BMJ Case Reports 2018; doi:10.1136/bcr-2017-221713
  • Learning from errors

Intracaval misplacement of a double-J ureteral stent

  1. Arnaldo Figueiredo1,2
  1. 1Serviço de Urologia e Transplantação Renal, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
  2. 2Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
  1. Correspondence to Dr Vera Marques, vm.veramarques{at}
  • Accepted 20 January 2018
  • Published 8 February 2018


Double-J ureteral stent (DJUS) is an important therapeutic tool in endourology. There are well-known frequent complications associated with DJUS placement such as distal and proximal migration within the urinary tract. However, perforation and stent misplacement are uncommon but serious complications of this technique. We present a case of a 63-year-old man who had a misplacement of a DJUS into the inferior vena cava during an elective procedure of ureteral catheterisation. The stent placement was performed under fluoroscopic control and it seemed well positioned. Actually, the DJUS was misplaced in the inferior vena cava after drilling at the level of the crossing of the ureter with the ipsilateral iliac vessels. Diagnosis was incidentally made 3 months after the placement of the stent in a renal CT scan. The patient was always asymptomatic. We performed an endoscopic removal of the ureteral stent, which took place without complications.


  • Contributors Conception or design of the work: VM, BP, FR. Data collection: VM, BP. Data analysis and interpretation: VM, BP. Drafting the article: VM, BP, AF. Critical revision of the article: VM, BP, FR, AF. Final approval of the version to be published: VM, BP, FR, AF.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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