Chyluria - An Overview

Article Information:


Group: IJNU, 2009
Subgroup: Volume 1, Issue 1, Summer
Date: January 2009
Type: Review Article
Start Page: 14
End Page: 26

Authors:

  • Sachit Sharma
  • Department of Urology, All India Institute of Medical Sciences, New Delhi, India
  • Ashok Kumar Hemal
  • Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

      Correspondence:

      Affiliation: Department of Urology, All India Institute of Medical Sciences
      City, Province: Ansari Nagar, New Delhi
      Country: India
      Tel: +91-1262-210100
      Fax: +91-1262-211308
      E-mail: drsachitsharma@yahoo.co.uk

Abstract:


Chyluria,recognized as a urological manifestation of lymphatic system abnormality has been a curious entity since long. With varied options for management, this tropical, debilitating disease is known for recurrence.The article provides an in-depth review into the subject with the author's experience in the field along with the recent advances in management. This article also describes the entity from its historical background, etiopathogenesis,investigative and management protocols including complications. Recent treatment modalities reported in literature are reviewed with author's innovative contributions in the form of applying MR scan for diagnosing and robotics for treating chyluria.

Keywords: Chyluria;Laparoscopy;Recurrence;Sclerotherapy;Surgery

Manuscript Body:


Chyluria, recognized since the time of Hippocrates (400BC) is described as the passage of milky appearing white urine due to the presence of chyle composed of albumin, emulsified fat and fibrin in varying proportions that are absorbed by intestinal lacteals. It is associated with spontaneous remissions and exacerbations. Although rare in the West, it is not uncommon in Asia. It has been recognized as a tropical disease more prevalent in the rural and poverty stricken population. This review article provides an in-depth into the subject with the author's experience in this field along with the recent advances in management (1-4).

History of Hypothesis

The following were the explanations in the past for causation of chyluria:

Prout (1841): Secretion of fat from blood through kidneys (5).

Ackerman (1863): Blockage of major lymphatics or thoracic duct causing retrograde flow of lymph from the gut and pelvis into lumen of GIT (6).

Wucherer (1869): Presence of microfilaria in blood/urine of chylurics (7).

Lazarus and Marks (1946): Presence of fistulous openings in bladder causing chylous efflux from ureteric orifices (8).

Manson-Bahr (1954): Rupture of lymph varix anywhere in urinary tract leading to escape of lymph in urine (9).

Sen and Elappan (1968): Parasitic / bacterial infections -> fibrosis -> reduced lymphatic bed -> lymphatic HT -> lymph stasis & shunt formation (10).

Recently the following theories have been implicated as causative factors:

Obstructive theory (Aye and Aung, 1975): Inflammatory reactions due to parasitic infestation lead to obliterative lymphangitis, lymphatic HT, valvular incompetence and retrograde flow of chyle producing a lymphatico-renal shunt (11).

Regurgitative theory (Ngan and Leong, 1977): Toxic metabolites or immune reaction to parasitic infestation leads to lymphatic ectasia and varicosities, that rupture, releasing chyle from dilated intestinal lymphatics into the renal system (12).

Etiopathogenesis

Chyluria is associated with abnormal retrograde or lateral flow of lymph from the intestinal lymphatics of the kidney, ureter or bladder allowing chylous material to be discharged into the urinary collecting system (1). Various causative factors have been implicated. Passage of chyle into the urine has been related to a consequence of the rupturing of the lymphatic varices leading to the aperture of one or more perirenal lymphatic vessels to the pyelocaliceal system, characterized by milky urine, rich in protein, lipids, cholesterol and triglycerides. A malformation of the chyliferous vessels of the small intestine associated to hypoplasia of Pecquet's cistern has also been suggested.

