Images in Clinical Urology A Nephropleural Fistula Complicated by Distal Ureteral Obstruction Results in Tension Hydrothorax After Percutaneous Nephrostolithotomy Jason M. Scovell and Richard E. Link We present the case of a patient with nephrocalcinosis and chronic kidney disease who underwent percutaneous nephrostolithotomy via a mid-pole access. After nephroureteral stent removal, the patient developed a tension hydrothorax due to the rare combination of a nephropleural fistula and ipsilateral distal ureteral obstruction. This complication was managed by percutaneous nephrostomy and thoracostomy placement and subsequent thoracoscopic surgery without further sequelae. UROLOGY 84: e28ee29, 2014. 2014 Elsevier Inc.
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ephropleural fistulas are a rare complication after percutaneous nephrolithotomy, associated almost exclusively with supracostal access (1.3%3.3%).1,2 Management is often conservative, occasionally requiring surgery for persistent pleural effusions.1-6 A 21-year-old male patient with nephrocalcinosis and chronic kidney disease underwent left percutaneous nephrolithotomy via mid-pole access and subsequently developed a tension hydrothorax. His nephroureteral stent was removed on postoperative day 4. That same day, he complained of left arm and/ or chest pain and shortness of breath. Chest radiographs (Fig. 1A) and abdominal computed tomography were unremarkable other than 2-mm nonobstructing ureteral fragments. Ten days later, he complained of worsening shortness of breath (O2 saturation, 95%) and left flank pain. Chest radiographs (Fig. 1B) showed a left hydrothorax with mediastinal shift, and computed tomography (Fig. 2) demonstrated obstructing stones in the left distal ureter. The rare combination of a nephropleural fistula and distal ureteral obstruction appears to have resulted in progressive filling of the left chest with fluid under pressure. A thoracic pigtail catheter and nephroureteral stent were placed promptly with drainage (Fig. 3). Because of residual fluid in the left thorax, thoracic surgery performed video-assisted exploration and washout of the chest on hospital day 2. The thoracostomy tube was removed at 48 hours; Financial Disclosure: The authors declare that they have no relevant financial interests. From the Scott Department of Urology, Baylor College of Medicine, Houston, TX Address correspondence to: Richard E. Link, M.D., Ph.D., Scott Department of Urology, Baylor College of Medicine, McNair Medical Campus, 7200 Cambridge, 10th floor, Urology Suite B, Houston, TX 77030. E-mail: [email protected] Submitted: June 20, 2014, accepted (with revisions): August 18, 2014
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ª 2014 Elsevier Inc. All Rights Reserved
Figure 1. Posterior-anterior chest radiographs. (A) Six hours after removal of nephroureteral stent on postoperative day 4 showing normal lung fields without evidence for pneumothorax or pleural effusion. (B) Ten days later on postoperative day 14 showing diffuse opacification of the left hemithorax consistent with a large hydrothorax. A mediastinal shift to the right is also visible. http://dx.doi.org/10.1016/j.urology.2014.08.009 0090-4295/14
Figure 2. Coronal (A, C) and axial (B) views of a noncontrast computed tomography scan of the chest, abdomen, and pelvis on postoperative day 14. It demonstrates complete opacification of the left hemithorax due to a large pleural effusion with mediastinal shift to the right. A small obstructing stone is noted at the left ureterovesicle junction (arrow) and an additional stone is observed in the dilated distal ureter. There is no significant perinephric fluid seen.
the patient had no further sequelae after nephrostomy tube removal 2 weeks later. References
Figure 3. Antegrade left nephroureterogram showing a dilated ureter and the distal obstructing calculus (arrow) at the ureterovesical junction.
UROLOGY 84 (6), 2014
1. Lallas CD, Delvecchio FC, Evans BR, et al. Management of nephropleural fistula after supracostal percutaneous nephrolithotomy. Urology. 2004;64:241-245. 2. Munver R, Delvecchio FC, Newman GE, et al. Critical analysis of supracostal access for percutaneous renal surgery. J Urol. 2001;166: 1242-1246. 3. Agranovich S, Cherniavsky E, Tiktinsky E, et al. Unilateral urinothorax due to nephropleural fistula detected on Tc-99m diethylenetriamine pentaacetic acid renal scintigraphy. Clin Nucl Med. 2008;33:889-891. 4. Caberwal D, Katz J, Reid R, et al. A case of nephrobronchial and colonobronchial fistula presenting as lung abscess. J Urol. 1977;117:371-373. 5. Jones GH, Kalaher HR, Misra N, et al. Empyema and respiratory failure secondary to nephropleural fistula caused by chronic urinary tract infection: a case report. Case Rep Pulmonol. 2012;2012:1-5. 6. Raj GV, Auge BK, Weizer AZ, et al. Percutaneous management of calculi within horseshoe kidneys. J Urol. 2003;170:48-51.
