蔡長佑、陳柏仲、沈正煌、周詠欽、林昌德、鄭明進

嘉義基督教醫院 外科部 泌尿科

Chang-Yu Tsai, Bo-Jung Chen, Cheng-Huang Shen, Yeong-Chin Jou, Chang-Te Lin, Ming-Chin Cheng

Divisions of Urology, Department of Surgery, Chia-Yi Christian Hospital

 

    Misplacement of nephrostomy catheter into the inferior vena cava (IVC) is a rare complication during percutaneous nephrostomy (PCN) insertion. In this article, we present a case with initial presentation of fever, general weakness and flank pain. Related literatures of misplaced nephrostomy catheter into the surrounding vessels will also be reviewed.

Case presentation: 

    This is a 63-year-old female with diabetes mellitus and liver cirrhosis. The patient presented with fever, right flank pain and general weakness for 1 day. At the emergency department, the urinary analysis showed hematuria and pyuria. Abdominal computed tomography (CT) scan revealed right upper ureteral stone with obstructive uropathy. Urinary diversion and echo-guided right PCN insertion was conducted.

    However, during insertion of the PCN, bloody fluid was observed from the drainage tube. Hence the tube was clamped immediately and the radiologist was consulted. After the second PCN was inserted successfully, abdominal CT was arranged which revealed the previous catheter traversing across the renal parenchymal and pelvis, perforating through the right renal vein and ending with the loop in the IVC.

    After the infection was controlled, the radiologist was consulted again for removal of the PCN tube. Multiple coils and gel-foam were used for occlusion of the perforating site between the right renal vein and the collecting system. The procedure was completed and she was discharged on postoperative day 4.

Discussion: 

    Misplacement of the nephrostomy catheter with the use of ultrasonic guidance during PCN insertion in reported literatures was about 0.1%. This was considered rare due to the high technical success rate of 90-100% in related studies. Risk factors for the above situation include post-PCNL, post-nephrostomy tube exchange, solitary kidney, non-dilated urinary system, hemorrhage in the kidneys, pre-existing chronic infection and insufficient experience of the surgeons. Current treatment strategies encompass the use of balloon tamponade, controlled removal of the tube under general anesthesia, open pyelotomy and exploratory laparotomy. In our case, coil and gel-foam was an effective and minimally invasive procedure which serves as an alternative treatment for the management of PCN catheter misplacement.

    Misplacement of the PCN catheter could occur even with the use of ultrasonic-guidance despite high technical success rate observed in various studies. Transarterial embolization might serve as an additional treatment modality for vessel injuries during PCN insertion.