On anatomical basis, the renal lymphatics follow the renal vein and end in lateral aortic glands; efferents  from  which  flow  to  the  lumbar  trunks. The intestinal trunks receive lymph from stomach, intestine, pancreas, spleen and liver. Physiologically chyle travels from the lacteals to the cisterna chyli or   thoracic   duct.   Pathological   obstruction   and/ or insufficiency of the valvular system of lymph channels leads to retrograde flow to lumbar lymph glands draining renal lymphatics. Thus there is a short circuiting of chyle drainage from intestinal lacteals to renal lymphatics.

Classification

The classification is based on the etiological factors- broadly divided into two groups, parasitic and non parasitic (Table 1). Although rarely seen in some countries, however its prevalence is high in areas where infections with Wuchereria bancrofti are endemic. Chyluria is extremely rare in Europe, but is frequently reported from Asian countries like India, China, Taiwan and Japan (13-17). Epidemiological surveillance since 1984 indicates that the transmission of infection has been interrupted (18). Approximately 120   million people worldwide are affected by lymphatic filariasis.

Chyluria can also have non-parasitic causes of which only a few cases have been described. Chyluria due to a congenital fistulous communication between the lymphatic system and the bladder has been described in children (19). Chyluria may occur as an exceptional complication of retroperitoneal lesions in lymphangiomatosis in rare cases (20, 21).

Chylous ascites and chyluria have been reported in   nephrotic    syndrome   with   focal  segmental glomerulosclerosis and nephrotic syndrome due to retroperitoneal lymphangioma. Hypoalbuminemia- induced bowel edema may predispose to change in the permeability of mucosal or serosal lymphatics resulting in chylous ascites (22, 23).

Clinical features

The most common clinical symptom is passage of milky urine in up to 70% cases (24). Other symptoms include chylous clot, bloody and milky urine, dysuria, frequency, urgency and urinary retention in decreasing order of presentation. Constitutional symptoms include  weight  loss,  low-back  ache,  fever,  chills and hydrocele. The duration of symptoms may be as long as 2- 11 years (1). The disease is significantly higher in males (86%) than in females (14%) (25). It has been more frequently reported on the left side (26).  Majority of the cases present in the second and third decade of life. About 70% cases have genital manifestations, 25% lymphatic obstruction in limbs and 5% suffer from manifestations like cellulitis, abscesses, hematuria and chyluria. Previous history of filariasis or its complication has been documented in 19% cases (27).

 

Table1. Classification of chyluria based on etiological factors 

Parasitic (primary-tropical)

Non-parasitic (secondary-nontropical)

  • Wuchereria bancrofti (90%)
  • Taenia echinococcus
  • Taenia nana
  • Ankylostomiasis
  • Trichiniasis
  • Malarial parasites

 

  • 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

 Grading

The severity of the disease can be graded into (1):

Mild chyluria (34-50%): Intermittent milky urine; no clot colic/chylous coagulum/urinary retention/ weight loss; involvement of single calyx on RGP.

Moderate  chyluria (33- 40%):   Intermittent continuous milky urine with occasional clot colic/ chylous coagulum; no urinary retention/weight loss; involvement of 2 or more calices on RGP.

Severe chyluria(15-26%): Continuous milky urine with clot colic/chylous coagulum/urinary retention /weight loss; involvement of most of calices with/without involvement of ureter on RGP (1).

Investigations

Urinary Examination

A fatty diet a day or night before enhances chyluria and helps in its diagnosis. A fresh sample of urine is grossly inspected. The classical urine in chyluria is like milk, frequently containing a semisolid gel, blood and fibrin clots. On standing in test tubes, it separates into a top fat layer, middle fibrin and bottom layer of cells and debris. Microscopic examination of the sediment comprises of erythrocytes and lymphocytes. In the presence of symptoms like milky urine, proteinuria and leukocyturia in the urinary sediment and a negative urine leukocyte stick test and absence of infectious signs, chyluria must be suspected (13).

Ether test

Vigorous shaking (few minutes) with equal amount of ether clears opacity.

Methylene blue test

Fresh stain with one/two drops of 1:1500 reveals small lymphocytes (single/clump).

Sudan III test

Oral ingestion of fat labelled with Sudan III (10 gm butter + 100 mg Sudan red III) causes orange pink colouration of urine in chylurics within 2-6 hours.

