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Introduction: The treatment of complicated parapneumonic effusion (PPE) and thoracic empyema (TE) is controversial; and the choice of treatment after confirming the failure of simple drainage remains unclear. The purpose of this study was to compare the outcomes of intrapleural urokinase (UK) administration and video-assisted thoracoscopic surgery (VATS) as initial treatment options for PPE and TE. Materials and Methods: We retrospectively reviewed and compared the data of 20 patients with PPE and TE diagnosed between January 2010 and December 2012 at our hospital, dividing them on the basis of the initial treatment into a video-assisted thoracoscopic surgery (VATS) group (n=9) and UK group (n=11). Results: Age was the only statistically different parameter between both groups (P=0.025); with the mean age of the VATS and UK groups being 64 and 76 years, respectively. There was no significant difference in the duration of drainage or success rate between the UK or VATS groups. Although no statistically significant differences (P=0.20) were observed, duration of hospital stay was longer in the UK group (21 and 28 day for VATS and UK, respectively). Conclusion: VATS for PPE and TE may shorten the duration of hospital stay.However, UK administration may be used for selective patients because it is considered to yield outcomes similar to VATS.