When there is any suspicion of obstruction, an antegrade pyelogram, with or without percutaneous nephrostomy, is the next step. If the clinical and ultrasound evidence of obstruction is strong with a high serum potassium, an urgent nephrostomy should be performed. If possible, it is preferable to move the patient to the imaging department. An antegrade pyelogram can then be performed first, if merely wanting to exclude obstruction, with fluoroscopy and spot films showing free flow of contrast down the ureter to the bladder. Fluoroscopy is also helpful when placing the nephrostomy to ensure that the catheter is well sited in the collecting system (KelJeíl.§nd.,GuntherJ992), but if necessary nephrostomy can be undertaken in the ICU with ultrasound to guide the puncture.
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