Figure 4 - uploaded by Chrysovalantis Toutziaris
Content may be subject to copyright.
Source publication
Urinothorax (UT) is a rare and often undiagnosed condition, defined as the presence of urine in the pleural cavity due to the retroperitoneal leakage of urine accumulation, known as urinoma, into the pleural space. UT usually is a transudative pleural effusion that presents in patients with obstructive uropathy and it may occur following surgical p...
Context in source publication
Context 1
... scanning of the entire abdomen was performed which demonstrated a large hydronephrotic kidney with concomitant urine extravasation. A right chest tube and a nephrostomy tube were placed for drainage (Figure 4). The pleural fluid revealed a creatinine level higher than serum which demonstrated that consisted of urine. ...
Similar publications
Clean intermittent self-catheterization is the standard method for bladder evacuation in these patients today. The patient was diagnosed with urethrogluteal fistula and gluteal-perineal abscess by radiological evaluation. Gluteal drainage decreased after cystostomy. In our paper, a case of urethrogluteal fistula and pelvic urinoma that developed as...
Postoperative urinary retention (POUR) is a known complication following a variety of procedures, with a reported incidence of 2.1–3.8% in general surgery and up to 52% in anorectal surgery. We report a case of POUR in a female resulting in severe unilateral hydronephrosis with a perinephric urinoma due to a ruptured fornix. The extent of hydrouret...
Posterior urethral valves (PUV) are an uncommon urologic congenital anomaly in males often discovered antenatally and more rarely after birth. PUV can lead to obstructive nephropathy and voiding dysfunction, putting patients at increased risk for irreversible renal damage and subsequent progression to end-stage renal disease. Much of the renal dama...
Available online xxx Keywords: Nephritic colic Rupture of the fornix Urinoma Endo-urology Radiology a b s t r a c t Rupture of the pyelocalyceal cavities or fornix is a rare and potential urological emergency. It is most often secondary to obstructive uropathy. It can lead to extravasation of urine at the perirenal or retro-peritoneal level, which...
Key Clinical Message
Renal collecting system rupture is a rare manifestation of obstructive uropathy. The majority of cases are attributed to ureteric calculi and extrinsic ureteric compression. The optimal diagnostic image is contrast‐enhanced CT scan with delayed phase protocol. Management is usually conservative and generally depends on the etio...
Citations
... Its diagnosis centres on high clinical suspicion and the biochemical analysis of pleural fluid, with treatment focusing on alleviating urinary obstruction or treating traumatic injuries [1][2][3]. While the literature reports cases of urinothorax due to isolated obstructive uropathies (e.g., prostatic adenocarcinoma) [2,3] or iatrogenic causes [4][5][6][7], our case report introduces what we believe to be the first documented instance of urinothorax precipitated by urine retention secondary to an enlarged prostate in the postoperative period after percutaneous nephrolithotomy (PCNL) with subcostal access. ...
... Others have similarly reported urinothorax following iatrogenic trauma from PCNL, ureteroscopy, and partial nephrectomy [4][5][6][7][8][9]. Urinothorax has also been found to arise in the setting of obstructive prostatic adenocarcinoma and renal calculi [7,9,10]. ...
... The pathogenesis of urinothorax is primarily explained by two theories: one theory suggests that urine crosses a diaphragmatic defect to reach the pleural space, while the other proposes that urine from the retroperitoneal area enters the peritoneal cavity, eventually reaching the pleural cavity via lymphatic channels [6,9]. We propose that our patient developed postoperative urine retention due to his large prostate, which led to secondary left vesico-ureteric reflux aggravated by an indwelling ureteric stent, thereby causing urine leakage from the site of his PCNL. ...
... A pleural fluid to serum creatinine ratio greater than 1 often supports the diagnosis of urinothorax, whereas a ratio greater than 1.7 may be considered diagnostic, which in our case was 20.6:1. [1] In view of shock, inotropic support was started with World J Emerg Med, Vol 14, No 6, 2023 noradrenaline infusion at a rate of 20 mL/h (10 μg/min in a 50 mL syringe via an infusion pump) and a sodium bicarbonate infusion at the rate of 20 mL/h (5 mEq/kg titrated in a 50 mL syringe via an infusion pump). Post intubation, sedation was started with fentanyl at the rate of 50 μg/h and maintenance balanced crystalloids at the rate of 100 mL/h. ...
... It was found that the effusion was mostly unilateral (87%), covering over two-thirds of the hemithorax in most cases (64%), and was straw-coloured mostly (72%) but in all of the occurrences, the fluid smelled like urine. [7] Urinothorax is a highly misdiagnosed and undiagnosed condition [1] that occurs due to retroperitoneal leakage and accumulation of urine within the pleural cavity. A high degree of suspicion is required to diagnose this condition, as the patient may present with mild, moderate or severe respiratory complaints. ...
