Management of iatrogenic urinothorax following ultrasound guided percutaneous nephrostomy

A Rare Case of Urinothorax as a Result of Penetrating Trauma

Urinothorax, defined as urine within the pleural space, is an uncommon finding in published trauma literature. To date, there are less than ten recorded cases of non-iatrogenic trauma-induced urinothorax, most resulting from blunt traumatic injuries from motor vehicle collisions. Given the rarity of the condition, the diagnosis is often missed or delayed. Once the diagnosis is suspected, the most reliable finding is a pleural fluid to serum creatinine ratio of >1. A confirmed diagnosis of urinothorax then requires drainage of pleural fluid and management of distal ureteral obstruction. Unfortunately, the added complexity of the poly-trauma patient obscures this difficult diagnosis often leading to a delay in treatment and prolonged hospital stay. No current published literature exists on penetrating trauma as a cause of urinothorax. Here, we describe a unique case of urinothorax in a 32-year-old male as a result of penetrating trauma.

Intrathoracic ureteric stent migration through a reno-pleural fistula: a case report of rare antegrade ureteric stenting complication

BACKGROUND

Malignant obstruction and associated hydronephrosis is a common complication of advanced cervical cancer. Percutaneous nephrostomy (PCN) followed by antegrade stenting is often required to relieve obstruction as retrograde access fails in considerable proportion of such patients. Reno-pleural fistula is a rare complication of PCN which creates a patent connection between the renal collecting system and the thoracic cavity, and urine accumulation in the pleural space can cause pleural effusion (i.e., urinothorax). Upward or downward migration is a complication of indwelling ureteric stents. Further migration with extrusion outside of the urinary tract is uncommon. Herein we present an unprecedented case in adult of ureteric stent upward migration through a reno-pleural fistula into the thoracic cavity managed by thoracoscopy.

CASE PRESENTATION

A 66-year-old female was diagnosed of advanced stage cervical cancer with suspicious bladder invasion. Given her bilateral hydronephrosis with impaired renal function, she underwent bilateral PCN and subsequent antegrade ureteric stenting. However, she presented with dyspnea, right back pain, and oliguria four days after bilateral PCN catheter removal. Computed tomography reported massive right pleural effusion and an intrathoracic ureteric stent within reno-pleural fistula. Thoracoscopy with thoracostomy was performed to remove the ureteric stent and urine in right pleural space. A week later, urinothorax had resolved and right PCN was performed again. She was discharged after regaining normal renal function with right PCN and a left ureteric stent in place.

CONCLUSIONS

A reno-pleural fistula can serve as a route for ureteric stent migration and that continuous drainage of urine can cause urinothorax once the stent reaches the thoracic cavity. Anytime a supracostal approach is used for PCN, even when using small caliber catheters, clinicians should pay special attention given the risk of pleural injury and subsequent complications.

Pleural Effusion Secondary to Obstructive Uropathy: A Case of Urinothorax

Urinothorax is a rare type of pleural effusion and usually the result of genitourinary tract disease. An accurate and early diagnosis is crucial as resolution of the underlying pathology is the mainstay of treatment. We report the case of a 69-year-old man who was admitted to the Internal Medicine ward due to obstructive acute kidney injury of unknown origin. The patient was submitted to urinary catheterization and to right percutaneous nephrostomy. Two weeks after admission he developed a large left pleural effusion; a left urinoma was also visible on computed tomography. After thoracentesis, pleural fluid analysis demonstrated a paucicellular transudate with pH <7.40 and pleural fluid/serum creatinine ratio >1.0. The diagnosis of urinothorax was made and further study allowed the diagnosis of prostate cancer as the aetiology of the obstruction. When bilateral percutaneous nephrostomy was performed, resolution of the urinothorax and normalization of renal function occurred.

LEARNING POINTS

Urinothorax is a rare and possibly under-recognized cause of transudative pleural effusion; over the last five decades, fewer than 60 cases have been reported in the English literature worldwide.Diagnosis of urinothorax depends upon a high index of clinical suspicion and on pleural fluid analysis, but imaging can also support the diagnosis, for example by showing the presence of a urinoma.Clinicians should recognize urinothorax early in its clinical course as favourable outcomes are often achieved after correction of the underlying genitourinary tract pathology.

