Inadvertent insertion of nephrostomy tube into the renal vein following percutaneous nephrolithotomy: A case report and literature review

doi:10.1016/j.ajur.2018.06.003

Asian Journal of Urology, 2020, 7 (1): 64-67 doi: 10.1016/j.ajur.2018.06.003

Case Reports

Inadvertent insertion of nephrostomy tube into the renal vein following percutaneous nephrolithotomy: A case report and literature review

Guangju Ge^a,Zhenghui Wang^a,Mingchao Wang^a,Gonghui Li^a,*(

),Zuhao Xu^a,Yukun Wang^a,Shawpong Wan^b

^a Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
^b Department of Urology, First People's Hospital of Xiaoshan, Hangzhou, China

Abstract
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Abstract

Percutaneous nephrolithotomy (PCNL) is an effective and well accepted procedure for the treatment of large and complex renal calculi. We encountered a patient with a misplaced percutaneous nephrostomy drainage tube (PNDT) into the contralateral renal vein resulting thrombus formation after undergoing right side PCNL. We placed a temporary filter to prevent embolism and started anti-coagulation therapy immediately and finally the PNDT was removed without bleeding.

Key words： Complication Inferior vena cava Percutaneous nephrolithotomy Embolization Renal calculus

Received: 04 March 2018 Available online: 21 June 2018

Corresponding Authors: Gonghui Li E-mail: 3193119@zju.edu.cn

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	Guangju Ge
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	Gonghui Li
	Zuhao Xu
	Yukun Wang
	Shawpong Wan

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Cite this article:

Guangju Ge,Zhenghui Wang,Mingchao Wang, et al. Inadvertent insertion of nephrostomy tube into the renal vein following percutaneous nephrolithotomy: A case report and literature review[J]. Asian Journal of Urology, 2020, 7(1): 64-67.

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http://www.ajurology.com/EN/10.1016/j.ajur.2018.06.003 OR http://www.ajurology.com/EN/Y2020/V7/I1/64

Computed tomography showing that the nephrostomy tube pierced through the right renal parenchyma and traversed across the right renal vein and the inferior vena cava, and ended in the left renal vein.

Contrast enhanced T1-weighted coronal imaging showing the end of the nephrostomy tube (blue arrow) and a thrombus (red arrow) in the inferior vena cava.

In inferior vena cava venography revealing that the temporary filter was implanted above the tube.

Computed tomography confirming the nephrostomy tube was in the renal pelvis.

Reports of intravenous misplacement of a nephrostomy tube.

[1]	Fernstr?m I, Johansson B . Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol 1976; 10:257-9.
[2]	Mazzucchi E, Mitre A, Brito A, Arap M, Murta C, Srougi M . Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports. Clin Sao Paulo Braz 2009; 64:69-70.
[3]	Dias-Filho AC, Coaracy GAV, Borges W . Right atrial migration of nephrostomy catheter. Int Braz J Urol Off J Braz Soc Urol 2005; 31:470-1.
[4]	Shaw G, Wah TM, Kellett MJ, Choong SKS . Management of renal-vein perforation during a challenging percutaneous nephrolithotomy. J Endourol 2005; 19:722-3.
	Shaw G, Wah TM, Kellett MJ, Choong SKS . Management of renal-vein perforation during a challenging percutaneous nephrolithotomy. J Endourol 2005; 19:722-3.
[5]	Mallmann CV, Wolf K-J, Wacker FK . Retrieval of vascular foreign bodies using a self-made wire snare. Acta Radiol Stockh Swed 1987; 2008:1124-8.
	Mallmann CV, Wolf K-J, Wacker FK . Retrieval of vascular foreign bodies using a self-made wire snare. Acta Radiol Stockh Swed 1987; 2008:1124-8.
[6]	Koseoglu K, Parildar M, Oran I, Memis A . Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004; 49:281-5.
	Koseoglu K, Parildar M, Oran I, Memis A . Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004; 49:281-5.
[7]	Winfield HN, Weyman P, Clayman RV . Percutaneous nephrostolithotomy: complications of premature nephrostomy tube removal. J Urol 1986; 136:77-9.
	Winfield HN, Weyman P, Clayman RV . Percutaneous nephrostolithotomy: complications of premature nephrostomy tube removal. J Urol 1986; 136:77-9.
[8]	Chen XF, Chen SQ, Xu LY, Gong Y, Chen ZF, Zheng SB . Intravenous misplacement of nephrostomy tube following percutaneous nephrolithotomy: three new cases and review of seven cases in the literature. Int Braz J Urol 2014; 40:690-6.
	Chen XF, Chen SQ, Xu LY, Gong Y, Chen ZF, Zheng SB . Intravenous misplacement of nephrostomy tube following percutaneous nephrolithotomy: three new cases and review of seven cases in the literature. Int Braz J Urol 2014; 40:690-6.
[9]	Kotb AF, Elabbady A, Mohamed KR, Atta MA . Percutaneous silicon catheter insertion into the inferior vena cava, following percutaneous nephrostomy exchange. Can Urol Assoc J J Assoc Urol Can 2013;7:E505-7. https://doi.org/10.5489/cuaj.1403.
	Kotb AF, Elabbady A, Mohamed KR, Atta MA . Percutaneous silicon catheter insertion into the inferior vena cava, following percutaneous nephrostomy exchange. Can Urol Assoc J J Assoc Urol Can 2013;7:E505-7. https://doi.org/10.5489/cuaj.1403.
[10]	Tarhan H, Akarken I, Cakmak O, Can E, Ilbey YO, Zorlu F . Misplaced nephrostomy catheter in left renal vein: a case report of an uncommon complication following percutaneous nephrolithotomy. Urol J 2014; 11:1714-6.
	Tarhan H, Akarken I, Cakmak O, Can E, Ilbey YO, Zorlu F . Misplaced nephrostomy catheter in left renal vein: a case report of an uncommon complication following percutaneous nephrolithotomy. Urol J 2014; 11:1714-6.
[11]	Li D, Xiao L, Tang Z, Qi L, Luo K, Huang Ll . Management of intravenous migration of urologic catheter. Urology 2013; 82:248-52.
	Li D, Xiao L, Tang Z, Qi L, Luo K, Huang Ll . Management of intravenous migration of urologic catheter. Urology 2013; 82:248-52.
[12]	Wang C, Chen S, Tang F, Shen B . Metachronous renal vein and artery injure after percutaneous nephrostolithotomy. BMC Urol 2013; 13:69.
	Wang C, Chen S, Tang F, Shen B . Metachronous renal vein and artery injure after percutaneous nephrostolithotomy. BMC Urol 2013; 13:69.
[13]	Fu W, Yang Z, Xie Z, Yan H . Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports and literature review. BMC Urol 2017; 17:43.
	Fu W, Yang Z, Xie Z, Yan H . Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports and literature review. BMC Urol 2017; 17:43.