Table of Contents    
CASE REPORT
Year : 2015  |  Volume : 6  |  Issue : 1  |  Page : 213-216  

Urinothorax: A path, less travelled: Case report and review of literature


1 Department of General Surgery, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India
2 Department of Urology and Kidney Transplantation, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India
3 Department of Respiratory Medicine, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India

Date of Web Publication14-Jan-2015

Correspondence Address:
Dr. Santosh Agrawal
Department of Urology and Kidney Transplantation, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-9668.149182

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   Abstract 

Urinothorax is a very rare occurrence of urine in the pleural space. Urinothorax can occur as a consequence to percutaneous nephrolithotomy (PCNL), ureterorenoscopic lithotripsy (URSL) or shock wave lithotripsy (SWL). We herewith report a rare case of Urinothorax in a 35 years old male patient and discuss its current knowhow and clinical management.

Keywords: Nephrostomy, percutaneous nephrolithotomy, urinothorax


How to cite this article:
Ranjan V, Agrawal S, Chipde SS, Dosi R. Urinothorax: A path, less travelled: Case report and review of literature. J Nat Sc Biol Med 2015;6:213-6

How to cite this URL:
Ranjan V, Agrawal S, Chipde SS, Dosi R. Urinothorax: A path, less travelled: Case report and review of literature. J Nat Sc Biol Med [serial online] 2015 [cited 2020 Oct 20];6:213-6. Available from: http://www.jnsbm.org/text.asp?2015/6/1/213/149182


   Introduction Top


The urinothorax or collection of urine in the pleural space is a rare and unusual cause of pleural effusion. This entity was first being described as a consequence to ureteral obstruction in dogs. [1] The etiologies of urinothorax could be traumatic or obstructive. [2] It may also occur after iatrogenic intervention such as percutaneous nephrolithotomy (PCNL), ureterorenoscopic lithotripsy or shock wave lithotripsy. For proper management of urinothorax, etiologies need to be understood carefully. Awareness of this condition and the appropriate diagnostic tests, performed early, is the most important for the diagnosis and treatment of urinothorax. [3] We here discuss a rare case of urinothorax arising after left PCNL performed for removal of left renal stone and its management.


   Case Report Top


A 35-year-old male was presented to outpatient department with the complaint of pain in left flank region for 1 month. Ultrasound examination revealed small contracted right kidney with stone and hydronephrotic left kidney with multiple calculi. His intravenous urography suggested poor contrast excretion from the right kidney with normal functioning left kidney with multiple superior calyceal stones [Figure 1]. Diethyl triamine penta acetic (DTPA) renogram further revealed poorly functional right kidney (glomerular filtration rate-18%) and normal functioning left kidney. Preoperative workup including renal function and chest X-ray was normal [[Figure 2]a]. Patient was taken up for left PCNL under general anesthesia. Superior calyceal supracostal puncture above 11 th rib was done under fluoroscopic guidance. Tract dilated until 24 Fr, stones fragmented with lithotripter and near complete clearance was achieved. A 5.5/26 Fr Double J (DJ) stent and 16 Fr nephrostomy drain were placed. Patient tolerated the procedure well without any significant intraoperative bleeding.
Figure 1: Intravenous urogram

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Figure 2: Chest X-ray (a) at admission, (b) postoperative day-2 showing left pleural effusion, (c) post intercostal drain insertion, (d) at the time of discharge

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Postoperatively, he developed mild pain over left hypochondrium and back with difficulty in breathing. His peripheral oxygen saturation was 85%. Chest X-ray was done, which revealed mild left pleural effusion. However patient stabilized after supportive treatment. On second postoperative day, nephrostomy drain was removed, following which his condition deteriorated. He complained of pain again over the same site with difficulty in breathing and diminished urine output. Fluid challenge along with diuretic was given which resulted in increased respiratory distress without improvement of urinary output. Ultrasonography chest revealed left moderate pleural effusion and 600 ml pleural fluid was aspirated. The patient condition deteriorated again at night, repeat chest X-ray [[Figure 2]b] showed recurrence of effusion on the left side for which intercostal drain was placed [[Figure 2]c]. A volume of 2 L of mild hemorrhagic fluid was drained immediately followed by 1.6 L until the next morning. The analysis of pleural fluid was suggestive of transudate fluid with ammonical odor and an increased pleural fluid to serum creatinine ratio (9:1). Abdominal X-ray was performed to confirm DJ stent position, which revealed displaced DJ stent in the urinary bladder [Figure 3]. Patient was taken into the operation theater and left retrograde pyelogram revealed contrast leak from superior calyceal system along with evidence of numerous clots in the left ureter on ureteroscopy. A 5.5/26 Fr DJ stent was placed again. Urinary output increased after stenting and the chest drain decreased gradually with complete resolution on 12 th postoperative day. Intercostal drain was removed with chest X-ray showing full expansion [[Figure 2]d]. Patient was discharged on 15 th postoperative day. DJ stent and Foleys catheter were removed 1 week after discharge.
Figure 3: Displaced Double J stent