Biochemistry

Urinary triglycerides are invariably present in morning sample, 100% sensitive/specific test. Postprandial urine lipids, especially triglycerides (TGs) ranging from 10 to 1955 mg/dl, might be used as markers for the clinical evaluation of chyluria. Urine albumin is abnormally high in most cases (16).

Immunoelectrophoresis

Shows globulins of various types of apolipoprotein .A 48 (of intestinal origin).

Cystourethroscopy

Helps to localize the side of milky efflux from one/ both ureteric orifices. Rarely chylous efflux may be seen from bladder or even posterior urethra. A fatty diet previous day/night enhances results. Ureteric catheterisation (5-6 F) and split urinanalysis may be done simultaneously.

Retrograde pyelography (RGP)

With help of fluoroscopy and spot films it demonstrates   pyelolymphatic   backflow.   RGP   is not specific as the same is also seen in normal kidneys if contrast is injected under pressure. 20° Trendelenberg  position  is  used  under  fluoroscopy for  ureteric  catheterization  to  reach  renal  pelvis after cystoscopically identifying laterality of efflux. Gravity propagated contrast instillation prevents sudden distension of renal pelvis which may lead to loin pain due to opening up of pyelovenous/pyelosinus channels thus causing inadvertent reactions.

Lymphangiography

Lymphangiography is the preoperative imaging procedure of choice and the most powerful diagnostic tool as it demonstrates the site, the caliber and the number  of  the  fistulous  communications.  It  can also diagnose vascular dysplasias of the lymphatic vessels (28). Findings generally include lymphatico- urinary fistulae at level of kidney, ureter or bladder; tortuous dilated lymphatics around hilar region (lymphangiectasia) communicating with paravertebral lymphatics; contrast outlining major/minor calyces. Other findings that may be seen include tortuosity and beading of thoracic duct, round granular enlarged nodes in paraortic area, skipping of lymphatic chain, dilated cisterna chylii and abnormal lymphatics coursing down along the ureters. In 40% cases contrast may enter PCS and drain via bladder.

It is not routinely done as it is time consuming, technically demanding and invasive (29).

Unilateral pedal lymphangiography can detect lymphaticorenal fistulae via lymphatic crossover even when it is on the side opposite from which contrast agent has been injected. The advantages of unilateral lymphangiography  over bilateral procedures  are that it is easy to identify crossover channels, and the discomfort for the patient is reduced because there are fewer incisions and it is quicker (29, 30).

Lymphangioscintigraphy

Though useful in delineating the site of the fistula it is not as precise as lymphangiography. However, it is a useful, noninvasive, safe, simple technique using Tc99 human serum albumin sulphur colloid, Tc-99m diethylenetriamine pentaacetic acid,99mTc-antimony sulfide colloid or dextran.It is the investigation of choice (if available) to localize, lateralize and to know the functional extent of reflux and to detect recurrence on follow-up. It can demonstrate abnormal lymphatic drainage in chylurics and allows functional assessment of lymphatic transport and depiction of regional  lymph  nodes. A rapid  and  non-traumatic investigative procedure, it has no known side effects (31-33).

Immunological Studies

ELISA Test:

The test is useful in diagnosing cases where causative agent is suspected to be filarial and is based on humoral immune response of host to filarial antigen. Filarial IgG antibodies against microfilarial excretory-secretory (mf ES) antigen have been detected in 89% of cases with genital manifestations, 87% with lymphoedema, 67%with lymphadenitis and 60% with other clinical manifestations. With a 85% specificity and 95% sensitivity, it is positive in 3% of endemic normals (25).

Immune function of the patients who present with filarial chyluria is impaired in terms of the changes in T-lymphocyte subsets. The percentage of CD3+, CD4+ cell is significantly decreased, the ratio of CD4+/ CD8+ being under 1.0 (34). Both cell-mediated and humoral immunity are low in chyluric cases. OKT3 and OKT4 levels are commonly low, and OKT8 is higher than normal value with the OKT4/OKT8 ratio inverted (35).

