奇美醫療財團法人奇美醫學中心 外科部 泌尿科
A Case of Empyema after Percutaneous Nephrostomy Insertion and Retrograde Intrarenal Surgery: A Case report
I-Chen Tsai, Chye-Yang Lim, Chien-Liang Liu, Steven K. Huang
Divisions of Urology, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan;
Purpose: Percutaneous nephrostomy (PCN) placement is performed to relieved upper urinary tract obstruction, which can be of benign or malignant nature. It is one of the commonest procedures for patients with stone-related obstructive uropathy in Chi-Mei Medical Center if the lithotripsy elevates the sepsis risk. After broad-spectrum antibiotics treatment, ureterorenoscopic lithotripsy (URSL) or retrograde intrarenal surgery (RIRS) was performed to retrieve the stones. As with any surgical procedure, there are complications inherent to PCN tube placement, URSL and RIRS. Empyema is a rare complication after PCN placement and RIRS.
Case presentation: The 60-year-old female presented right flank pain and fever for one day. She had systemic diseases such as hypertension, type 2 DM and chronic peptic ulcer. There was no history of respiratory symptoms. Pyuria and leukocytosis were noted before admission. Abdominal CT revealed right lower caliceal stones and right lower third ureteral stone (1.5cm), resulting in moderate hydroureteronephrosis. Right side PCN was inserted on the same day. After Zinacef treatment for 3 days, she received right URSL (rigid and flexible) to retrieve the ureter and lower caliceal stone. On the same day, fever and dyspnea were noted. CXR showed right pleural effusion with right CP angle blunting. Chest CT was also followed, which showed RLL hematoma with right hemothorax. The patient underwent pigtail drainage of the pleural fluid and Tazocin treatment.
On post-operation day 5, leukocytosis and elevated CRP were still noted. Meanwhile, the pigtail drainage amount decreased. We arranged chest echo, which showed loculated collection and internal septum at RLL. Empyema was highly suspected. CS doctor was consulted, and the patient received video-assisted thoracoscopic surgery (VATS)-guided decortication of the empyema. During VATS, the peel that had developed around the loculated collection was removed along with all the necrotic material. An intercostal chest tube was inserted in right pleural area after the operation. Patient recovered well after surgical and antibiotics treatment.
Conclusions: Extrathoracic causes of empyema are uncommon. Pleural injury could happen during PCN insertion. Additionally, the increasing pressure in ureter and kidney during URSL give rise to backflow and fluid accumulation in pleural cavity, which result in the empyema formation. Initial treatment includes adequate drainage of pleural effusion and prompt antibiotics. Early referral to chest surgeon is needed if the empyema had developed.