Chyluria

dr rajendra prasad r

1. CHYLURIA Dr rajendra prasad ray , mch urology,IPGMER,kolkata,westbengal

2. Def:- Chyluria is recognized as a urological manifestation of lymphatic system abnormality characterized by presence of chyle in urine which results white appearing urine. Epidemiology- Prevalent among of Africa& Indian subcontinent. Mostly due to filariasis . Rare in Western countries and mostly due to post-operative. Common age group- 2 nd or 3 rd decade of life. Male: female- 6: 1. Left sided kidney is mostly affected.

3. History of hypothesis- Prout (1841)-secretion of fat from blood through kidney. Ackerman (1863)- Blockage of major lymphatics or thoracic duct- retrograde flow of lymph from gut into lumen of urinary tract. Wucherer (1869)- Presence of microfilaria in blood and urine. Manson-Bahr (1954)-Rapture of lymph varix anywhere in urinary tract leading to escape of lymph in urine.

4. Sen & Elappan (1968)- parasitic/bacterial infections-fibrosis-reduced lymphatic bed-lymphatic HT- lymph stasis and shunt formation. Recent Theory: Inflamatory reaction due to parasitic/ bacterial infection> obliterative lymphangitis > lymphatic HT> vulvular incompetence> retrograde flow & varicosities> rapture & fistula formation.

5. Etiopathogenesis

6. It is basically a disease of lymphatic system. Sceondarily involves Urinary system. Obstruction or insufficiency of vulvular system > retrograde flow of lymph > vericosities > rapture of lymphatic channel to pyelocaleceal system.

7. Etiology Classification of chyluria based on etiological factors Parasitic (primary-tropical) Wuchereria bancrofti (90%) Taenia echinococcus Taenia nana Ankylostomiasis Trichiniasis Malarial parasites

8. Non-parasitic (secondary- nontropical ) Congenital Lymphangioma of urinary tract Megalymphatics & urethral/ vesical fistulae Stenosis of thoracic duct Retroperitoneal lymphangiecatasia Traumatic lymphangiourinary fistulae Obstruction of thoracic duct/ lymphatics (tumor, granulomas , aortic aneurysm) Other causes (pregnancy, diabetes, abscess) Nephrotic syndrome

9. Clinical presentation Passage of milky urine-most common. Clot colic / passage of chylous clots. Passage of bloody & milky urine. Dysuria , frequency, urgency. Acute urinary retension ( chylous clot retension ). Constitutional symptoms- fever, wt.loss , back pain. Genital manifestation- filarial scrotum & penis. Lower limb oedema - filarial lower limb.

10. Grading Mild chyluria - Intermittent milky urine. -No clot colic/ AUR/ wt. loss. - Involvment of single calyx on RGP. 2.Moderate chyluria -Intermittent milky urine. -occasional clot colic/no AUR or wt.loss . - Involvment of 2or more calyx on RGP. 3.Severe chyluria - Continuous milky urine. -presence of clot colic/AUR/wt. loss. - Involvment of most of calyx with or without involvment of ureter on RGP.

11. INVESTIGATION Aims- Confirmation of presence of chyle in urine. -Identification of communication. - Findout the etiology. Modalities: 1.urine examination. 2.blood examination. 3.cystourethroscopy. 4.RGP. 5.lymphangiography. 6.lymphangioscintigraphy. 7.USG/IVU/CT scan/ MRI.

12. Urine: Macroscopic- milky white in colour . -on standing- 3 layers, upper fat,middle fibrin,lower cells. -Ether test- positive. -Sudan 3 test- positive. Microscopic- To exclude pyeuria ,tuberculosis(AFB), phosphaturia . Biochemical- presence of triglycerides: confirm - Albuminuria

13. BLOOD: eosinophilia : TLC-raised :ELISA- for detection of filarial antibodies. :LFT-hypo albuminemia .

14. CYSTOURETHROSCOPY: -help to localize the side of lesion. - ureteric catheterization and split urinanalysis may be done. -Rarely chylous efflux may be seen from bladder or post. Urethra.

15. RGP: -Help to demonstrate pyelo -lymphatic back flow. - ureteric catheterization upto pelvis should be done. -spot film should be taken. -patient is placed in head down position. -Gravity propagated contrast instillation should be done.

16. LYMPHANGIOGRAPHY: -previously it was the investigation of choice. -At present it is not done routinely as it is time consuming & invasive. LYMPHANGIOSCINTIGRAPHY: -It is useful, noninvasive,safe procedure. -Localizes communication site. -Indicated when RGP fails to demonstrate.

17. USG/ IVU/ CT SCAN/ MRI: -Not routinely recommended. -MR urography recommended in low down fistula (lower ureter /bladder/urethra)

18. MANAGMENT Chyluria should be considered as filarial cause untill prove otherwise. MEDICAL MANAGEMENT: -Bed rest -Dietary Modification -Nutritional support if required -Analgesic & antipyretic if needed - Antifilarial drugs: DEC-6mg/kg-14d :Ivermectin-400micgm/kg :Albendazole-400mg -Usage of abdominal belt Spontaneous remission occurs within 6 months- mostly

19. SCLEROTHERAPY: Indication: Failed conservative/ medical therapy. Agents used- Silver nitrate (0.1-3.0%) - Povidone Iodine (0.2%) -Dextrose (50%) -Hypertonic saline (76%) -Combination therapy

20. Mechanism

21. PROCEDURE: Cystoscopy with ureteric catheterization. Catheter must reach renal pelvis. -Should be done aseptically with antibiotic coverage. Patient should be placed head down position. Gravity propagated instillation of sclerosant should be done. Catheter is clamped for 45 min.and then released. Patient should be monitored closely. Done 8 hourly for 3 days.

22. Complications: -pain abdomen -Vomiting -Fever - Haematuria - Papillary necrosis -ATN

23. SURGERY: Indication- Failed sclerotherapy (3 courses). PROCEDURE- 1. Surgical lymphatic disconnection. 2.Renal auto transplantation. 3.Nephrectomy. 4.Micro surgery - Lymphovenous anastomosis . - Lymphonodovenous anastomosis .

24. SURGICAL LYMPHATIC DISCONNECTION: Consist of – Nephrolympholysis - Ureterolympholysis - Hilar vessels stripping - Gerota fasciectomy - Nephropexy .

25. Lympho -venous anastomosis This is the most physiological method of surgical correction for recurrent chyluria . The procedure increases the drainage of lymph into venous system, which rapidly decreases the intralymphatic pressure. Thus facilitating the healing of pyelo -lymphatic fistulae. The procedure is technically cumbersome as lymphatics are difficult to identify, lymphatic channels are thin, brittle and liable to collapse, which requires microsurgical expertise. Retro-peritoneal lympho -venous anastomosis The technique was described by Cockett and Goodwin Trans-inguinal spermatic lympho -venous anastomosis Xu et al shows 60% while Zhao et al reported 76.3% success rate.

26. Inguinal lymph node- saphenous vein anastomosis lymphnodo -venous anastomoses is made according to the principles of lymphovenous shunt. A conical tissue of lymph node close to the greater saphenous vein in the inguinal region is removed and the remaining tunnel-shaped node is anastomosed to the vein to drain the lymph into the venous system. Hou et al 85.7% effective rate. This operation avoids damage to both the afferent and efferent lymphatic vessels and affords a large anastomotic stoma for free passage of the lymph into the vein. .

27. Thank you