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Nephropleural Fistula Repair

For diagnosis and pleural-fluid interpretation, see Nephropleural Fistula. Treatment addresses both the urinary source and its thoracic consequences. Urinothorax can arise without a persistent direct fistula, so define the anatomy and cause rather than treating every postoperative effusion identically.[3][4][6]

Acute Management​

Assess respiratory status, hemodynamics, infection and urinary drainage promptly. Tension physiology or significant respiratory compromise requires urgent pleural decompression and simultaneous treatment of the urinary problem. A reported case of tension hydrothorax after nephroureteral-stent removal involved distal ureteral obstruction and required nephrostomy, thoracostomy and subsequent thoracoscopy.[2]

Select pleural drainage according to the collection, respiratory effects and suspected infection. Benson's small-bore catheter study concerned postoperative hydrothorax/pneumothorax, not exclusively nephropleural fistulae: only 15 of 735 PCNL procedures required drainage, with ten small-bore and five large-bore tubes. Its nonrandomized comparison does not establish that an 8–12 Fr catheter is sufficient for every infected, loculated or hemorrhagic collection.[1]

Control the Urinary Source​

Use ureteral stenting, nephrostomy or both to provide reliable low-pressure drainage and correct obstruction or a displaced device. Choice depends on anatomy, access, infection and whether the obstruction can be traversed. If an existing stent does not provide adequate drainage, reassess its position and patency and obtain additional drainage as needed; distal obstruction does not by itself prove that a correctly placed stent cannot work.[2][3][5]

In the 2017 urinothorax systematic review, treatment directed at the uropathy was generally associated with favorable outcomes, whereas the reported cases treated only by thoracentesis/chest drainage did poorly. These were case reports and retrospective descriptions, not a comparison establishing a universal failure probability. Persistent urinary leakage should trigger reassessment of its cause rather than repeated isolated chest drainage.[6]

What the Post-PCNL Evidence Shows​

Lallas reported four nephropleural fistulae among 375 patients and 462 access tracts. The rate was 3.3% specifically among the 120 supracostal tracts, not among all PCNL cases. Three patients recovered without thoracic surgery; one required thoracoscopic decortication for persistent effusion. All four had resolved at the three-month follow-up. This does not establish either a 75% general success rate or a three-month period during which ongoing leakage can be left untreated.[3]

Reassess symptoms, pleural drainage, renal drainage and imaging as clinically indicated. Confirm resolution of the leak and relief of obstruction before removing supporting drainage. A pediatric report involved displacement of a JJ stent into the pleura and improved after repositioning plus nephrostomy; it illustrates the need to check hardware rather than defining a standard protocol.[5]

Persistent or Infected Collections​

Failure to improve requires renewed imaging and review by urology, interventional radiology and the pleural/thoracic team. Distinguish ongoing urine entry from loculated infection, inadequate drain position and trapped lung. Surgical drainage, debridement or decortication may be necessary; direct fistula/diaphragm repair is reserved for suitable persistent anatomical defects.[3][11]

A 2012 report used intrapleural t-PA for a nonresolving post-PCNL collection. It is single-case evidence, not a standard escalation step or proof that surgery can be avoided.[7] For established adult pleural infection, BTS 2023 conditionally supports t-PA plus DNase when drainage has stopped but a residual collection remains, and advises against either agent alone. Bleeding risk and recent surgery require individualized assessment. This recommendation treats pleural infection; it does not close the urinary fistula.[11]

Do not transfer peritoneal-dialysis pleuroperitoneal-fistula pleurodesis results into nephropleural repair. No nephropleural evidence establishes a universal 2 cm suture-versus-mesh cutoff, mandatory talc pleurodesis, or superiority of open thoracotomy over VATS. Access and repair materials depend on the defect and contamination.

Nephrobronchial Fistula​

Communication with the bronchial tree introduces an additional risk of airway contamination. Published cases frequently involve a severely infected or destroyed kidney and have been managed with infection control, nephrectomy and drainage; outcome reports include deaths. Assess renal function, infection extent and surgical fitness jointly with thoracic surgery and anesthesia.[8][9]

Plan airway protection before manipulation. A 1981 fatal case described pus entering the opposite lung during nephrectomy; its authors advocated lung isolation with a double-lumen tube and early control of the fistulous tract. That report supports explicit planning to prevent contamination, not a universal requirement for one airway device or operative sequence in every anatomical situation. Avoid pressurizing an infected collecting system without considering its airway communication.[10]

References​

1. Benson JS, Hart ST, Kadlec AO, Turk T. "Small-bore catheter drainage of pleural injury after percutaneous nephrolithotomy: feasibility and outcome from a single large institution series." J Endourol. 2013;27(12):1440–1443. doi:10.1089/end.2013.0175

2. Scovell JM, Link RE. "A nephropleural fistula complicated by distal ureteral obstruction results in tension hydrothorax after percutaneous nephrostolithotomy." Urology. 2014;84(6):e28–e29. doi:10.1016/j.urology.2014.08.009

3. Lallas CD, Delvecchio FC, Evans BR, et al. "Management of nephropleural fistula after supracostal percutaneous nephrolithotomy." Urology. 2004;64(2):241–245. doi:10.1016/j.urology.2004.03.031

4. Austin A, Jogani SN, Brasher PB, et al. "The urinothorax: a comprehensive review with case series." Am J Med Sci. 2017;354(1):44–53. doi:10.1016/j.amjms.2017.03.034

5. Arora S, Raj A, Ansari MS. "Nephropleural fistula after percutaneous nephrolithotomy in a pediatric patient: diagnosis and management." Urology. 2015;85(1):e3–e4. doi:10.1016/j.urology.2014.09.019

6. Toubes ME, Lama A, Ferreiro L, et al. "Urinothorax: a systematic review." J Thorac Dis. 2017;9(5):1209–1218. doi:10.21037/jtd.2017.04.22

7. Delvecchio FC, Hall MK, Farber S. "Intrapleural t-PA therapy for loculated pleural effusion arising after percutaneous nephrolithotripsy: a case report." Urology. 2012;80(4):e41–e42. doi:10.1016/j.urology.2012.06.010

8. Burbano MA, Nati-Castillo HA, Castaño-Giraldo N, et al. "Fatal nephrobronchial fistula arising from xanthogranulomatous pyelonephritis: a case report." Front Med. 2024;11:1374043. doi:10.3389/fmed.2024.1374043

9. Hampel N, Sidor TA, Persky L. "Nephrobronchial fistula. Complication of perinephric abscess secondary to ureteral obstruction and pyonephrosis." Urology. 1980;16(6):608–610. doi:10.1016/0090-4295(80)90571-3

10. Rao MS, Bapna BC, Rajendran LJ, et al. "Operative management problems in nephrobronchial fistula." Urology. 1981;17(4):362–363. doi:10.1016/0090-4295(81)90267-3

11. British Thoracic Society. Guideline for pleural disease. 2023. Pleural infection: intrapleural therapy and surgical management. Full guideline.