Although percutaneous nephrolithotomy is generally safe, it has various complications. We present an extremely rare case in which the nephrostomy tube pierced renal parenchyma, proceeded through the right renal vein and inferior vena cava, finally reaching the right atrium. Such a tube misplaced to atrium level was firstly reported, which was safely withdrawn using a 2-step process under fluoroscopic monitoring. We also recommend the tube be marked with different color lines to maintain awareness of the tube length that has passed the peel-away sheath. Such information might help to avoid such complication.

1.
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
. .
2.
Fernström
I
,
Johansson
B
.
Percutaneous pyelolithotomy. A new extraction technique
.
Scand J Urol Nephrol
.
1976
;
10
:
257
9
. .
3.
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
. .
4.
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
.
2013
;
7
:
E505
7
. .
5.
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
.
6.
Skolarikos
A
,
Alivizatos
G
,
Papatsoris
A
,
Constantinides
K
,
Zerbas
A
,
Deliveliotis
C
.
Ultrasound-guided percutaneous nephrostomy performed by urologists: 10-year experience
.
Urology
.
2006
;
68
:
495
9
. .
7.
Li
D
,
Xiao
L
,
Tang
Z
,
Qi
L
,
Luo
K
,
Huang
L
,
Management of intravenous migration of urologic catheter
.
Urology
.
2013
;
82
:
248
52
. .
8.
Mazzucchi
E
,
Mitre
A
,
Brito
A
,
Arap
M
,
Murta
C
,
Srougi
M
.
Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports
.
Clinics
.
2009
;
64
:
69
70
. .
9.
Shaw
G
,
Wah
TM
,
Kellett
MJ
,
Choong
SK
.
Management of renal-vein perforation during a challenging percutaneous nephrolithotomy
.
J Endourol
.
2005
;
19
:
722
3
. .
10.
Dias-Filho
AC
,
Coaracy
GA
,
Borges
W
.
Right atrial migration of nephrostomy catheter
.
Int Braz J Urol
.
2005
;
31
:
470
1
.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.