張珝^{1, 2}、陳毅軒^{1, 2}、陳鈺昕^{1, 2}、陳建志^{1, 2}

¹馬偕紀念醫院 泌尿科；²馬偕醫學院

Syu Jhang^{1, 2}, Yi-Hsuan Chen^{1, 2}, Yu-Hsin Chen^{1, 2}, Marcelo Chen^{1, 2}

¹Department of Urology, Mackay Memorial Hospital, Taipei, Taiwan; ²School of Medicine, Mackay Medical College, Sanzhi, Taiwan;

 

Purpose: Urinothorax is defined as urine in the pleural cavity, a rare cause of a pleural effusion. It was first reported by Corriere et al. in 1968 during experiments involving ureteral obstruction in mongrel dogs. About 60 cases of urinothorax have been reported, increasing the awareness of this diagnosis. We report a case of urinothorax caused by malpositioning of antegrade double J.

Case report: This 66-year-old healthy female complained of postmenopausal vaginal bleeding for several years. Decreased urine output and progressive right flank pain were noted for a few days. She visited our emergency room. Pelvic speculum showed an erosion tumor on cervix with bleeding. Impaired renal function was found. Abdominal computed tomography suspected cervical cancer with bladder invasion and bilateral hydronephroureter. Cystoscopy showed bullous edema on trigone without visible ureteral orifice. Bilateral percutaneous nephrostomy tubes with antegrade double J were placed by the radiologist. Then we removed bilateral percutaneous nephrostomy tubes under cystoscopic assistance. Four days later, she complained severe back pain accompanied with oliguria. Physical examination revealed right costovertebral angle knocking tenderness. Chest computed tomography illustrated a catheter within right basal pleural cavity indicating malpositioning of right double J passing beyond the diaphragm into right pleural cavity resulting in massive right pleural effusion. We performed cystoscopy but right double J cannot be identified. Thus, we consulted the thoracic surgeon. Single-incision thoracoscopic surgery underwent. More than 2600 ml of pleural effusion was aspirated. The double J was seen in pleural space and removed. The chest tube was placed for drainage. One week later, the chest tube was removed and right ultrasound-guided percutaneous nephrostomy tube was placed. She was discharged given her improvement in symptoms and stable vital signs.

Conclusion: Urinothorax may occur as a rare but important treatable complication of percutaneous nephrostomy or antegrade double J insertion despite image guidance. Patients may present with chest/back pain, dyspnea, and reduced urine output. Hence patients need to be appraised of this complication when obtaining informed consent. Early diagnosis is critical as appropriate urological diversion and pleural drainage result in cure.