Urinothorax, is the accumulation of urine in the
pleural space, and is a rare and unusual condition.[1]
Several etiologies are responsible for this, with trauma
being the most common,[2] along with, surgical renal
procedures (percutaneous nephrolithotomy, PCNL),
retroperitoneal inflammation, urinary obstruction and
malignancies.[3,4] Massive collections of a urinothorax
or a hydrothorax can lead to tension, mediastinal shifts
and cardiac arrests. We describe a case of tension
urinothorax that led to cardiac arrest and was resuscitated
successfully in the emergency department (ED).
... A pleural fluid to serum creatinine ratio greater than 1 often supports the diagnosis of urinothorax, whereas a ratio greater than 1.7 may be considered diagnostic, which in our case was 20.6:1. [1] In view of shock, inotropic support was started with World J Emerg Med, Vol 14, No 6, 2023 noradrenaline infusion at a rate of 20 mL/h (10 μg/min in a 50 mL syringe via an infusion pump) and a sodium bicarbonate infusion at the rate of 20 mL/h (5 mEq/kg titrated in a 50 mL syringe via an infusion pump). Post intubation, sedation was started with fentanyl at the rate of 50 μg/h and maintenance balanced crystalloids at the rate of 100 mL/h. ...
... It was found that the effusion was mostly unilateral (87%), covering over two-thirds of the hemithorax in most cases (64%), and was straw-coloured mostly (72%) but in all of the occurrences, the fluid smelled like urine. [7] Urinothorax is a highly misdiagnosed and undiagnosed condition [1] that occurs due to retroperitoneal leakage and accumulation of urine within the pleural cavity. A high degree of suspicion is required to diagnose this condition, as the patient may present with mild, moderate or severe respiratory complaints. ...
... Urinothorax is defined as accumulation of urine into the pleural space, and is an unusual cause of pleural effusion. [4] The most common etiology responsible for urinothorax is extravasation of urine from the reno-ureteric system causing the formation of urinoma. The etiologies can be classified as (i) obstructive urinothorax due to obstructive uropathy, (ii) traumatic urinothorax due to trauma to the genitourinary tract, [5] and (iii) iatrogenic urinothorax due to injury caused by iatrogenic procedures such as PCNL, ureterorenoscopic lithotripsy, or shock wave lithotripsy. ...
... [7,8] It has been seen that pleural effusion is generally present on the same side of the obstructive uropathy, however, the presence of it on the contralateral side is not rare. [4] There are two theories proposed and debated regarding the mechanisms responsible for the transdiaphragmatic evasion of urine. Urine accumulation into the pleural space, can be either due to (1) the lymphatic drainage into the pleural space or (2) retroperitoneal fluid first entering into peritoneal space than through direct transdiaphragmatic passage into the pleural cavity. ...
... On contrast-enhanced CT, during the excretory phase, contrast extravasation from the urinary tract helps to confirm the urinary leakage and urinoma formation which reveal attenuation equivalent to water. [4] Intravenous pyelogram and renal scintigraphy are the other modalities that help to reveal contrast extravasation from the urinary tract to the pleural space and thus help in the diagnosis of urinothorax. Technetium-99m renal scan also helps to confirm the diagnosis of urinothorax by revealing the presence of technetium-99m-labeled albumin from the genitourinary tract in the pleural space. ...
... In our case, x-ray chest revealed a massive right sided effusion with DJ stent inside pleural cavity. CT urography very well documents the nephropleural fistula in most of the cases and is usually used to confirm the diagnosis [7] . In our case, CT was showing DJ stent across an abnormal tract between pleura and pelvicalyceal system. ...
Percutaneous nephrolithotomy is usually considered as safe and effective in the management of renal stones in pediatric population. Urinothorax defined as presence of urine in pleural cavity is a rare complication of percutaneous nephrolithotomy. We present a rare case of slowly developing urinothorax in a 9-year-old boy following PCNL due to migration of DJ stent into the pleural cavity. The case was managed by intracostal tube drainage and repositioning of DJ stent.
... On ultrasound, an urinoma may show a well-defined anechoic or hypoechoic fluid collection, partially contouring any portion of the genitourinary system. On CT, urinomas show water attenuation, and on the excretory phase of contrast-enhanced studies, urine leakage may be visualized from contrast extravasation from the genitourinary tract [11] . Renal scintigraphy has also been reported to serve a role in detecting an urinothorax [12,13] . ...
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.
