Changes

*'''Engage the obturator ''' of the catheter, but loose enough so that you can remove it with one hand if needed.*'''Position the patient ''' on the side

*'''Check the position of the previous catheter tip ''' with a few ml of iodinated contrast (enough to delineate the renal pelvis but yet not obscuring the catheter tip), preferably in two projections such as a lateral and a more frontal one.* <br>''[[#Troubleshooting|Troubleshooting: Catheter in calyx]]''*'''Loosen ''' the pigtail<ref group="notes" name="loosen">Often by loosening a thread that keeps the pigtail spiraled.</ref>*'''Insert a guidewire ''' (such as Amplatz) into the renal pelvis or proximal ureter.* <br>''[[#Troubleshooting|Troubleshooting: Cannot advance guidewire]]''*'''Remove the previous catheter ''' while keeping the guidewire in place<ref group="notes">Always keep at least one hand on the guidewire. The grip needs to be switched to just above the skin as the catheter tip exits.</ref>.* <br>''[[#Troubleshooting|Troubleshooting: Catheter stuck]]''

*'''Insert the new catheter ''' with obturator over the guidewire,<ref group="notes>It is useful to let an assistant advance the catheter tip until reaching skin level, letting you keep the position of the guidewire.</ref> keeping the same direction as the guidewire through the tissues to avoid pulling or kinking it.**'''Enter the renal pelvis ''' with the obturator, and then advance with only the soft catheter.**'''Confirm proper location ''' within the renal pelvis by injection of a few ml of contrast, with two projections from different directions.**'''Fixate the pigtail ''' of the catheter.*'''Confirm functionality ''' by injection of a few ml of contrast, looking for spontaneous dripping from the catheter when left open, as well as aspiration of the contrast.* <br>Check whether there is blood or pus in the aspirate or spontaneous return.*'''Attach the outside ''' end of the catheter to a bag.<ref group=notes>Plug it only if there is a clear plan to attach a bag at a specific later time.</ref>*'''Fixate the catheter to the skin''', preferably both directly at insertion as well as enough to the side to have a soft S-shaped bend of the catheter in order to give certain room for stretching without pulling the catheter.

If a previous pigtail catheter is located in a calyx, '''push it in ''' with a stiff guidewire (such as Amplatz). If this is not directly successful, try:*Push the catheter from different '''angles''', and/or '''rotate'''.**Use the '''stiffer ''' end of the Amplatz wire.*'''Loosen ''' the pigtail.<ref group="notes" name="loosen"/>If this is not successful, possibly use a '''hydrophilic ''' guidewire to reach the renal pelvis, on which to switch catheters.*

*Try a '''hydrophilic ''' or '''smaller guidewire ''' in order to get through the catheter.*Advance '''around ''' the catheter with a larger tube.*If the catheter has been used for weeks, it can generally be pulled out, and a new catheter inserted through the '''same tunnel ''' without any guidewire.

If a previous pigtail catheter can not be pulled out after loosening of the pigtail threads, it may help to '''cut off the pigtail threads ''' by the external tip, or even cutting off the entire external tip, which may loosen the threads.

*'''Position ''' of the previous catheter.*Absence of '''complications''', or a description thereof.*'''Type, size and position ''' of the new catheter.*'''Color of urine'''. Signs of blood or pus, if suspected.