Ultrasonography : Echolucent areas may be seen within blood clot due to the chylous component; leading to heterogenous character of clot. This needs to be differentiated from carcinoma bladder.

Intravenous pyelography : Rarely used to demonstrate  dilated  para-calyceal  lymphatics (need for application of ureteric pressure), it may delineate increased renal size in severe disease state due to obstruction. Overall it is not a cost effective investigation.

CT scan : Fat in the bladder secondary to chyluria can be picked up on CT (36). Dilated lymphatic channels may mimic a mass of confluent low-density lymph nodes (37).

MR scan (Figure 1) : A non-invasive and less time consuming study -best to delineate anatomy (but no functional assessment). It is most useful in cases where site of obstruction is lower ureter/bladder. On MR urography, the lymphatic channels are seen as a meshwork of multiple tubular, tortuous, fluid filled structures  in  the  retroperitoneum  of  the  abdomen and pelvis. On axial T1W images, these channels are seen as numerous, interconnected small, nodular and streaky intensities and as a cloak of diffuse homogenous hyperintensity on T2W axial images (37). An innovation of the author, the results of this useful modality of investigation are being evaluated.

Renal biopsy : Mainly undertaken for academic research generally shows immune complex type of glomerulonephritis (38).

Others : Serum type I collagen and type III procollagen are decreased in patients with filariasis. In contrast, serum hyaluronan (linked to perilymphatic granulomatous inflammation) and serum eosinophil cationic protein is significantly increased in patients of fileria exhibiting chyluria (39).

Management

Non surgical management

Dietary modifications: As absorption of dietary fats leads to chyle formation, hence a fat restricted diet is recommended (<25 g/day). Fats containing MCT (<12 C atoms) are absorbed directly through portals- hence use of coconut oil recommended (40). In heavy chyluria, parenteral administration containing fat as MCT with albumin is given. TPN with enteric rest is advised in intractable chyluria (41).

Diethyl carbamazine (DEC/ Hetrazan / Benocide): The dose is 6mg/kg in 3 divided doses after food for 10-14 days (42). Ivermectin 400mg/kg (single dose) and/or albendazole 400mg may be given along with DEC as symptomatic treatment where filarial infection seems to be the cause.

Supportive treatment: High protein diet is advised to make up for the albumin lost in the form of chyle. Hematinics, multivitamins and green leafy vegetables are recommended in hematochyluria. Bed rest, anti- inflammatory, analgesics and antipyretics are useful in managing in associated lymphadenitis. Abdominal binders may be applied during acute attacks of chyluria to reduce loss of chyle. Cytoscopic bladder wash is recommended in cases of clot/chylous urine retention and/or recurrent urinary tract infections.

Sclerotherapy (Table 2): Comprises of instillation of renal pelvis with chemicals - silver nitrate (0.1-3.0%) ,   0.2%   povidone   iodine,   15-25%   sodium iodide, 10-25% potassium iodide, 50% dextrose, 76% hypertonic saline, combination therapy using 5/6 F ureteric catheter after localizing site on cystoscopy in cases of failure of conservative management i.e. dietary modifications and as prophylaxis. These agents bring about relief by causing chemical lymphangitis (Diagram 1).

 

Figure 1. Non-invasive MR scan shown extensive involvement of bilateral lymphatics with good anatomical background

 

Permanent relief: The procedure is performed under LA/ sedation with aseptic precaution keeping the head down (200) and instilling 7-10ml sclerosant  

under gravity (fluoroscopy assisted). Analgesic / antibiotic cover is given for at least 5 days. Dosage schedule is 8 hourly for 3 days or 12 hourly for 2 days or weekly for 6-8 weeks. Recurrence after 1st course can be treated for second time with high success rate. Patients with shorter as disease free duration fare poorly with second course. In bilateral efflux gap period of minimum 6-8 weeks between 2 sittings is recommended (43).