... It occurs directly by moving into the pleural space down the pressure gradient between the abdomen and the pleural space through diaphragmatic pores. Another direct mechanism is through the development of a urinoma -urine collection outside the urinary tract in the retroperitoneum [5] -which can directly rupture into the pleural space, causing urinothorax. Urinothorax can develop indirectly when urine moves via lymphatic communication between the retroperitoneum and the pleural space. ...
... [3]. Glucose levels are usually low [5] because they are typically low in urine [2]. PFA commonly shows few nucleated cells. ...
Urinothorax is the presence of urine in the pleural space. It can occur at any age and is more common in males. It typically results from obstructive uropathy but can also be caused by malignancy or trauma. Urinothorax is a rare cause of transudative pleural effusion and the only cause of low pH (pH <7.4) transudative effusion. We present the case of a 51-year-old female patient who had recently undergone a urological procedure and came to the emergency department reporting shortness of breath. A chest X-ray revealed a newly developed, large, right-sided pleural effusion. Thoracentesis yielded a transudative yellow fluid of normal pH with a creatinine-to-serum creatinine ratio of 1.7. A computed tomography (CT) cystogram showed extravasated contrast material within the pelvis, from which a diagnosis of urinothorax was confirmed and treated. Urinothorax is a rare diagnosis that requires a multidisciplinary treatment approach, usually including a pulmonologist and a urologist. After the genitourinary disease is treated, the urinothorax usually resolves.
... Urinothorax refers to the presence of urine in the pleural space, but rarely causes pleural effusion [1]. Since the first description in 1968 by Corriere et al., fewer than 70 cases have been reported worldwide [2]. ...
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.
Electronic supplementary material
The online version of this article (10.1186/s12882-018-0903-8) contains supplementary material, which is available to authorized users.
... Seventy eight studies involving 88 patients were selected for review, spanning a period of 62 years. Figure 1 presents a flowchart showing a complete breakdown (2,5-24) of how (25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44) appropriate studies (45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64) were identified (65)(66)(67)(68)(69)(70)(71)(72)(73)(74)(75)(76)(77)(78)(79)(80)(81), corresponding to isolated case reports (between 1 and 4 cases per article). ...
... PE was unilateral in 74 patients (87%), right-sided in 43 (58.1%) and left-sided in 31 (41.9%). In 11 patients, PE was bilateral (12.9%) and corresponded to obstructive (5 cases) (20,22,45,53,62) and traumatic uropathy (6 cases) (17,23,36,62,70,74). In 3 cases the authors did not specify whether it was unilateral or bilateral (15,58,59). ...
... PE was unilateral in 74 patients (87%), right-sided in 43 (58.1%) and left-sided in 31 (41.9%). In 11 patients, PE was bilateral (12.9%) and corresponded to obstructive (5 cases) (20,22,45,53,62) and traumatic uropathy (6 cases) (17,23,36,62,70,74). In 3 cases the authors did not specify whether it was unilateral or bilateral (15,58,59). ...
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.
... 8 Urinothorax most often are ipsilateral as in our case, but contralateral 9 as well as bilateral effusions have also been observed. 10 In urinothorax, the aspirated fluid has a pale yellow appearance with an odor of urine. There are few criteria to be fulfilled for a confirmed diagnosis, such as the fluid being transudative with an acidic pH and a pleural/serum creatinine ratio of >1, where the latter is considered as a typical characteristic of urinothorax. ...
... 11 Renal scintigraphy with the use of technetium-99m diethylene-triamine-pentaacetate, technetium-99m ethylene dicysteine, or technetium-99m-mercaptoacetyltriglycine-3 helps reveal the existence of an extravasation of urine from the kidney or [12][13][14] Intravenous pyelography can also help detect any seepage of contrast from the retroperitoneal space into the pleural cavity, but sometimes this examination may not be useful. 10 Correction of the urinary obstruction generally leads to the resolution of the effusion with no recurrence; however, if the effusion still persists, then drainage of the urine through an intercostal thoracic tube is recommended. 15,16 The reported cases of urinothorax are generally seen in adults; however, there are cases where it is diagnosed in children as well. ...
Urinothorax is a rare cause of pleural effusion characterized by the collection of urine in the pleural space. The index of suspicion should be higher when a pleural effusion is associated with cases of urinary tract obstruction or obstructive uropathy (renal calculi) and trauma. The characteristic feature in the diagnosis of urinothorax lies in the biochemistry, where the ratio of pleural fluid to serum creatinine is higher than 1. The present case is a unique instance of urinothorax with left urinoma and hydronephrosis where the ratio of pleural fluid to serum creatinine is below one.
