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Abstract Objective This study aimed to evaluate the clinical efficacy, safety, and feasibility of medical thoracoscopy combined with fibrinolytic therapy for the treatment of complicated parapneumonic effusions and empyema, with a focus on therapeutic outcomes and recovery duration. Methods A retrospective cohort study was conducted involving 108 patients treated at Zhongshan Hospital, Xiamen University, between January 2015 and May 2024. Patients were categorized into two groups: the medical thoracoscopy group (n = 33) and the traditional treatment group (n = 75). The thoracoscopy group underwent thoracoscopic adhesiolysis and loculation breakdown, followed by intrapleural urokinase administration. The traditional treatment group received pleural catheter drainage combined with urokinase therapy. Primary outcomes included changes in inflammatory markers (white blood cell count, C-reactive protein, and procalcitonin), imaging outcomes (resolution of pleural effusion, pulmonary inflammation, and the incidence of pleural thickening at three months), pulmonary function assessed by forced vital capacity (FVC), and in-hospital mortality. Secondary outcomes encompassed the duration of postoperative fever, drainage time, intravenous antibiotic use, complication rates, initial treatment failure, length of hospital stay, and hospitalization costs. Results Both groups demonstrated significant reductions in inflammatory markers post-treatment (P 0.05). Improvements in FVC were observed in both groups, with significantly greater gains in the thoracoscopy group (P 0.05). Conclusions Medical thoracoscopy combined with fibrinolytic therapy offers significant advantages in the management of complicated parapneumonic effusions and empyema. This approach effectively enhances inflammation control, improves pulmonary function, and accelerates recovery time without compromising safety or increasing costs, underscoring its potential for broader clinical application.