Silver Nitrate (0.1-3.0%): It is most commonly used sclerosant till date. 2gm silver nitrate powder is dissolved in 200ml of water in a bottle (black paper/dark room). The need for sterilization (autoclaving) results in a 8-24 hr undesirable delay. Other disadvantages include procuring and precisely weighing good quality silver nitrate, water insolubility, susceptibility to light, and precipitation with normal saline to form insoluble silver chloride salts that may cause uretric obstruction.  As  even  mortality  has  been  reported due to acute tubular necrosis (ATN) on instillation of silver nitrate in both ureters simultaneously, care needs to be observed (44, 45).

Povidone Iodine (0.2%): It is a water soluble, non- ionic surfactant polymer that releases iodine slowly. Prepared by mixing 2ml 5% povidone iodine to 8ml distilled water it is to be used as a fresh solution. It is as effective as 1% silver nitrate with no side effects like flank pain, nausea, vomiting, interstitial nephritis, chemical   cystitis,   papillary   necrosis   and   ATN. Also having antiseptic antibacterial and antifungal properties (46) it is considered safe and effective for managing chyluria (15).

Combination therapy: Combination sclerotherapy using a 5% povidone iodine and 50% dextrose solution has been found to be a safe and cost-effective minimally invasive therapy for chyluria refractory to conservative treatment. 5ml of 50% dextrose combined with 5ml 0.2% povidone iodine provides stronger and better fibrotic response (24).

Heat-clearing  and  hemostatic  treatment:  26 out of 30 patients of chyluria have been reported to be cured completely with a basic heat-clearing and hemostatic prescription (35).

Surgical management: Surgery is the treatment of choice in severe forms of chyluria i.e. significant weight loss; hypoproteinemia, anasarca,  and/or severe anemia; recurrent clot retention and hematochyluria; recurrent UTI; refractory chyluria (failure of conservative treatment with adequate dietary modification, medical management and two or more instillations of sclerosants); clinicallysignificant chyluria (associated with chylous clot or  hematochyluria or duration of more than 1 year or failure to respond to conservative medical measures) (47);  altered immune status; marked psychological disturbance.

 

Table 2. Results of sclerotherapy of different series 

Study

Year

Response (%)

FU (months)

FU (months)

Silver Nitrate

 

 

 

 

Yu et al (70)

1978

119/161 (74%)

-

26%

Ohyama et al (71)

1979

-               (62%)

2 -115

37%

Okamoto and Ohi (72)

1983

129/217 (59%)

24

40%

Tan et al (73)

1990

46/55 (83%)

24

16%

Sabnis et al (74)

1992

51/62 (82%)

24-84

18%

 

 

 

 

 

Povidone Iodine

 

 

 

 

Shanmugam et al (75)

1998

5/5 (100%)

6

-

Goel et al (46)

2004

36/41 (88%)

24

12%

50% Dextrose

 

 

 

 

Goel et al (46)

2004

20/21 (95%)

5.2

98%

Povidone Iodine + 50%

 

 

 

 

dextrose

2004

40/46 (87%)

24

13%

Nandy et al (24)

 

 

 

 

 

Open surgical techniques

Lympho-venous  disconnection:  First  described by Katamine in 1952 it is the most commonly performed procedure. A fatty diet 24-36 hr prior to surgery facilitates detection of lymphatics. Pedal lymphangiography and/or methylene blue injection delineates the lymph channels. Reno-lymphatic disconnection operation is performed via a lumbar incision. The kidney is freed, lymphatics in hilar area coursing along the renal vein are dissected, ligated & cut. Areolar tissue containing dilated lymphatics travelling to the kidney in the perirenal and hilar region are dissected and divided between ligatures - thus stripping these structures completely. Hilar stripping is continued up to proximal 3-4cm ureter, the site for majority of shunts. Recurrence or bladder leak on imaging, mandates stripping of the entire ureter (48).

