Abstract
BACKGROUND: Intravenous misplacement of a nephrostomy tube after percutaneous nephrostolithotomy (PCNL) is very rare in clinical experiences. This report summarizes the characteristics and management of intravenous misplacement. CASE PRESENTATION: We present two uncommon cases of intravenous nephrostomy catheter misplacement after PCNL from among 4220 patients who underwent PCNL between January 2009 and December 2015. The tip of the tube was located in the inferior vena cava in one case and in the renal vein in the other. We preferably performed open surgery to treat the two patients, mainly to remove the residual calculi and to prepare for any possible adverse event. All patients were successfully managed and discharged uneventfully. CONCLUSION: Intravenous nephrostomy tube misplacement is an uncommon PCNL complication. Furthermore, the study illustrates the importance of prompt diagnosis of renal vein perforation and its prompt management using open surgery, similar to conservative therapies.