Intravenous misplacement of the nephrostomy catheter following percutaneous nephrolithotomy: A case report and review of 26 cases in the literature.

Intravenous misplacement of the nephrostomy catheter following percutaneous nephrolithotomy (PCNL) is severe and 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 report a case with intravenous misplacement of nephrostomy catheter and severe bleeding from the catheter after PCNL was transferred to our hospital. The patient was successfully managed using a two-step intervention. First, the patient underwent embolization of the pseudoaneurysms in renal parenchyma, then underwent catheter withdrawal under digital subtraction angiography (DSA) and control bleeding by pushing the absorbable hemostatic material (Surgicel) into the tunneled renal drainage. There were no severe complications. Withdrawal could be performed by open surgery or under the supervision of imaging modalities. Some reports showed that minimally invasive management was safer and less invasive than open surgery.