A traumatic ureteral catheterization

CASE REPORT

Giordano Polisini, Matteo Mantovan, Leonard Perpepaj, Andrea Benedetto Galosi.

Division of Urology, Azienda Ospedaliero-Universitaria delle Marche, Faculty of Medicine, School of Urology, Department of Clinical, Special and Dental Sciences, Università Politecnica delle Marche, Ancona, Italy.

SUMMARY Urethral catheterization is commonly a safe and simple procedure. Urinary tract infection, bleeding or genitourinary trauma are common complications (1, 2). The risk of complication is increased in patients with an indwelling catheter and in patients who perform daily intermittent catheterization (2). Accidental ureter catheterization is an exceptional complication, only reported in about ten cases in the literature. We report a case of left ureter catheterization associated with ureteral rupture.

KEY WORDS: Case report, ureteral catheterization, traumatic catheterization.

CASE REPORT

A 77 years old woman was referred to the Emergency Department for haematuria, anemization, and acute renal failure. She was institutionalized in a nursing home. She suffered from fronto-temporal dementia with severe cognitive-motor impairment, epilepsy, type II diabetes mellitus, major depression, gallbladder stones, SARS COV2 pneumonia in January 2021 complicated by pulmonary embolism, severe dysphagia requiring PEG placement, chronic immobilization syndrome with indwelling catheter, and history of urinary tract infection. She had no history of urological surgery. At physical examination, the patient was on acute urinary retention despite the presence of a bladder catheter in situ. She had a CT scan which showed a voluminous fecaloma, that displaced the bladder, the bladder catheter was placed in the pelvic tract of the left ureter with suspicion of ureteral rupture and bilateral hydronephrosis (Figure 1). For that reason, the catheter was removed and replaced in the bladder with spill of 500 mL of clear urine. A left percutaneous nephrostomy was placed and anterograde and retrograde pyelography showed

Figure 1. A-C coronal section and D-F sagittal section. The CT scan shows a voluminous fecaloma and a catheter with inflated balloon placed in the pelvic tract of the left ureter (red circle).

extravasation of the contrast medium in the middle part of the left ureter. The catheter was in the bladder but with its tip in the ureter (Figure 2). So, under fluoroscopic guidance, the bladder catheter was repositioned correctly. Unfortunately, the patient died a few days later from cardiac failure. specific risk factors for accidental ureteral catheterization (1, 2). If ureteral catheterization is suspected, the diagnosis can be made with CT (spherical hypodense structure filled with water attenuation in the ureter with or without hydronephrosis) or ultrasound (a spherical hypo-anechoic Foley balloon may be seen in the abdomen with or without hydronephrosis) (4). When ureteral catheterization is confirmed, deflation of the catheter balloon and manual removal or replacement of the catheter should be attempted (2, 4). If a ureteral injury is present, management requires anterograde or retrograde stent placement, percutaneous nephrostomy (in case of abscess formation, urinary tract infection, or urinary fistula formation), or surgery (depending on the type of injury and the comorbidities of the patient) (4). In our case, the patient had an indwelling catheter, she had not performed urological surgery previously and the ureteral orifice was in its natural location. At first, we repositioned the catheter in the bladder. At final, due to ureteral rupture with the presence of urinoma, we also decided to place a percutaneous nephrostomy for urine drainage. Although there is not univocal consensus for the execution of the procedure correctly, to prevent the risk of injuries always it is advisable to check urine return before inflation of the catheter balloon, verify if the length of the catheter outside of the urethra is suitable and readapt the balloon position if sudden pain occurred.

Figure 2. Retrograde pyelography shows extravasation (S) of the contrast medium from the left ureter (U). B: bladder.

DISCUSSION

Urethral catheterization is a safe and simple procedure but not exempt from complications. The most frequent complications procedure-related are early balloon inflation in the urethra, inability to place the catheter into the bladder (5), urinary tract infections, bleeding, and genitourinary trauma. Bladder perforation, peritonitis, and recto-vesical fistula are rare but have been reported in the literature (13, 6). The risk of complication is increased in patients with an indwelling catheter and in patients who perform daily intermittent catheterization (2). Accidental ureteral catheterization is a rare complication, only reported in about ten cases in the literature. Neurogenic bladder dysfunction, empty bladder, and history of re-implantation of the ureter into the bladder are REFERENCES

1. Oehler E, Le Guern A. An unusual complication of urethral catheterization: hydronephrosis with pyelonephritis after ureteral catheterization. J Visc Surg. 2015; 152(2):141-2. 2. Anderson BW, Greenlund AC. Ureteral cannulation as a complication of urethral catheterization. Korean J Urol. 2014; 55(11):768-71. 3. Kim MK, Park K. Unusual complication of urethral catheterization: a case report. J Korean Med Sci. 2008; 23(1):161-2. 4. Baker KS, Dane B, Edelstein Y, et al. Ureteral rupture from aberrant Foley catheter placement: a case report. J Radiol Case Rep. 2013; 7(1):33-40. 5. Hale N, Baugh D, Womack G. Mid-ureteral rupture: a rare complication of urethral catheterization. Urology. 2012; 80(5):e65-6. 6. Ishikawa T, Araki M, Hirata T, et al. A rare complication: misdirection of an indwelling urethral catheter into the ureter. Acta Med Okayama. 2014; 68(1):47-51.

CORRESPONDENCE

Giordano Polisini Division of Urology, Azienda Ospedaliero-Universitaria delle Marche, Faculty of Medicine, School of Urology, Department of Clinical, Special and Dental Sciences, Università Politecnica delle Marche, Ancona, Italy E-mail: gio.pol.93@gmail.com