A 32-year-old woman with a history of nephrolithiasis presented to the emergency department with left costovertebral angle tenderness and fevers to 38.8°C. At presentation, the patient had no dysuria, urgency, or increased frequency of urination. A computed tomography (CT) kidney and urinary bladder (KUB) was ordered that demonstrated a 5-mm ureteropelvic junction stone and mild proximal hydronephrosis. During initial evaluation in the emergency department, the patient had a white blood cell count of 46.1 × 10/L and was tachycardic with a heart rate into the 140s. Her tachycardia initially responded to a 5-L bolus of normal saline. Urinalysis performed in the emergency department demonstrated many bacteria, positive leukocyte esterase, and nitrites. The patient was started on ceftriaxone and levofloxacin in the emergency department and admitted to the intensive care unit prior to urgent percutaneous nephrostomy placement. Given the patient's fevers and tachycardia, anesthesia was consulted to provide hemodynamic support and intubation during the interventional radiology procedure. After placing the patient prone, a posterior calyxwas accessed under direct ultrasound guidance using a 21-gauge ultrasound-scored Chiba needle (Cook Medical, Inc., Bloomington, IN) (►Fig. 1). A small amount of contrast was injected to confirm placement, and following placement of a 0.018-inch wire, an AccuStick transitional dilator was placed (Boston Scientific, Natick, MA). The 0.018-inch wire was exchanged for an Amplatz wire (Cook), the tract was dilated to 8F, and an 8F percutaneous nephrostomy tube was placed. A gentle diagnostic nephrostogram was performed prior to suturing the tube to the skin and placing the bag to gravity drainage. The patient was transferred to the intensive care unit for close monitoring and a diagnosis of urosepsis. In the first 24 hours, the patient had 1875mL of urine output but only 5mL of urine output via the percutaneous nephrostomy tube. The patient was brought back to interventional radiology for a nephrostogram and tube upsizing to 10F to facilitate drainage. Nephrostogram done at that time was suggestive of thrombus within the collecting system (►Fig. 2). In the next 24 hours, urine output through the nephrostomy tube did not increase, and a repeat CT KUB was ordered. Repeat CT KUB demonstrated the nephrostomy tube completely traversing the kidney, with the pigtail ventral to the renal cortex and some of the sidehole within the collecting system. The patient again returned to interventional radiology, and an unsuccessful attempt was made to salvage the original tract. Using ultrasound guidance, the collecting system was accessed, and using standard technique a new tube was placed in the renal pelvis (►Fig. 3). In the 24 hours after replacement, the new nephrostomy tube drained 1475 mL The offending stone and nephrostomy tube were ultimately removed by urology 20 days later.