authors currently allow urine output to remain above
fluid inputs throughout hospitalization while maintain-
ing appropriate cardiovascular stability to prevent this
phenomenon.
Most of the patients in the present study had a de-
finitive treatment either during or after the PNC was
placed. All catheters in surviving animals were able to
be removed under fluoroscopic guidance, with 1 cath-
eter removal resulting in ureteral stent dislodgement.
After appropriate drainage, each renal pelvis was small-
er in diameter, compared with before PNC placement.
The limitations of the present study include the ret-
rospective nature, paucity of data regarding procedure
times because of PNC placement during other proce-
dures, and various reasons for PNC placement, mak-
ing it difficult to compare outcomes. The goal of the
present study was to describe the use of locking-loop
PNCs and any complications and clinical outcomes as-
sociated with their use. In summary, as determined on
the basis of results of the present study, the use of lock-
ing-loop PNCs appears safe, secure, and effective, pro-
vided that appropriate techniques are followed. These
catheters need to be carefully placed, monitored, and
secured to prevent complications. The procedure can be
performed either percutaneously or via a ventral midline
laparotomy with fluoroscopy, with or without ultrasono-
graphic guidance. Catheters were typically placed via a
ventral midline laparotomy in cats and percutaneously
in dogs. Careful monitoring for urinary tract infections is
necessary, and the avoidance of concurrent transurethral
urinary catheters should be considered.
a. Berent A, Weisse C, Bagley D, et al. The use of locking-loop neph-
rostomy catheters for ureteral obstructions in dogs and cats (ab-
str). Vet Surg 2009;38:E26.
b. Berent A, Weisse C, Bagley D, et al. Ureteral stenting for feline
ureterolithiasis (abstr). J Vet Intern Med 2009;23:688.
c. Renal access needle, 18 gauge X 15 cm, Cook Medical, Bloom-
ington, Ind.
d. Omnipaque, Iohexol 240 mg/mL, GE Healthcare, Princeton, NJ.
e. ISO-C, Fluoroscopy, Seimens, Malvern, Pa.
f. Weasel Wire 0.018 or 0.035-inch hydrophilic angle-tipped
guidewire, Infiniti Medical LLC, Malibu, Calif.
g. 5F Dawson-Meuller locking-loop pigtail catheter, Cook Medi-
cal, Bloomington, Ind.
h. 6F locking-loop pigtail catheter, Infiniti Medical LLC, Malibu, Calif.
i. Berent A, Weisse C, Bade H, et al. The use of a subcutaneous
 ureteral bypass for the treatment of ureteral obstructions in cats
(abstr). J Vet Intern Med 2011;25:1506.
References
1. Kyles AE, Hardie EM, Wooden BG, et al. Clinical, clinicopatho-
logic, radiographic, and ultrasonographic abnormalities in cats
with ureteral calculi: 163 cases (1984–2002). J Am Vet Med Assoc
2005;226:932–936.
2. Kyles AE, Hardie EM, Wooden BG, et al. Management and out-
come of cats with ureteral calculi: 153 cases (1984–2002). J Am
Vet Med Assoc 2005;226:937–944.
3. Berent A, Weisse C, Bagley D, et al. Ureteral stenting for benign
and malignant disease in dogs and cats. Vet Surg 2007;36:E1–E29.
4. Berent AC, Weisse C, Beal MW, et al. Use of indwelling, double-pig-
tail stents for treatment of malignant ureteral obstruction in dogs:
12 cases (2006–2009). J Am Vet Med Assoc 2011;238:1017–1025.
5. Zaid M, Berent A, Weisse C, et al. Feline ureteral strictures: 10
cases. J Vet Intern Med 2011;25:222–229.
6. Steffey M, Rassnick KM, Porter B, et al. Ureteral mast cell tumor
in a dog. J Am Anim Hosp Assoc 2004;40:82–85.
7. Snyder DM, Steffery MA, Mehler SJ, et al. Diagnosis and surgical
management of ureteral calculi in dogs: 16 cases (1990–2003).
N Z Vet J 2004;53:19–25.
8. Hardie EM, Kyles AE. Management of ureteral obstruction. Vet
Clin North Am Small Anim Pract 2004;34:989–1010.
9. McLouglin MA, Bjorling DE. Ureters. In: Slatter D, ed. Textbook
of small animal surgery. 3rd ed. Philadelphia: WB Saunders Co,
2003;1619–1628.
