Nephrostomy catheter entering the right renal vein during an exchange procedure: A case report and literature review

INTRODUCTION: We encountered an extremely rare case of a nephrostomy catheter entering the right renal vein during an exchange procedure. CASE PRESENTATION: An 80‐year‐old man underwent radical cystectomy. Urinary diversion was achieved through right percutaneous nephrostomy. After the 15(th) nephrostomy catheter exchange, the patient bled heavily from the catheter. We clamped the catheter immediately, and the patient became hemodynamically stable. Emergency angiography showed the nephrostomy catheter entering the renal vein from outside the renal pelvis. Under fluoroscopy, we pulled the catheter until its tip was located in the previous penetration site of the renal pelvic wall and inserted the catheter over the guidewire into the renal pelvis. CONCLUSIONS: Herein, we report an extremely rare case of a nephrostomy catheter inserted into the right renal vein during an exchange procedure. Inserting a nephrostomy catheter in the appropriate position and performing exchange under imaging guidance techniques could help clinicians avoid severe complications.