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   Discussion Top


Urinothorax is the presence of urine in the pleural space, which is a very unusual condition. [4] Several possible etiologies are proposed, with obstructive uropathy with hydronephrosis and disruption of the diaphragm by blunt abdominal trauma being the most common cause. [5] The other etiologies reported are percutaneous endoscopic renal procedures, retroperitoneal inflammatory processes, polycystic renal disease, ureteral valves, extracorporeal lithotripsy, and intra-abdominal compression from gravid uterus or lymphomatous masse. [2],[6],[7] Direct collection of the extraperitoneal urine into the pleural space or collections by lymphatic drainage are the proposed pathologic mechanism of development of urinothorax. [8] In the present case, urinothorax resulted as a direct complication of supracostal puncture during PCNL, as preprocedural chest X-rays were reported as normal. Most of cases of urinothorax report symptoms of cough, chest pain, dyspnea or asymptomatic. [2] Nevertheless, one should be suspicious enough to diagnose this condition earliest when the patient develops symptoms. A chest X-ray may show mild to moderate collection on the ipsilateral side, but contralateral involvement has also been reported. [4],[8] Our case presented with massive unilateral effusion on the ipsilateral side. The diagnosis was confirmed by analysis of pleural fluid. Grossly, the fluid was clear to pale yellow in color with distinctive ammonia odor. The nature of fluid is transudative. The raised pleural fluid creatinine to serum creatinine ratio is a diagnostic feature [Table 1]. [2],[3],[7] Other inconsistent markers are normal to raised lactate dehydrogenase low protein and glucose content, low pH and presence of pleural fluid carcino embryonic antigen. [2] Renal scans are preferred choice of radiological investigation with mercaptoacetyltriglycine scans preferred over DTPA scans and invasive tests are rarely required. [9] The treatment is directed to correction of underlying pathology and removal of collected effusion. [10] The minor effusion with asymptomatic patients may require only needle drainage, but thoracostomy and tube placement (in case of recurrent or large effusions) and partial nephrectomy has also been reported (preferably in cases of nonfunctioning kidneys). [8],[10],[11] High index of suspicion for the early diagnosis of urinothorax and proper management targeted at the underlying cause is necessary so that a good outcome can be obtained as in this case.
Table 1: Analysis of studies on urinothorax

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   References Top

1.
Corriere JN Jr, Miller WT, Murphy JJ. Hydronephrosis as a cause of pleural effusion. Radiology 1968;90:79-84.  Back to cited text no. 1
    
2.
Garcia-Pachon E, Padilla-Navas I. Urinothorax: Case report and review of the literature with emphasis on biochemical diagnosis. Respiration 2004;71:533-6.  Back to cited text no. 2
    
3.
Kamble RT, Bhat SP, Joshi JM. Urinothorax: A case report. Indian J Chest Dis Allied Sci 2000;42:189-90.  Back to cited text no. 3
    
4.
Laskaridis L, Kampantais S, Toutziaris C, Chachopoulos B, Perdikis I, Tahmatzopoulos A, et al. Urinothorax - An underdiagnosed cause of acute dyspnea: Report of a bilateral and of an ipsilateral urinothorax case. Case Rep Emerg Med 2012;2012:395653.  Back to cited text no. 4
    
5.
Leung FW, Williams AJ, Oill PA. Pleural effusion associated with urinary tract obstruction: Support for a hypothesis. Thorax 1981;36:632-3.  Back to cited text no. 5
    
6.
Karkoulias K, Sampsonas F, Kaparianos A, Tsiamita M, Tsoukalas G, Spiropoulos K. Urinothorax: An unexpected cause of pleural effusion in a patient with non-Hodgkin lymphoma. Eur Rev Med Pharmacol Sci 2007;11:373-4.  Back to cited text no. 6
    
7.
Oðuzülgen IK, Oðuzülgen AI, Sinik Z, Köktürk O, Ekim N, Karaoðlan U. An unusual cause of urinothorax. Respiration 2002;69:273-4.  Back to cited text no. 7
    
8.
Ferreira PG, Furriel F, Ferreira AJ. Urinothorax as an unusual type of pleural effusion - clinical report and review. Rev Port Pneumol 2013;19:80-3.  Back to cited text no. 8
    
9.
Bhattacharya A, Sunil VH, Santosh K, Mittal BR. Urinothorax demonstrated on 99 m TC ethylene dicysteine renal scintigraphy. Nephrol Dial Transplant 2007;22:1782-3.  Back to cited text no. 9
    
10.
Izzo L, Caputo M, De Toma G, Izzo P, Bolognese A, Basso L. Urinoma and urinothorax: Report of a case. Am Surg 2008;74:62-3.  Back to cited text no. 10
    
11.
Wei B, Takayama H, Bacchetta M. Urinothorax: An uncommon cause of pleural effusion. Respir Med CME 2009;2:179-80.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


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