Progressive respiratory insufficiency after cesarean section

Case of urinothorax - A rare presentation

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 (known as urinoma) into the pleural space. It is a rare cause of pleural effusion and is secondary to traumatic or obstructive reasons. UT is usually a transudate pleural effusion. Its diagnosis requires a high degree of clinical suspicion, because the respiratory symptoms tend to be absent or mild and urological signs tend to dominate. Thoracocentesis followed by measurement of creatinine in the pleural fluid is a procedure to establish the true diagnosis. The average pleural fluid-to-serum creatinine ratio is in the range of 1.09–19.8. Pleural fluid-to-serum creatinine ratio >1 is the diagnostic criterion of UT. We report a case of UT associated with trauma.

Urinothorax: a systematic review

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.

The Urinothorax: A Comprehensive Review With Case Series

Urinothorax is an uncommon thoracic complication of genitourinary (GU) tract disease, which is most frequently caused by obstructive uropathy, but may also occur as a result of iatrogenic or traumatic GU injury. It is underrecognized because of a perceived notion as to the rarity of the diagnosis and the absence of established diagnostic criteria. Urinothorax is typically described as a paucicellular, transudative pleural effusion with a pleural fluid/serum creatinine ratio >1.0. It is the only transudate associated with pleural fluid acidosis (pH < 7.40). When the pleural fluid analysis demonstrates features of a transudate, pH <7.40 and a pleural fluid/serum creatinine ratio >1.0, a confident clinical diagnosis of urinothorax can be established. A technetium 99m renal scan can be considered a confirmatory test in patients who lack the typical pleural fluid analysis features or fail to demonstrate evidence of obstructive uropathy that can be identified via conventional radiographic modalities. Management of a urinothorax requires a multidisciplinary approach with an emphasis on the correction of the underlying GU tract pathology, and once corrected, this often leads to a rapid resolution of the pleural effusion.

Urinothorax-an underdiagnosed cause of acute dyspnea: report of a bilateral and of an ipsilateral urinothorax case

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 procedures in the ureter or kidney such as ESWL, PCNL, and URS. Its diagnosis requires a high degree of clinical suspicion since the respiratory symptoms tend to be absent or mild and the urological signs tend to dominate. However, UT may rarely present with severe and acute dyspnea as well. The objectives of this study are to describe two new cases of this rare entity, a bilateral case and an ipsilateral case focusing on the side that occurs according to the affected renal insult, and to alert the physicians to include UT in their differential diagnosis of pleural effusions especially in patients with recent urinary tract disorders.

Pleural effusions of extravascular origin

Most pleural effusions are caused by hydrostatic and oncotic pressure imbalance, inflammation or infection, or abnormalities in lymphatic drainage. A select number of effusions are caused by fluid of extravascular origin. Some of these effusions result from complications of treatment, whereas others are a ramification of the underlying disease. The incidence, pathogenesis, clinical presentation, chest radiographic manifestations, pleural fluid analysis, diagnosis, and management are discussed.

Urinothorax: a new approach

PURPOSE OF REVIEW

The presence of urine in the pleural space (urinothorax) is a rarely recognized cause of pleural effusion. To date, only 58 cases have been reported. In this article the features of urinothorax are analyzed, and clinical and biochemical characteristics are reviewed in order to propose a classification, founded on pathogenic criteria, that will be useful in achieving the diagnosis.

RECENT FINDINGS

Recently reported cases of urinothorax provide a more detailed description of the biochemical characteristics that allow a better understanding of this entity.

SUMMARY

Urinothorax can be divided into two categories: (1) obstructive urinothorax, due to bilateral obstructive uropathy; and (2) traumatic urinothorax, due to unilateral traumatic injury of the urinary system, mostly iatrogenic. In patients with urinothorax, the pleural effusion usually has the biochemical characteristics of a transudate, with a pH lower than 7.30 and a pleural fluid/serum creatinine ratio higher than 1. These characteristics are not always present, however, and individually are shared by a significant number of pleural effusions of different etiology.

Glycinothorax: a new complication of transurethral surgery

A 76-year-old woman sustained inadvertent perforation of her posterior bladder wall during transurethral resection of a bladder tumour. In the immediate postoperative period, she developed life-threatening respiratory failure following the formation of a large, unilateral pleural effusion. After therapeutic drainage, biochemical analysis of the effusion revealed that it had a high concentration of glycine. The fluid used for intra- and postoperative bladder irrigation had leaked from the perforated bladder and collected in the pleural cavity. This type of hydrothorax complicating endoscopic urological surgery has not been described previously.