10. Wen JG, Frokiaer J, Jorgensen TM, et al. Obstructive ne-
phropathy: an update of the experimental research. Urol Res
1999;27:29–39.
11. Fink RW, Caradis DT, Chmiel R, et al. Renal impairment and
its reversibility following variable periods of complete ureteric
obstruction. Aust N Z J Surg 1980;50:77–83.
12. Kerr WS. Effect of complete ureteral obstruction for one week
on kidney function. J Appl Physiol 1954;6:762–772.
13. Vaughan ED Jr, Sweet RE, Gillenwater JY. Unilateral ureteral oc-
clusion: pattern of nephron repair and compensatory response.
J Urol 1973;109:979–982.
14. Langston CE, Cowgill LD, Spano JA. Applications and outcome
of hemodialysis in cats: a review of 29 cases. J Vet Intern Med
1997;11:348–355.
15. Coroneos E, Assouad M, Krishnan B, et al. Urinary obstruction
causes irreversible renal failure by inducing chronic tubuloint-
erstitial nephritis. Clin Nephrol 1997;48:125–128.
JAVMA, Vol 241, No. 3, August 1, 2012 Scientific Reports 357
16. Wilson DR. Renal function during and following obstruction.
Ann Rev Med 1977;28:329–339.
SMALL ANIMALS
17. Block G, Adams LG, Widmer WR, et al. Use of extracorporeal
shock wave lithotripsy for treatment of nephrolithiasis and ure-
terolithiasis in five dogs. J Am Vet Med Assoc 1996;208:531–536.
18. Adams LG, Senior DF. Electrohydraulic and extracorporeal
shock-wave lithotripsy. Vet Clin North Am Small Anim Pract
1999;29:293–302.
19. Weisse CW, Berent AC, Todd KL, et al. Clinical applications of
interventional radiology in veterinary medicine. J Am Vet Med
Assoc 2008;233:1564–1574.
20. Rawlings C, Bjorling D, Christie B. Ureteral surgery. In: Slatter D,
ed. Texbook of small animal surgery. 3rd ed. Philadelphia: Saunders,
2003;1614–1615.
21. Nwadike BS, Wilson LP, Stone EA. Use of bilateral temporary
nephrostomy catheters for emergency treatment of bilateral ure-
ter transection in a cat. J Am Vet Med Assoc 2000;217:1862–1865.
22. Chambers JN, Selcer BA, Barsanti JA. Recovery from severe hy-
droureter and hydronephrosis after ureteral anastomosis in a
dog. J Am Vet Med Assoc 1987;191:1589–1592.
23. Ehnen SJ, Divers TH, Gillette D, et al. Obstructive nephroli-
thiasis and ureterolithiasis associated with chronic renal fail-
ure in horses: eight cases (1981–1987). J Am Vet Med Assoc
1990;197:249–253.
24. Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (nee-
dle) nephrostomy in hydronephrosis. JAMA 1955;157:891–894.
25. Park BK, Kim SH, Moon MH. Nonvascular interventions of the
urinary tract. J Korean Med Sci 2002;17:727–736.
26. Dyer RB, Regan JD, Kavanagh PV, et al. Percutaneous neph-
rostomy with extension of the techniques: step by step. Radio-
graphics 2002;22:503–525.
27. Wah TM, Weston MJ, Irving HC. Percutaneous nephrostomy
insertion. Clin Radiol 2004;59:255–261.
28. Ogeer-Gyles J, Mathews K, Weese JS, et al. Evaluation of cathe-
ter-associated urinary tract infections and multi–drug-resistant
Escherichia coli isolates from the urine of dogs with indwelling
urinary catheters. J Am Vet Med Assoc 2006;229:1584–1590.
29. Sullivan LA, Campbell VL, Onuma SC. Evaluation of open ver-
sus closed urine collection systems and development of nosoco-
mial bacteriuria in dogs. J Am Vet Med Assoc 2010;237:187–190.
30. Smarick SD, Haskins SC, Aldrich J, et al. Incidence of catheter-
associated urinary tract infection among dogs in a small animal
intensive care unit. J Am Vet Med Assoc 2004;224:1936–1940.
31. Lennon GM. Double pigtail ureteric stent versus percutaneous
nephrostomy: effects on stone transit and ureteric motility. Eur
Urol 1997;31:24–29.