URINOTHORAX SECONDARY TO UNILATERAL URINOMA CAUSED BY URETERAL STRICTURE

Abstract

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Urinothorax is a rare and atypical cause of pleural effusion and it usually involves patient with obstructive uropathy, iatrogenic genitourinary procedure complications or abdominal trauma. CASE PRESENTATION: A 67-year-old male with PMHx of colon cancer s/p right hemicolectomy with entero-colonic anastomosis presented with right flank pain radiating to umbilical/pelvic region for 5 days. He was hemodynamically stable. His P/E showed decrease air entry with decreased percussion in the right mid lung and tenderness in the right flank area. His CXR which was significant for right pleural effusion and CT abdomen showed severe right kidney perinephric fluid, stranding with dilation of the pelvicalyceal system and focal rupture of the superior right renal pelvis and proximal-mid ureter stricture without any present of renal or ureteral calculus. This large perinephric collection is consistent with Urinoma. Patient underwent thoracocentesis yellow color fluid was removed. The analysis showed pH of 7.34, glucose 102, WBC 27 (Lymph: 87), RBC 26, LDH of 53 and protein of 2. Serum chemistry showed protein of 8.1 and LDH of 108.The pleural fluid was transudative which is suggestive of urinothorax. The patient successfully received a right ureteral stent, relieving his obstruction, and was subsequently discharged home. Follow up CXR and CT abdomen after discharge showed resolved pleural effusion and patent ureteral stent. DISCUSSION: In our patient, the cause of the pleural effusion is due to unilateral obstructive uropathy leading to rupture pelvis and accumulation of urine in the retroperitoneal space (Urinoma) that leaked into the pleural space. The most plausible theory that would explain our case is that the urinoma drained into the pleural space via the communication between the retroperitoneal and pleural lymphatic systems due to increased retroperitoneal or intraperitoneal pressure. Urinothorax is mostly a transudative process where the pleural fluid is typically a yellow color with very low total urine protein, pH <7.4 and low cell count as well which correlated with the finding of the pleural fluid analysis in our patient. The diagnosis of urinothorax and its underlying cause can be identified with an ultrasound or CT scan of the abdomen. The management of the urinothorax may require a thoracentesis for diagnostic and symptomatic relief purposes. In our case, the underlying cause was ureteral stricture most likely risen from the complication of his right hemicolectomy. The ureteral stricture was relieved with a ureteral stent resulting in the rapid resolution of the urinothorax. CONCLUSIONS: Unilateral urinothorax is rare entity caused due to genitourinary obstruction, surgical complications and abdominal trauma, which can be resolved once the underlying cause is treated. We highlight this case to show that “zebras” should always remain in the differential diagnosis of pleural effusion. Reference #1: Casallas A, Castañeda-Cardona C, Roselli D. Urinothorax: case report and systematic review of the literature. Urol Ann 2016;8:91-4. 10.4103/0974-7796.164851 Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systematic review. Journal of Thoracic Disease. 2017;9(5):1209-1218. https://doi.org/10.21037/jtd.2017.04.22 Reference #3: Garcia-Pachon E, Padilla-Navas I. Urinothorax: case report and review of the literature with emphasis on biochemical diagnosis. Respiration. 2004;71(5):533-36. DISCLOSURES: No relevant relationships by Waheed Abdul, source=Web Response