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ephropleural fistulas are a rare complication after percutaneous nephrolithotomy, associated almost exclusively with supracostal access (1.3%3.3%).1,2 Management is often conservative, occasionally requiring surgery for persistent pleural effusions.1-6 A 21-year-old male patient with nephrocalcinosis and chronic kidney disease underwent left percutaneous nephrolithotomy via mid-pole access and subsequently developed a tension hydrothorax. His nephroureteral stent was removed on postoperative day 4. That same day, he complained of left arm and/ or chest pain and shortness of breath. Chest radiographs (Fig. 1A) and abdominal computed tomography were unremarkable other than 2-mm nonobstructing ureteral fragments. Ten days later, he complained of worsening shortness of breath (O2 saturation, 95%) and left flank pain. Chest radiographs (Fig. 1B) showed a left hydrothorax with mediastinal shift, and computed tomography (Fig. 2) demonstrated obstructing stones in the left distal ureter. The rare combination of a nephropleural fistula and distal ureteral obstruction appears to have resulted in progressive filling of the left chest with fluid under pressure. A thoracic pigtail catheter and nephroureteral stent were placed promptly with drainage (Fig. 3). Because of residual fluid in the left thorax, thoracic surgery performed video-assisted exploration and washout of the chest on hospital day 2. The thoracostomy tube was removed at 48 hours; Financial Disclosure: The authors declare that they have no relevant financial interests. From the Scott Department of Urology, Baylor College of Medicine, Houston, TX Address correspondence to: Richard E. Link, M.D., Ph.D., Scott Department of Urology, Baylor College of Medicine, McNair Medical Campus, 7200 Cambridge, 10th floor, Urology Suite B, Houston, TX 77030. E-mail: [email protected] Submitted: June 20, 2014, accepted (with revisions): August 18, 2014
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ª 2014 Elsevier Inc. All Rights Reserved
Figure 1. Posterior-anterior chest radiographs. (A) Six hours after removal of nephroureteral stent on postoperative day 4 showing normal lung fields without evidence for pneumothorax or pleural effusion. (B) Ten days later on postoperative day 14 showing diffuse opacification of the left hemithorax consistent with a large hydrothorax. A mediastinal shift to the right is also visible. http://dx.doi.org/10.1016/j.urology.2014.08.009 0090-4295/14
Figure 2. Coronal (A, C) and axial (B) views of a noncontrast computed tomography scan of the chest, abdomen, and pelvis on postoperative day 14. It demonstrates complete opacification of the left hemithorax due to a large pleural effusion with mediastinal shift to the right. A small obstructing stone is noted at the left ureterovesicle junction (arrow) and an additional stone is observed in the dilated distal ureter. There is no significant perinephric fluid seen.
the patient had no further sequelae after nephrostomy tube removal 2 weeks later. References
Figure 3. Antegrade left nephroureterogram showing a dilated ureter and the distal obstructing calculus (arrow) at the ureterovesical junction.
UROLOGY 84 (6), 2014
1. Lallas CD, Delvecchio FC, Evans BR, et al. Management of nephropleural fistula after supracostal percutaneous nephrolithotomy. Urology. 2004;64:241-245. 2. Munver R, Delvecchio FC, Newman GE, et al. Critical analysis of supracostal access for percutaneous renal surgery. J Urol. 2001;166: 1242-1246. 3. Agranovich S, Cherniavsky E, Tiktinsky E, et al. Unilateral urinothorax due to nephropleural fistula detected on Tc-99m diethylenetriamine pentaacetic acid renal scintigraphy. Clin Nucl Med. 2008;33:889-891. 4. Caberwal D, Katz J, Reid R, et al. A case of nephrobronchial and colonobronchial fistula presenting as lung abscess. J Urol. 1977;117:371-373. 5. Jones GH, Kalaher HR, Misra N, et al. Empyema and respiratory failure secondary to nephropleural fistula caused by chronic urinary tract infection: a case report. Case Rep Pulmonol. 2012;2012:1-5. 6. Raj GV, Auge BK, Weizer AZ, et al. Percutaneous management of calculi within horseshoe kidneys. J Urol. 2003;170:48-51.
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