NEPHROPLEURAL FISTULA AND URINOTHORAX AFTER PERCUTANEOUS NEPHROLITHOTOMY

Abstract

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Urinothorax is a rare diagnosis caused by urinary tract obstruction or trauma resulting in leakage of urine from the retroperitoneum into the pleural space. These effusions are typically large, unilateral, and nearly always associated with a ratio of pleural fluid creatinine to serum creatinine greater than one. Definitive treatment requires correction of the uropathy, as thoracentesis or chest tube insertion alone is invariably ineffective. Here we describe a case of urinothorax due to nephropleural fistula which formed after percutaneous nephrolithotomy for staghorn calculi. CASE PRESENTATION: A 54 year-old female with morbid obesity and bilateral staghorn calculi was admitted to the hospital for elective bilateral percutaneous nephrolithotomy (PCNL) for progressive renal dysfunction. A left sided PCNL was performed and a percutaneous nephrostomy (PCN) tube was left in place. Four days post procedure, the PCN tube was removed. Six days post procedure, the patient developed severe left-sided pleuritic chest pain, orthopnea, and dyspnea at rest. She required two liters of oxygen by nasal cannula to maintain her oxygen saturation above 90%. Exam was notable for super morbid obesity (BMI of 60), mild respiratory distress, and absent left sided breath sounds with dullness to percussion. Chest x-ray showed a large left pleural effusion. Urgent bedside thoracentesis was performed, and 1.8 liters of clear, pink-tinged fluid was removed. Pleural fluid analysis revealed a transudate by Light’s criteria with a pH of 7.8, creatinine of 6.69 mg/dL, and a pleural fluid to serum creatinine ratio of 2.9. CT scan of her chest, abdomen, and pelvis revealed bilateral staghorn calculi, a large left pleural effusion, and a fistulous tract between the kidney and the posteroinferior pleural space. A chest tube was placed, and the patient underwent double J-stent placement within the urinary tract which relieved the obstruction and halted the accumulation of pleural fluid. The chest tube was removed, and the patient was discharged with plans to undergo right sided PCNL in the future. DISCUSSION: Urinothoraces can be caused by urinary tract obstruction or trauma. PCN tube placement above the 12th rib can lead to pleural transgression and injury, as in this case. Traumatic urinothoraces are typically symptomatic, unilateral, and large. In most cases, pleural fluid analysis shows an acidic transudate with a pleural fluid to serum creatinine ratio of greater than one. Diagnosis can be made on the basis of pleural fluid analysis or imaging with either CT or radionucleotide scans. Treatment with thoracentesis or chest tube drainage alone leads to unfavorable outcomes in nearly all cases; therefore, management should focus on correction of the uropathy which provides definitive treatment. CONCLUSIONS: See Discussion Reference #1: Toubes, M. E et al. Urinothorax: a systematic review. J Thorac Dis. 2017 May; 9(5): 1209-1218. Reference #2: Chandra A, Pathak A, Kapur A, Russia N, Bhasin N. Urinothorax: A rare cause of severe respiratory distress. Indian J Crit Care Med. 2014;18(5):320-2. Reference #3: Dagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011;28(4):424–437. DISCLOSURES: No relevant relationships by Traci Adams, source=Web Response No relevant relationships by Carlos Cardenas, source=Web Response No relevant relationships by Dylan Lovin, source=Web Response no disclosure on file for Arthi Satyanarayan