Fig. 5.

A 49-year-old woman with a vesicovaginal fistula requires bilateral diverting nephrostomies. After ultrasound-guided access into a nondilated collecting system is attempted, urine cannot be aspirated, and wire passage is met with resistance. Contrast injection is performed, resulting in subintimal and perinephric extravasation of both contrast and air. Further attempts at access are unsuccessful because the collecting system is obscured under both ultrasound and fluoroscopy, and the procedure is aborted.