Urinothorax: A rare complication of percutaneous nephrostomy

We present a case of a urinothorax resulting from treatment of genitourinary pathology. The presentation, diagnosis, and management of a 46-year-old female with an urinothorax are discussed. Urinothorax is a rare cause of a pleural effusion, most commonly arising from a traumatic etiology. Imaging can be crucial in the diagnosis, particularly computerized tomography (CT), which can help characterize any associated causative genitourinary abnormalities such as anatomical defects or a urinoma. A urinothorax is often posttraumatic in etiology, associated with the treatment of genitourinary pathology, as in this case. Treatment of the source of the urine leak is required to properly manage an urinothorax and often requires a multi-disciplinary approach.

Urinothorax after ultrasonography-guided renal biopsy: a case report

BACKGROUND

Urinothorax is defined as the presence of urine in the pleural space and is a rather rare cause of transudate pleural effusion. The potential etiologies are urinary tract obstruction and trauma. Diagnosis requires a high index of clinical suspicion and the condition is completely reversible following relief of underlying disease.

CASE PRESENTATION

We report a 27-year-old man who developed urinothorax after renal biopsy. Urine leakage was confirmed with ^99mTc DTPA (diethylenetriaminepentacetate) and single-photon emission computed tomography scans and retrograde pyelography. The pleural effusion was completely resolved by removing the leakage with a Foley catheter and a double J stent.

CONCLUSIONS

Urinothorax has not been reported in patients doing renal biopsy in the literature. Based on our experience, urinothorax should be suspected, diagnosed, and managed appropriately when pleural effusion occurred after renal biopsy.

Urinothorax: a systematic review

BACKGROUND

The characteristics of patients with urinothorax (UT) are poorly defined.

METHODS

A systematic review was performed searching for studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of UT. Case descriptions and retrospective studies were included.

RESULTS

The review included 78 studies with a total of 88 patients. Median age was 45 years, male/female ratio was 1.6:1 and in 76% of cases the etiology was trauma. Pleural effusion (PE) was predominantly unilateral (87%) and occupied over 2/3 of the hemithorax in most cases (64.4%). PF was straw-colored (72.7%) or hematic (27.3%) with urine-like odor in all cases. PF was transudate in 56.2% of cases (18/32) and among 14 exudates (43.8%), 3 were concordant exudates, 1 protein-discordant and 10 LDH-discordant, with lymphocyte (44.4%) and neutrophil (38.5%) predominance. The PF/serum (PF/S) creatinine ratio was >1 in all cases except one (97.9%). The diagnosis was established on the basis of PF/S creatinine ratio >1 (56.6%), urinary tract contrast extravasation (12%), abnormal computed tomography (8.4%), laparotomy findings (6%), and association of obstructive uropathy with PE (6%). The outcome was favorable (74/77; 96.1%) when treatment was direct towards the uropathy (alone or associated with thoracentesis/thoracic drainage). Outcome was unfavorable in the 15 patients who were only treated with thoracentesis/thoracic drainage.

CONCLUSIONS

UT is usually traumatic, unilateral, and PF does not have a specific pattern or cellularity predominance, with a PF/S creatinine ratio almost always >1. Treatment should include the uropathy, with or without PF evacuation.

Urinothorax: Case report and systematic review of the literature

Urinothorax, the presence of urine in the pleural space, is a rare cause of pleural effusion, usually associated with obstructive uropathy, or urinary trauma. We present the case of a 3 year-old boy and a systematic review of the literature of the 44 cases encountered. After resection of a Wilm's tumour in the right kidney our patient presented acute respiratory distress associated with radiographically confirmed pleural effusion. With the initial diagnosis of pneumonia or malignant pleural effusion, a closed thoracotomy was performed. The liquid obtained suggested urine, which was confirmed by the laboratory. Cystoscopy with retrograde pyelography detected a fistula on the posterior wall of the right kidney. The report of cases worldwide is low, probably due to its low incidence but also to underdiagnosis. Respiratory symptoms are not always present and urological symptoms usually predominate. Diagnosis requires a high degree of clinical suspicion and is confirmed by the main biochemical marker: The ratio >1.0 pleural fluid creatinine and creatinine serum.