Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: a case report and literature review

Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy (PCNL) is extremely rare, and little information is available about this complication. Because the patient's prognosis may be poor, sufficient attention should be paid to early identification and treatment of this complication. We present an uncommon case of a patient with intravenous nephrostomy catheter misplacement after PCNL at our hospital. In our patient, the tip of the nephrostomy catheter was located in the inferior vena cava. It was successfully managed using two-step catheter withdrawal under fluoroscopy, and the percutaneous nephrostomy catheter was able to be withdrawn 7 to 8 cm back into the collecting system in stages with the surgical team on standby. There were no severe complications such as deep vein thrombosis that developed during or after the catheter withdrawal. Patients could be managed conservatively using intravenous antibiotics, strict bed rest, and tube withdrawal using computed tomography (CT) or fluoroscopy guide in most cases combined with information in the literature. Additionally, open surgery could be used as an alternative treatment.