# Intravenous Misplacement of the Nephrostomy Catheter Into the Renal Vein Following Percutaneous Nephrolithotomy (PCNL): A Case Report and Literature Review

## TL;DR

A rare case of a nephrostomy catheter being misplaced into a renal vein after kidney stone surgery is reported and reviewed.

## Contribution

This case report adds to the limited literature on intravenous nephrostomy tube misplacement following PCNL.

## Key findings

- The nephrostomy catheter tip was found in the left renal vein after PCNL in a 63-year-old male.
- Conservative management was successful without the need for surgical intervention.
- Good imaging is critical to assess and manage such rare complications safely.

## Abstract

Background: After percutaneous nephrolithotomy (PCNL), intravenous misplacement of a nephrostomy tube is a very rare clinical occurrence. This report summarizes the characteristics and management of intravenous misplacement of a nephrostomy tube.

Case Presentation: We present a rare case of intravenous nephrostomy catheter misplacement after PCNL in a 63 years old male. The tip of the tube was located in the left renal vein. The patient was managed conservatively and treated safely.

Conclusion: Intravenous nephrostomy tube misplacement is a rare PCNL complication. Good Imaging can rule out through and through renal vein perforation and thus patients can be safely managed using conservative approach.