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Nephropleural Fistula — Management

A nephropleural fistula is an iatrogenic complication of approximately 3.3% of supracostal PCNL accesses.[1] Most resolve with conservative management; refractory cases require thoracoscopic intervention. See clinical page: Nephropleural Fistula.

Initial Conservative Measures​

Urinary diversion via percutaneous nephrostomy or double-J stent to decompress the collecting system, combined with chest tube drainage (thoracostomy) for associated hydrothorax or pneumothorax. Small-bore catheters (8–12F) appear comparable to standard chest tubes, with a trend toward shorter hospital stays.[2]

Most nephropleural fistulas resolve within 3 months with conservative management.[1]

Refractory Cases​

Thoracoscopic surgery with decortication for persistent or loculated pleural effusions. Intrapleural fibrinolytic therapy (t-PA) has been described for loculated collections resistant to drainage.[3][1][4]

References​

1. Lallas CD, Delvecchio FC, Evans BR, et al. Management of nephropleural fistula after supracostal percutaneous nephrolithotomy. Urology. 2004;64(2):241–5. doi:10.1016/j.urology.2004.03.031

2. Benson JS, Hart ST, Kadlec AO, Turk T. Small-bore catheter drainage of pleural injury after percutaneous nephrolithotomy. J Endourol. 2013;27(12):1440–3. doi:10.1089/end.2013.0175

3. Scovell JM, Link RE. A nephropleural fistula complicated by distal ureteral obstruction results in tension hydrothorax after percutaneous nephrostolithotomy. Urology. 2014;84(6):e28–9. doi:10.1016/j.urology.2014.08.009

4. Delvecchio FC, Hall MK, Farber S. Intrapleural t-PA therapy for loculated pleural effusion arising after percutaneous nephrolithotripsy. Urology. 2012;80(4):e41–2. doi:10.1016/j.urology.2012.06.010