Background: Parapneumonic empyema (PPE) management remains debated. Here we present the outcome of a comparable population with PPE treated over a 4-year period in two Thoracic Surgery University Centers with different approaches: one with an early "surgical" and the other with a "fibrinolytic" approach. Methods: All operable patients with PPE managed in both centers between January 2014 and January 2018 were reviewed. Patients with persistent pleural effusion/loculations following drainage were managed by a "surgical" approach in one center and by "fibrinolytic" approach in the other. For each patient, we recorded the age, sex, hospital stay, morbidity/mortality and change in pleural opacity on chest X-ray before and at the end of the treatment. Results: During the study period, 66 and 93 patients underwent PPE management in the "surgical" and "fibrinolytic" centers respectively. The population characteristics were comparable. Infection was controlled in all patients. In the "fibrinolytic" group, 20 patients (21.5%) underwent an additional drain placement while 12 patients (12.9%) required surgery to correct PPE. In the "surgical" group, 4 patients (6.1%) developed postoperative arrhythmia while 2 patients (3%) underwent a second surgery to evacuate a hemothorax. Median drainage {3 [2-4] vs. 5 [4-7] days} and hospital {7 [5-10] vs. 11 [7-19] days} durations were significantly lower in the "surgical" compared to the "fibrinolytic" center. Pleural opacity regression with therapy was significantly more important in the "surgical" compared to the "fibrinolytic" group (-22%±18% vs. -16%±17%, P=0.035). Conclusions: Surgical management of PPE was associated with shorter chest tube and hospital duration and better pleural space control. Prospective randomized studies are mandatory.