CASE REPORT An Unusual Complication of Suprapubic Catheter Migration into the Left Ureter Wang Shuaibin, Mu Haiqi, Feng Qin, Yu Haifeng* Keywords: suprapubic catheter; complication; migration into ureter; pyelonephritis. Suprapubic cystostomy is a widely employed procedure that is used to drain the bladder. Despite being a safe procedure, suprapubic cystostomy has been reported to present multiple intra- and postoperative complications. Serious and unusual complications can occur during changing of the suprapubic catheter (SPC) in patients with neuropathic bladder. In this work, we report an elderly patient with neuropathic bladder suffering from an unusual complication involving migration of the SPC into the ureter during changing of the SPC, leading to ureteric ob- struction and left pyelonephritis. Department of Urology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, People’s Republic of China. *Correspondence: Department of Urology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, People’s Republic of China Tel: +86-577-88002815. Fax: +86-577-88002855. E-mail: 691898478@qq.com. Received June 2017 & Accepted October 2017 INTRODUCTION Suprapubic catheters (SPCs) are commonly used to drain the bladder. Early studies show that suprapubic cysto-stomy is an effective and well-tolerated method for patients with neuropathic bladder. The method can acceler- ate renal deterioration and prevent urinary tract complications, including stones, recurrent infections, and blocked catheters(1). Although suprapubic cystostomy is a safe procedure in most cases, unusual complications may occur either immediately after suprapubic cystostomy or several years after the procedure(2,3). Herein, we report an elder- ly male patient with senile dementia who suffered from an unusual complication of SPC migration into the ureter during SPC change. Suprapubic cystostomy was performed on the patient 3 years prior to this report. CASE REPORT An 80-year-old Chinese man with neurogenic bladder and benign prostatic hyperplasia was referred to the Urolo- gy Department of our hospital in October 2015. His past history included experiencing a stroke ten years prior to reporting and suffering from senile dementia. Thus, the patient exhibited difficulty in communicating with others and expressing his feelings. Preoperative ultrasound scan showed an enlarged prostate (50 mm × 39 mm × 37 mm in size). Urodynamics performed on 21 October 2015 showed weak contractility of the detrusor and moderate ob- struction of the bladder neck. The patient was treated through TURP (transurethral prostate resection) Figure 1. Computed tomography,performed on 14 May 2017, (A left picture)The dilated ureter and the tip of Foley catheter was located in ureter(white arrow) .(B right picture)The balloon of Foley catheter had been inflated in distal end of dilated ureter(white arrow). Case Report 62 Vol 15 No 03 May-June 2018 63 and suprapubic cystostomy. During the first month after operation, the patient continued to experience serious urinary incontinence. His SPC was changed every four weeks in the urology unit after surgery. Twelve days after a catheter change in May 2017, which was une- ventful, his family noticed that the drainage catheter showed hematuria and pyuria per urethra. Moreover, the patient experienced incontinence and fever (tym- panic temperature, 38.2 °C). He was brought directly to our Accident and Emergency Department, where laboratory investigations showed an elevated peripheral white blood cell (WBC) count of 25.4 × 109/L (normal range: 4–10 × 109/L), neutrophil ratio of 96%, and el- evated C-reactive protein of 186 mg/L (normal range: 0–8 mg/L). Serum creatinine and blood urea nitrogen were 104 µmol/L (normal range: 50–133 µmol/L) and 8.38 mmol/L (normal range: 2.9–8.2 mmol/L), respec- tively. The patient developed an increasing degree of left renal pain. Computed tomography and ultrasound examination of the abdomen and pelvis revealed that the SPC tube had migrated into the ureteral orifice and ureter. The tip of the Foley catheter was lying about 4cm from the ureterovesical junction (Figure 1). More significantly, hydronephrosis of the left kidney without hydroureter was found. Given the findings on the CT scan and the patient’s symptoms, diagnostic imaging demonstrated ureter obstruction and left pyelonephritis. The SPC (18 French) was changed under ultrasonogra- phy guidance, and the patient was prescribed 2 g of cef- triaxone administered intravenously every day for