Patna operation (1977): It is a modified procedure of peri-ureteric lymphovenous stripping. Disconnection of only abdominal ureter is done without hilar disconnection. "Ureter in Lymphatic Tunnel" i.e. pampniform plexus in front and pre/para aortic plexus behind is the basic concept followed (49).

Omental wrapping (2004): Omentum is used to wrap the renal vessels after stripping both anteriorly and posteriorly. This reduces the incidence of postoperative lymphatic drainage, lymphocele formation, recurrence, fibrosis and postoperative adhesions (47).

Renal autotransplantation: This is rarely indicated for fistulas in the lower portion of ureter /bladder or when renal pedicle stripping has failed (incomplete procedure/ recanalization) or there is formation of newer fistulas (50).

Nephrectomy: It is used only for kidneys rendered non-functional following lymphovenous disconnection and serves as a life saving measure in severely refractory chyluria (51).

 

Diagram1.Sclerotherapy-Mechanismof Action

Cockett and Goodwin procedure (1962): The procedure is based on diversion of a single hilar lymphatic to a spermatic/gonadal vein in end-to-side fashion. It provides a safety valve mechanism for renal lymphatic hypertension-the basis of chyluria. It obviates need for complete stripping and there is a decreased incidence of lymphocutaneous fistula. However, the demerits include increased operative time, technical difficulty and need for magnification (52).

Microsurgical procedures: Recommended in the old and debilitated patients unable to tolerate ligation/ division of lymphatics this technique has been found useful in persistent or recurrent chyluria. Aiming to physiologically decrease the intra lymphatic pressure by increasing lymph drainage into venous system it reduces incidence of lymphangiectasia and facilitates healing of lymphatic fistula in the renal papilla. A simple, easy relatively superficial procedure - less traumatic to surrounding tissues it obviates the use of CPE / lymphangiography as there is no correlation between site of operation or side of lympho-renal fistula. Technically demanding - magnification is very essential as 90% of lymphatic vessels have diameter <1mm making it difficult to finding vein of adequate diameter and in proper place (for anastomosis).

Lymphangiovenous anastomosis: An end-to-end anastomosis is made in the inguinal region in men (Figure 2) and either in dorsum of foot/leg/thigh in women. 3 to 4 anastomoses per side are made using 4 to 6 interrupted (9-11) 0 nylon sutures (53).

Lymph node - Saphenous vein anastomosis: An end-to-side anastomosis of inguinal lymph node to generally a tributary of saphenous vein (the distal end of which is ligated) is made.Generally a single anastomosis using 6 to 7 interrupted sutures is sufficient (54).

Laparoscopic procedures: The objectives of open surgical treatment of intractable chyluria can be achieved by  the  minimally  invasive  laparoscopic  techniques with the added advantages of magnified view, better identification of lymphatics, better anastomatic results,minimal  morbidity,  shorter  hospital  stay,excellent cosmesis and early return to work. Of the two main routes i.e. transperitoneal (peritoneum transgressed) and retroperitoneal (easy and straight access to kidney) the latter approach significantly reduces incision - related morbidity without compromising the principles of open surgery (2).

Retroperitoneoscopy:   The  technique of retroperitoneoscopic  management of chyluria comprise of nephrolympholysis, ureterolympholysis, hilar  vessel  stripping,  fasciectomy  or  nephropexy out of which the first three are mandatory while fasciectomy and nephropexy (to   prevent   renal pedicle torsion and nephroptosis) are not routinely recommended (1).

Robotics: The author has been a pioneer in the use of this modality of management for chyluria. Nephrolympholysis, ureterolympholysis, hilar vessel stripping, fasciectomy and nephropexy can all be done as in conventional laparoscopy. This state-of-the-art Master-Slave system provides 3-dimensional vision, seven degress of freedom, 540 wristed movements, elimination of hand tremors, accurate scaling of movements and ergonomic comfort in addition to the advantages and objectives of open surgery(58).

