Operative management problems in nephrobronchial fistula.

During left subcapsular nephrectomy in a patient with nephrobronchial fistula, the purulent material entered the bronchial tree through the fistulous tracts and flooded the dependent right lung. Patchy atelectasis and later massive consolidation of the lower lobe of the right lung ensued ultimately causing her death. A plea is made to use double-lumen endobronchial tubes for anesthesia to prevent such spillover of purulent secretions to the contralateral lung from the kidney. The fistulous tracts should be divided as the first step during surgery, before mobilization of the kidney. In a suspected case, retrograde pyelography should be done preferably under local or regional anesthesia, so that the patient could cough out the contrast material and purulent secretion that might enter the bronchial tree under pressure during the procedure.