Case Study: Urinothorax after total laparoscopic hysterectomy: a significant early sign of urinary tract injury

Abstract

BACKGROUND: Urinothorax is a rare cause of pleural effusion after gynaecolgical surgery and can happen after an undiagnosed urinary tract injury. It is defined as the presence of urine in the pleural cavity due to leakage of urine from the peritoneal and retroperitoneal space into the pleural space. One of the diagnostic criteria is the pleural fluid-to-serum creatinine level > 1 and urinothorax is completely reversible after treatment of the underlying urinary tract injury. We describe the first case of urinothorax which occurred after total laparoscopic hysterectomy. CASE DESCRIPTION: A 51-year-old woman underwent total laparoscopic hysterectomy and bilateral salpingooophorectomy for a 438 g fibroid uterus. Her postoperative course was complicated by pelvic abscess, which required laparoscopic drainage 2 weeks after the initial operation. In the following week, she developed massive right pleural effusion, which persisted despite repeated chest drainage. Abdominal and pelvic computed tomography, which showed a normal urinary system at 2 and 3 weeks, showed left hydroureter and left hydronephrosis, at 8 weeks after the initial operation. Left percutaneous nephrostomy and nephrostogram were performed, showing dilated left upper ureter with apparently complete obstruction at the left lower ureter at the sacral level. The pleural fluid-to-serum creatinine level was 1.02. There was no more reaccumulation of the pleura effusion after percutaneous urine drainage. Following reimplantation of the ureter at 3 months, the woman made a complete recovery. CONCLUSION: Presentation of urinary tract injury following laparoscopic surgery can be delayed and subtle. Urinothorax can be an early sign of urinary tract injury, and may precede the appearance of obstructive uropathy. Recognition and awareness of urinothorax as a possible suquelae of urinary tract injury may allow early diagnosis and management of laparoscopic related urological complications.