The role of lymphography in diagnosis and treatment of chyluria

Abstract

Objective To evaluate the use of unilateral pedicle lymphography(PLG) in preoperative localization and treatment of chyluria. Methods From October 2010 to March 2017, 25 cases with severe chyluria and undergoing cystoscopy and unilateral PLG before renal pedicle lymphatic disconnection were reviewed. There were 11 males and 14 females, aged 44-71 years, with an average of 58.5 years. The course of the disease was 6 months to 30 years, with an average of 8.3 years.Of them, 18 cases had undergone unilateral PLG and spiral CT angiography preoperatively. Surgical treatment was performed according to PLG imaging. Results Unilateral ureteral chyluria was discovered in 16 out of the 19 cases through cystoscopy, with the sensitivity of 84.2%(16/19). In contrast, unilateral chyluria was only detected in 4 of the other 6 patients with bilateral chyluria. Albiduria were found in the remaining 5 cases in bladder, without ureteral excreted chyle. The sensitivity for chyluria positioning by cystoscopy was 64.5%(20/31). The location of lesion in 19 patients with unilateral chyuria and 6 patients with bilateral chyluria could be correctly displayed by PLG and the sensitivity was 100%(31/31). There was no significant difference in location between cystoscopy and PLG in 19 patients with unilateral chyluria (P=0.2482). But in total lesion location, the sensitivity of PLG was higher than cystoscopy(P=0.0026). Eighteen patients who had undergone PLG combined with spiral CT angiography, could not only locate the chylous fistula, but also determine the number of renal vessels as well as their relationship with diseased lymphatic vessels. Chyluria had disappeared immediately after unilateral renal pedicle lymphatic exfoliation in 23 patients. However, it still presented in the other 2 patients who were confirmed contralateral pyeloymphatic fistulas by PLG 3 months after surgery and cured by reoperation. Chyluria recurred in 6 cases during follow-up of 6 to 58 months, and 4 were confirmed bilateral pyelolymphatic fistulas by PLG. Two of these 4 cases were cured by laparoscopic surgery or open surgery, respectively. The other 2 patients were cured by conservative treatment. Moreover, 2 patients with unilateral chyluria recurred in situ after the first laparoscopic surgery, which was confirmed by PLG. Notably, all these patients were cured by ESWL finally. Conclusions This study suggested that PLG displays remarkable advantage in terms of localization sensitivity. PLG combined with spiral CT angiography preoperatively can not only locate the chylous fistula, but also determine the number of renal vessels as well as their relationship with diseased lymphatic vessels. Depending on PLG and spiral CT angiography, renal pedicle lymphatic disconnection can effectively protect renal vessel. In addition, it can avoid the omission of ligation for perivascular lymphatic vessels. Furthermore, PLG plays a key role in temporarily obstructing the leakage of pyelolymphatic fistulas to some extent. Key words: Chyluria; Pedicle lymphography; Cystoscope; CT angiography