Other therapies

Medical therapy: Posttraumatic chyluria due to lymphorenal fistula has been found to regress after somatostatin therapy (59). Chyluria has been reported todisappearfollowingpercutaneoussclerotherapy to the left inguinal lymph nodes with doxycycline in a postoperative case of lymphangiomatosis (60). Chyluria (after radical nephrectomy) has o been treated with N-butyl-2-cyanoacrylate (61).

Gerota's fasciectomy: Bilateral excision of the perinephric fascia and fat (Gerota's  fasciectomy) in 2 stages has been reported to result in complete resolution of chyluria (62).

 

Figure 2. End-to-end lymphatico-venous anastomosis using spermatic cord (males)

 

Endoscopic  therapy: Chyluria has been successfully treated in 5 patients with endoscopic coagulation using guide tube methods (63).

Recurrence

Incompletestripping,recanalization,reflux from contralateral side, reflux from terminal ureter or bladder are important causes of recurrence generally diagnosed by radio imaging especially lymphangioscintigraphy, lymphangiography (detects leaks atbladder level) and cystoscopy (blebs under mucosa / loosely hanging chylous clots from bladder wall). This can however be prevented by use of magnifying loops, operating microscope, omental wrap technique or the use of laparoscope.

Complications

Although, Sclerotherapy is described  as  a relatively safe procedure, few complications have been reported with it. These include anuria with pelvi-calyceal  cast  formation, acute  necrotizing  ureteritis and fatal renal and hepatic failure (64-67). Complications of retroperitoneoscopic surgery are few - inferior vena cava injury, renal segmental artery injury, lymphatic leak through the drain, and delayed wound healing. Advancements in laparoscopy with the advent of robotics is a step forward to minimize the complication rate (58).

 

Table 3. Follow up results of operative procedures for chyluria in various series 

Study

Year

Technique

Complete cure

Improved

No change

Okamoto et al (72)

1983

LVD

375 (97.7%)

5 (1.3%)

3 (0.8%)

Punekar et al (76)

1997

LVD

69 (88.0%)

-

9 (12.0%)

Prasad et al (49)

1977

P

14 (93.3%)

1 (6.7%)

Nil

Dalela et al (47)

2004

LVD +0

4 (100.0%)

Nil

Nil

Brunkwall et al (50)

1990

RA

1 (100.0%)

Nil

Nil

Cockett et al (52)

1962

HLVD

1 (100.0%)

Nil

Nil

Xu YM et al (54)

1991

LVA

30 (60.0%)

6 (12.0%)

14 (28.0%)

Xu YM et al (54)

1991

LNSVA

6 (50.0%)

2 (16.7%)

4 (33.3%)

 

LVD,lymphovenous disconnection; P, Patna operation; O, Omental wrap; RA, Renal autotransplant; HLVD, Hilar LV disconnection; LVA, Lymphangiovenous anastomosis; LNSVA, Lymphnode saphenous vein anastomosis

Conclusions

Acute manifestations of filaria and chyluria have been reported to disappear or greatly improve after filariasis eradication by a low dose of DEC medicated salt for a period of 6 months while chronic ones remained unchanged (68).

The prognosis of non-parasitic chyluria is usually very good and the treatment is mostly conservative (19). A long-term remission rate of 62% in the conservatively managed group (DEC + fat restricted diet), and a cure rate of 90% of patients in the operated group has been reported. Postoperative recurrence rate was 10%. There was more weight gain and dietary freedom  along  with  a  longer  chyluria  free  period in the operated group relative to the conservatively managed group (27).

Though    pure    dextrose   treatment   has    been discontinued due to poor success, povidone iodine 0.2% has been found to be as effective as 1% silver nitrate [82% (silver nitrate) and 83% (povidone; P=1.0)] (45). Definitive surgical ablation of lymphatic urinary  fistula is  better  than  conservative  medical management because it has a higher success rate, more dietary freedom and better patient acceptability (27). Over 95% success rate has been described with a follow up of 1 to 9 years following a single microsurgical operation (54).

Reno-lymphatic disconnection is the reference procedure, with long-term success rates of 99% (69). The follow up results of various series are depicted (Table 3).

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