Accidental Insertion of a Peritoneal Dialysis Catheter in the Urinary Bladder

Percutaneous insertion of a peritoneal dialysis (PD) catheter has inherent risks of complications, more so if done "blind" (without fluoroscopy and ultrasound guidance). Despite the perceived disadvantages, there are very few reported cases of mechanical complications after PD catheter insertion. We present an 81-year-old man who underwent percutaneous insertion of dual-cuffed coiled Tenckhoff PD catheter under local anesthesia by a trained nephrologist. The procedure was uneventful, and the patient was discharged 45 min later in a stable state. A day later, he noticed a decline in the urine output. A week later at a scheduled clinic visit, upon unclamping the PD catheter, there was a sudden gush of amber colored fluid. A diagnostic CT scan confirmed the presence of PD catheter entering the abdominal cavity inferior to the umbilicus and the distal end coiled in the urinary bladder. This case illustrates the need for prophylactic Foley catheterization in individuals at high risk for a distended bladder either as a consequence of a mechanical obstruction from an enlarged prostate or due to a neurogenic bladder while undergoing "blind" percutaneous placement.