Misplacement of Nephrostomy Catheter into Inferior Vena Cava during Percutaneous Nephrostomy Procedure: A Case Report

نویسندگان

1 Department of Urology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

2 Clinical Research Development Unit, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

3 Department of Urology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

4 Clinical Research Development Unit, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

doi
10.22034/tru.2025.511487.1236
چکیده

Introduction: Inadvertent placement of a nephrostomy tube in the inferior vena cava (IVC) is a very rare complication that can occur in patients with hydronephrosis who are candidates for nephrostomy placement.Case presentation: In this study, we present a 73-year-old male patient with a history of left renal agenesis and a history of pyelolithotomy and PCNL of the right kidney for moderate hydronephrosis and fever, who was a candidate for right renal nephrostomy due to increased creatinine. In this report, we show that without open surgery, by correcting the nephrostomy site and pulling it out by 6 cm under the control of a C-arm device, a new nephrostomy site was observed.Conclusion: Our recommendation in this study: Accurate measurement of the depth of penetration of the Sheba needle into the dilator and nephrostomy should be performed at the nephrostomy coil position. Also, nephrostomy placement should be performed by experienced urologists and the nephrostomy site should be checked by C-arm at the end of the procedure, and the advancement of the nephrostomy metal pin without accurate measurement should be prevented.

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