Management of a nephrostomy tube misplacement into the inferior vena cava following PCNL

Abstract

A 50-year-old female with left flank pain and 3.1 cm renal calculi underwent PCNL. Intraoperatively, an anatomical variant led to accidental insertion of a nephrostomy tube into the inferior vena cava (IVC), while a second tube was correctly placed. Postoperative edema prompted CT imaging revealing the malposition. The misplaced tube was incrementally withdrawn under CT guidance over days to prevent bleeding complications, then repositioned successfully. Three-month follow-up confirmed resolution of hydronephrosis, absence of strictures or bleeding, and complete wound healing. This case underscores the necessity of intraoperative anatomical vigilance and staged management of iatrogenic vascular injuries during PCNL.

1 Introduction

Percutaneous nephrolithotomy (PCNL) provides a percutaneous access route to the kidney, enabling endoscopic removal of upper urinary tract calculi. Compared to open surgery, PCNL offers higher stone clearance rates, less trauma, and faster recovery, making it a common clinical approach for managing complex renal calculi and large upper urinary tract stones. Despite its high efficacy in stone clearance, PCNL is associated with potential postoperative complications, including bleeding and infection. ^, Vascular injury following PCNL, particularly involving the inferior vena cava (IVC), is extremely rare, with only a few cases reported in the literature. These injuries may lead to prolonged hospitalization and carry potential life-threatening risks, as documented in case reports. We describe a case in which a nephrostomy tube (8-Fr pigtail catheter) inadvertently migrated into the IVC after percutaneous renal access. The tube was retrieved through a stepwise withdrawal protocol implemented in our center.

2 Case presentation

A 50-year-old woman presented with left flank pain persisting for two months. Two months prior, she experienced unexplained left flank pain accompanied by urinary frequency, urgency, and dysuria, but without gross hematuria. On physical examination, tenderness upon percussion in the left renal region was noted. Non-contrast CT urography demonstrated left renal pelvis stones (largest 3.1 × 2.2 cm) with associated hydronephrosis and duplicated left renal vein anatomy. Significant hydronephrosis of the left kidney and dilation of the left renal pelvis and calyces were observed, along with anatomical variation of the left renal vein, showing two distinct renal veins ( Fig. 1 A–D). Urinalysis revealed a marked increase in leukocytes, indicating a urinary tract infection. Additionally, urine culture identified Staphylococcus equorum, a multidrug-resistant organism. After one week of anti-infective therapy, the patient’s urinalysis and urine culture returned negative. Following preoperative evaluation and exclusion of surgical contraindications, the patient underwent left PCNL, transurethral ureteroscopic lithotripsy, and percutaneous nephroscopic ureteral stent placement under general anesthesia.

Under ultrasound guidance, a puncture needle was used to access the left renal middle calyx through the renal pelvis at the intercostal space between the posterior axillary line and the subscapular line below the 12th rib. Clear renal pelvis fluid was observed upon removal of the needle core, confirming successful puncture. A guidewire was inserted, and an incision measuring 1 cm was made at the puncture site. The tract was dilated using serial Amplatz dilators (8–18F) under fluoroscopic guidance, with an 18F access sheath placement. Fresh blood was observed in the sheath. Nephroscopy revealed active venous bleeding from a rent in the renal pelvic wall. A guidewire was inserted, and a 16F nephrostomy tube was placed and clamped. A second puncture was made at the lower pole of the left kidney to establish another access point successfully. After establishing the second tract, a nephroscope was inserted into the renal calyx through the sheath. Multiple yellow-brown stones were observed in the left kidney. Holmium laser lithotripsy was used to fragment the stones, which were then aspirated. Larger fragments were removed with a stone basket. After clearing the visible stones, renal mucosa appeared edematous, and the calyces were disorganized with narrowed calyceal openings. Several fragments had migrated into the ureter. The ureteral stent was removed, and additional small ureteral stones were retrieved using a ureteroscope via the urethra. Some fragments retrograded into the renal pelvis and were removed through the nephroscope channel. Intraoperative blood loss was approximately 150 mL.

On postoperative day two, the patient developed abdominal distension, poor appetite, and generalized edema, with prominent facial and bilateral lower limb swelling. Non-contrast CT of the abdomen revealed that the tip of the first nephrostomy tube was close to the IVC, while the second nephrostomy tube was correctly positioned in the left renal pelvis ( Fig. 2 A–B). Immediate subcutaneous injection of low-molecular-weight heparin was administered to prevent thrombus formation. An attempt to withdraw the first nephrostomy tube was made, but fresh bleeding was observed during the process, necessitating its repositioning. Enhanced CT confirmed that the first nephrostomy tube had penetrated a branch of the left renal vein, extended into the main renal vein, and reached the IVC ( Fig. 2 C–F). Initial CT-guided retraction protocol involved 4 cm tube withdrawal with immediate clamping, followed by contrast-enhanced imaging to confirm positioning ( Fig. 3 A–B). After one week, the first nephrostomy tube was withdrawn an additional 3 cm under CT guidance, and follow-up imaging confirmed its tip was located in the left renal pelvis ( Fig. 3 C–D). On postoperative day nine, the tube was withdrawn to the perirenal region. The tube was unclamped, and no active bleeding was observed. On postoperative day 10, the first nephrostomy tube was removed without complications. On postoperative day 11, the second nephrostomy tube was removed, and the patient was discharged uneventfully. Three-month follow-up with CT urography and renal function testing confirmed complete resolution without stricture, hydronephrosis, or delayed vascular complications.