C45-06 Placement of a Tunneled Pleural Catheter to Treat Recurrent Urinothorax

Introduction Urinothorax is a rare cause of pleural effusion usually linked to urinary tract obstruction or trauma. Here, we report a case of recurrent urinothorax in a patient with advanced ovarian carcinoma and nephrotic syndrome, managed with the placement of a tunneled pleural catheter (TPC). Description In September 2025, a 54-year-old female with a past medical history of Stage IIIC high grade serous ovarian carcinoma complicated by malignant ascites (status post tunneled abdominal drain), bladder-peritoneal fistula on salvage chemotherapy and nephrotic syndrome presumed secondary to bevacizumab presented with tachypnea and a new onset hypoxemia in the setting of a large left pleural effusion. Initially the concern was for translocation of malignant ascites into the pleural space due to a malfunctioning abdominal drain. However, when point-of-care-ultrasound revealed minimal abdominal ascites and a large, simple left sided effusion, thoracentesis was pursued for both diagnostic and therapeutic purposes. Patient underwent first a 700 mL and then a 1,600 mL large volume thoracentesis. On both occasions, the aspirated pleural fluid appeared similar to urine (see image). The pleural fluid-to-serum creatinine ratios were 1.0 (first thoracentesis, using a non-simultaneous serum sample, in the setting of a resolving acute kidney injury) and 1.02 (second thoracentesis, with simultaneous sampling: pleural creatinine 1.68 mg/dL, serum creatinine 1.64 mg/dL). These findings, along with the patient’s known bladder-peritoneal fistula, were strongly suggestive of a urinothorax, due to translocation of urine across the diaphragm. After discussion with Gynecologic Oncology and Urology, any intra-abdominal procedure was deemed high risk given widespread malignancy. As such, during patient’s subsequent admission for tachypnea and hypoxemia, the decision was made to place a left-sided tunneled pleural catheter (see images). Prior to discharge home, patient had high outputs from her TPC, necessitating both daily in hospital and later at home drainage. The TPC effectively controlled her respiratory symptoms and prevented further hospital readmissions for pleural effusion management. Discussion While definitive management of urinthorax ideally corrects the underlying etiology and addresses the pleural space, such intervention was not feasible in this patient due to extensive metastatic disease and procedural risk. Therefore, a TPC was placed for palliation of symptoms and to avoid readmissions for patient’s recurrent, symptomatic urinothorax.