To our knowledge, this is the first reported clinical case of urinothorax secondary to fornix rupture due to bladder tumor. Based on the various data in the literature, we will discuss our case.
Spontaneous fornix rupture is a rare urological emergency and is one of the possible complications of excretory tract obstructions [1]. Obstruction of the upper urinary tract causes pressure in the renal pelvis that would lead to possible rupture of the fornix [2]. In most cases, it manifests itself by the sudden appearance of an intense loin pain. Diagnosis can be made by CT scan [3]. Total clotting gross hematuria associated with acute low back pain was the clinical manifestation in our patient. Chest pain was present.
It is a predominantly male entity (70% of men) that can lead to acute renal failure in 30% of cases. Urine culture was positive in 6 patients (15%) [4]. In this study, the patient was 56 years old. A renal insufficiency was found, the bacteriological examination of the urine isolated a germ, a multi-sensitive Escherichia Coli.
Out of 162 patients, urolithiasis was found in 60% of cases as the cause and in 28% of cases no cause was found for fornix rupture. Other causes were isolated but not the bladder tumor [1]. Urinothorax is a rare complication of blunt kidney trauma, ureteral instrumentation or ureteral surgery. Leakage from the urinary tract causes a urinoma (retroperitoneal accumulation of fluid) which can lead to a urinothorax [5]. The most specific biochemical aspect of urinothorax is the presence of a ratio of pleural fluid creatinine to blood creatinine greater than 1 [6]. The management of urinothorax requires a multidisciplinary approach based on the correction of the underlying genitourinary obstructive pathology, which allows for a rapid and spontaneous resolution of the pleural effusion [7]. We are reporting a case of ruptured fornix due to bladder tumor leading to an urinothorax. The biochemical analysis allowed us to consolidate the diagnosis.
Conservative management is a valid option in uncomplicated cases. Urinary derivation should be reserved for complicated cases or cases with significant urinoma [4]. Specifically, the emergency treatment consisted of a bilateral nephrostomy, urinary diversion which has a double interest in this patient (urinoma and obstructive renal failure). The definitive treatment consisted of endoscopic resection of the tumor with bilateral double J-tube stenting. Since our patient was asymptomatic on the respiratory level and the effusion was of low abundance, the urinothorax was respected. On the time of control by chest X-ray, we did not notice any pleural effusion. The consequences were simple by the improvement of clinical signs and symptoms and the normalization of biological parameters.