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BMJ Case Reports 2018; doi:10.1136/bcr-2018-225153
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Inadvertent inflation of Foley catheter balloon with contrast: an error that caused unnecessary apprehensions

  1. Satyanarayan Sankhwar
  1. Department of Urology, King George’s Medical University, Lucknow, Uttar Pradesh, India
  1. Correspondence to Dr Siddharth Pandey, sid1420{at}gmail.com
  • Accepted 4 April 2018
  • Published 11 April 2018

Description 

A 30-year-old male patient underwent percutaneous nephrolithotomy (PCNL) for a 3.5 cm right renal calculus. As per our institutional protocol he underwent a check X-ray the next day. The relatives of the patient immediately came to us asking whether some residual fragments of the calculus were there in the urinary bladder. When we reviewed the X-ray film, there was a radio-opaque shadow with a smooth contour in the region of urinary bladder. On careful examination this shadow was continuous with a radio-opaque line along the Foley catheter (figure 1). We immediately removed the Foley catheter and did another check X-ray. The shadow had disappeared. We then realised that the catheter’s balloon was inflated with contrast solution prepared for fluoroscopy-guided puncture during PCNL. We acknowledged this error to the patient and his relatives and explained them how sorry we were for their anxiety, following which they …

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