P2A217: Ureteral Placement of Indwelling Catheter in Patient with Abdominal Pseudocyst

Introduction: We present the case of a 10-year-old girl who was admitted with an abdominal pseudocyst and ascites who developed a Foley catheter complication due to malposition in the right ureter.

Case Description: 10 yr old female with ventricular-peritoneal shunt (VPS) presented with shunt infection, pseudocyst and ascites. Shunt was externalized and patient treated with antibiotics. 10Fr foley was replaced with 14 Fr for leakage with onset of hematuria and worsening abdominal pain. Hematuria cleared but pain continued leading suspicion of raised intra-abdominal pressure (IAP) and compartment syndrome (ACS). IAPs were elevated at 38-40 cmH2o which didn't improve with further drainage of abdominal ascites. Abdominal CT revealed a mispositioned Foley catheter in the proximal right ureter near the renal pelvis with an inflated balloon.
The urology team retracted the foley after successful deflation of balloon under fluoroscopy to the bladder for the remainder of her stay in the PICU. A peritoneal fluid sample was sent for creatine level for extravasation of urine into the abdominal cavity (resulting creatinine level of 0.7). An improvement in the patient’s abdominal discomfort was noted, while abdominal distention secondary to ascites gradually resolved. Repeat CT of the abdomen was obtained after a week, which demonstrated bilateral hydroureteronephrosis (Right>Left); however, no contrast extravasation was evident. Oxybutynin was continued upon discharge.

Discussion: The size of the Foley catheter should be determined based on the patient's age, weight, sex, and catheterization purpose. Calculating the appropriate Foley catheter size for pediatric patients is challenging. Choosing a catheter that is too small can lead to leakage and inadequate drainage, whereas a catheter that is too large can cause discomfort, trauma, and even injury. While the weight- and French-based guidelines are cumbersome for clinical practice and require tools such as ultrasound, the age-based guidelines are easy to implement and take into consideration the length of insertion as well as the size of the catheter.
In this case, the Foley catheter was advanced beyond the required length for the female urethra. Underlying abdominal ascites, may have changed the ureteral angle of insertion into the bladder further facilitating migration into the right ureter. Timely identification of the mispositioned catheter prevented further injury to the ureter and steered clinical decision-making away from ACS towards appropriate therapy.

Conclusion: In clinical practice, a tug on the catheter after inflating the balloon confirms its appropriate positioning in the bladder. In a patient with abdominal pathology such as ascites, confirmation of optimal Foley positioning with abdominal radiography and/or ultrasonography should be routine practice for patient safety.