CHYLURIA AFTER RADICAL NEPHRECTOMY TREATED WITH N-BUTYL-2-CYANOACRYLATE

Abstract

Chyluria is usually due to parasitic infection with Wuchereria bancrofti. Nonparasitic chyluria can be due to trauma, tuberculosis, surgery, for example aortoiliac bypass grafting, tumor or congenital lymphatic anomalies. We report a case of chyluria due to a lymphatic ureteral fistula after radical nephrectomy and lymphadenectomy. The fistula was treated successfully with ureteral occlusion using N-butyl-2-cyanoacrylate tissue adhesive. CASE REPORT A 42-year-old woman presented with severe left loin pain radiating to the iliac fossa. She had had 2 episodes of painless hematuria during the previous 4 months and was apyrexial with a large ballotable mass in the left loin. Erythrocyte sedimentation rate, serum albumin and creatinine were normal. Ultrasound and computerized tomography showed an 8 cm. heterogeneous solid lesion in the lower pole of the left kidney and suspiciously enlarged para-aortic nodes. Left radical nephrectomy was performed with the ureter ligated and transected at its mid third. The left para-aortic lymph nodes were 1 cm. in diameter and the entire lymphatic chain from the celiac axis to the pelvic brim was excised in continuity. Histology demonstrated Fuhrman grade II clear cell carcinoma without capsular invasion and reactive changes only in the lymph nodes. The patient noticed milky urine 3 weeks postoperatively. Urinalysis revealed 2.0 mmol./l. triglyceride concentration and 15.36 gm./l. proteinuria consistent with chyluria. There was post-prandial worsening of the chyluria and voiding was difficult due to obstruction from fibrin clots. Cystoscopy showed no chylous efflux. Retrograde assessment of the ureteral stump confirmed a fine communication with a lymphatic collection in the para-aortic space (fig. 1). There were multiple chyle clots in the bladder. Dilute povidone-iodine (0.2%, 15 ml.) was injected into the ureteral stump to sclerose the fistula.1 However, chyluria recurred 48 hours after the injection and persisted 2 months postoperatively, causing hypoproteinemia (albumin 27 gm./l.), ankle swelling, weight loss, lethargy and malaise. Under fluoroscopic guidance a catheter and long vascular sheath primed with 5% dextrose were advanced over a guide wire into the left ureteral stump. A mixture of 1 ml. N-butyl2-cyanoacrylate and 1 ml. iodized oil was injected into the upper half of the ureteral stump with immediate solidification (fig. 2). The chyluria resolved immediately and serial abdominal ultrasonography showed no evidence of intraabdominal lymphatic collection. At 1-year followup the patient was well with no recurrence of chyluria. DISCUSSION N-butyl-2-cyanoacrylate has been used to close minor superficial skin wounds as an alternative to sutures for many years. It has also been used by interventional radiologists for a wide variety of purposes, including embolization of intracranial arteriovenous malformations, spinal dural arteriovenous fistulas, uterine arteriovenous malformation, massive obstetric hemorrhage and high flow prapism due to blunt perineal trauma.2 In the urinary tract interventional radiologists have performed antegrade transrenal ureteral occlusion as palliative treatment of lower urinary tract fistulas, mainly in the presence of extensive pelvic malignancy or following radiotherapy. Gianturco coils with tissue adhesive and detachable balloons with or without tissue adhesive have also been used.3