five days. Hematuria and pyuria subsided after 72 h. The pa- tient was discharged in a stable condition after a week. DISCUSSION Suprapubic cystostomy catheter drainage is considered a valid and useful adjunct in various scenarios. Most commonly applied in urology practice, this drainage is vital in patients with long-term catheters (because of various causes) and many postoperative situations(4). A meta-analysis comparing SPC tubes with transurethral catheter drainage revealed that the suprapubic route is more acceptable to patients and reduces microbiologi- cal complications(5). Our patient used SPC instead of urethral catheterization after transurethral resection of the prostate and did not develop any problems in the following 30 months. Although suprapubic cystostomy is a well-established procedure, complications do occur. Multiple common complications, such as bacteriuria, bleeding, and blad- der calculi, have been reported(6,7). However, several rare and unusual complications of suprapubic cysto- stomy have also been reported. These complications include bowel perforation, expulsion through bladder, entero-cutaneous fistula, knotting of the catheter, and catheter migration in a gaping ureter. Vaidyanathan et al.(8) reported a serious complication during suprapu- bic cystostomy change in a spina bifida patient; in this case, inadvertent positioning of the SPC in the urethra led to urine drainage failure of the SPC. The patient de- veloped an increasing degree of pain, swelling in the suprapubic region, and hematuria. Hourglass deformity of urinary bladder is another unusual late complication of suprapubic cystostomy reported in patients with neu- ropathic bladder. Singh and colleagues reported a case of left pyelonephritis secondary to catheter insertion for traumatic urethral stricture in a young male in 2001(9). Cystographic evaluation revealed the contrast entering the left ureter with bilateral hydronephrosis. The author hypothesized the possibility of catheter migration into a gaping ureter with bilateral hydronephrosis. In 2010, Dangle and colleagues(10) reported another case of SPC migration into the left ureteral orifice that led to ureter obstruction and hydronephrosis. The patient who pos- sessed a solitary kidney with neurogenic bladder and voiding dysfunction was managed with SPC drainage. These reports suggest that, for patients with a solitary kidney, diagnosis of such a condition is crucial to pro- vide immediate relief to the obstructed kidney. In the present paper, we report an elderly male patient with senile dementia whose SPC had migrated into a previously normal non-gaping ureter. Given the com- munication barrier, the drainage color and volume changes per urethra were not discovered in time by his family, leading to serious complications of ureter- ic obstruction, left pyelonephritis, and a slight degree of renal damage. By reviewing this case report, we can postulate that the presence of bladder dysfunction in elderly patients combines detrussor overactivity and a patulous ureteral orifice, leading to migration of the catheter tip into the ureteral orifice and ureter. Ureter obstruction could lead to unilateral upper urinary hy- droceles and pyelonephritis, whereas normal ureters may cause bladder incontinence. Diagnosing such a condition is crucial to immediately rectify the incorrect placement of the SPC and relieve the obstructed kidney; prescription of antibacterial agents may help promote healing. We suggest that the SPC be anchored securely to reduce the occurrence of migration of the catheter tip into the ureter and accidental dislodgment of the cathe- ter. In case of difficulty, ultrasound guidance should be employed when performing catheter exchange. CONCLUSIONS SPC migration into ureter is a poorly reported com- plication that must be reported. Health professionals should be vigilant when inserting a catheter through the suprapubic track. A learning point from this case is as follows: Suprapubic catheters should be anchored se- curely to reduce the occurrence of the migration of the catheter into ureter and accidental catheter dislodgment. CONFLICT OF INTEREST None declared. REFERENCES 1. Vaidyanathan Subramanian, Soni Bakul, Hughes Peter, et al. Preventable long-term complications of suprapubic cystostomy after spinal cord injury: Root cause analysis in a representative case report. Patient Saf Surg. 2011;5:27. 2. Szolnoki J M, Puskas F, Sweeney D M, et al. 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