Inadvertent ureteric placement and successful readjustment of a urodynamic catheter via fluoroscopy in a spinal injury patient

Summary

We describe a case of accidental intra-ureteric catheter placement in a spinal cord injury patient which was promptly recognized radiologically and describe a simple method of repositioning via fluoroscopy allowing the study to continue to completion.

Case

A 26-year-old female with a background of polytrauma following a road traffic accident presented for a baseline video-urodynamic assessment 9 months after her injury. Her neurology was remarkable for a T10 ASIA A functioning level following a L2 chance fracture with subsequent posterior stabilisation of T12 to L4. Her current bladder management included a self-intermittent catheterization regime with no adjuvant medication. She was catheterized in the supine position with a 6Fr dual lumen catheter. On attempting to calibrate the trace, it was noticed that the resting detrusor pressure, prior to commencing filling, was too high and could not zeroed. Under fluoroscopic control 5 ml of contrast was injected and the urodynamic catheter was found to be in the distal right ureter (Figures 1a and b). The catheter was adjusted at the external meatus, which appeared normal, and positioned in the bladder correctly, under X-ray control (Figure 1c). Successful intravesical placement was verified using contrast and the investigation was completed uneventfully. No vesicoureteric reflux was detected during the investigation.

Figures 1a–c.

Demonstrating a ureteric catheter in the right distal ureter and successful readjustment under fluoroscopic guidance following contrast injection. Previous spinal stabilisation is also noted.

Discussion

Video-urodynamics are commonly performed in spinal cord injury patients to assess resting bladder pressures, incontinence, detrusor sphincter dyssynergia and to detect reflux. Additional important, functional information can be elicited regarding the bladder neck anatomy prior to sphincter insertion and baseline function can be assessed prior to intravesical Botulinum therapy.

In the neuropathic patient, regular urodynamic practice is required in order to survey upper tract integrity and continence [Nosseir et al. 2007] and video-urodynamic evaluation can detect important radiological and morphological changes in the urinary tract [Wöllner and Pannek, 2015]. The procedure is usually well tolerated although infection remains a recognized complication [Yip et al. 2004] as well as transient haematuria and bladder wall oedema. Twisting of a double lumen catheter during urodynamic investigation has been reported [Ayyildiz et al. 2006]. Rupture of an augmented bladder has also been reported following urodynamic investigation in two neuropathic patients [Blok et al. 2007]. Ordonez and colleagues in 1998, reported two suspected cases of intraureteric placement of urodynamic catheters in nonspinal patients but could not confirm radiological insertion in the ureter [Ordonez et al. 1998]. Agarwal and Sandhu in 2011, described a case of inadvertent placement in a post-prostatectomy patient that eventually required catheter insertion under cystoscopic guidance to allow urodynamic evaluation to proceed [Agarwal and Sandhu, 2011].

In the neurologically-intact patient a sudden rise in vesical pressure and onset of flank pain may suggest an intraureteric catheter placement during urodynamics. In the spinal cord injured patient, altered anatomy, intravesical pathology and lack of sensation may pose difficulties for catheter insertion. Prior to commencing a urodynamic evaluation, if difficulties persist with calibration, contrast should be injected into the catheter to verify its position and if found to be in the ureter, continuous fluoroscopy should be used to reposition it. Finally, as described here, additional contrast should be injected to verify correct intravesical placement prior to starting filling. Specific to spinal urology, simple diagnostic techniques have been modified to permit safer use of catheters in neuropaths and we believe this to be an additional useful one when performing urodynamics to prevent ureteric trauma.