Management Of Chyluria Research Articles

As Milky as It Can Get; Chyluria: A Case Report and Review of Literature

Abstract Filariasis is an important public health problem in India. Extralymphatic manifestation of filariasis includes chyluria or passage of intestinal lymph or chyle into urine imparting a milky-white color, is an important manifestation of renal involvement. A young woman residing in a filaria endemic region, presented with persistent chyluria of 3-month duration. She did not have any features of nephrotic or nephritic syndrome or features of connective tissue disease. After routine hematological, biochemical, serological, and urinalysis, nephrotic range proteinuria and lipiduria were confirmed, and kidney biopsy was performed. Kidney biopsy showed an elongated parasitic sheathed structure with multiple basophilic nuclei spread along the length of the tail, suggestive of microfilaria, in capillaries of a single glomerulus; immunofluorescence was negative for immunoglobulin (Ig) A, IgM, IgG, C3, C1q, kappa, and lambda. She was given antifilarial drug and chyluria promptly subsided. The complex evaluation and management of chyluria have been discussed.

Management of chyluria using percutaneous thoracic duct stenting

BackgroundThoracic duct stenosis or obstruction is one of the causes of chyluria. Although the diagnosis of chyluria is not difficult, treatment is still challenging. Although there have been no standard guidelines for the treatment of chyluria, interventional techniques now offer minimally invasive treatment options for chyluria such as interstitial lymphatic embolization, ductoplasty with balloon, or thoracic duct stenting.Case presentation Here, we report a case of chyluria due to obstruction of the junction between the thoracic duct and subclavian vein in a 64 -year- old female patient. The patient was treated with balloon plasty for lymphovenous junction obstruction and interstitial lymphatic embolization for chyluria. However, chyluria was recurrent after 6 months so intranodal lymphangiography was performed. Anterograde thoracic duct was accessed through a transabdominal to the cisterna chyli which showed that the thoracic venous junction was re-obstruction. The patient was successfully treated by placing a uncovered drug-eluting stent with the size of 2.5 mm x 15 mm in length for resolving the thoracic occlusion.ConclusionThis report demonstrates the feasibility of using thoracic duct stenting in the treatment chyluria due to lymphovenous junction obstruction.

Management of Chyluria by Laparoscopic Ligation of Renal Lymphatic Vessels

A 74-year-old male was admitted due to chyluria for 60 years without scrotal or lower extremity edema. He had received an open cystotomy and clot aspiration one week before admission for acute urine retention and failure of catheterization at another hospital. He was probably infected by filariasis because filariasis had been reported as an epidemic disease in his growing town located in the southwest of China approximately 50 years ago. The patient was underweight and diagnosed with hypoproteinemia.

Ethiodised Oil Lymphangiography in the Management of Chyluria

Chyluria is clinical condition in which there is excretion of chyle in urine. The most common cause of chyluria is lymphatic filariasis. This case report describes imaging findings of non filarial chyluria due to retroperitoneal lymphatic cyst and its successful management by minimally invasive percutaneous lymphangiography procedure. The patient presented with complaints of passing milky white urine which was confirmed to be chyluria. After a non successful trial of conservative approach in form of highprotein and low-fat diet, percutaneous ethiodised oil lymphangiography was performed, which resulted in immediate symptomatic improvement and no recurrence on follow-up.

Single-dose instillation of povidone iodine for chyluria: A safe and effective therapy.

Introduction:Management of chyluria with initial conservative approach and then using endoscopic sclerotherapy is a mainstay approach. However, a wide range of sclerosants are available with differential success rates and complication rates. This study evaluated the safety and efficacy of a single-dose instillation of 1% povidone iodine for the treatment of chyluria.Materials and Methods:This was a prospective, observational study conducted on patients with chyluria who did not respond to conservative management with dietary restriction and diethylcarbamazine. The site of chyle efflux was identified by cystoscopy. A 6 Fr ureteral stent was inserted into effluxing side, diluted contrast was injected to delineate the pelvicalyceal system and the pyelolymphatic connection (arborization of the pelvicalyceal system), and a single-dose of 1% povidone iodine was instilled. Patients were observed for loin pain, fever, and disappearance of milky urine postinstillation and followed up at intervals of 3 months for a total duration of 1 year.Results:Of a total 50 patients included, 35 were men and 15 were women, with a mean age of 37 years. Pyelolymphatic connections were noted in 48% of the patients. All patients showed an immediate disappearance of milky urine. During 1-year follow-up, 92% of the patients were symptom-free till the last follow-up while only 8% of the patients experienced recurrence of chyluria which were treated with other treatment modalities. The mean duration of recurrence was 8 weeks.Conclusion:Single dose of 1% povidone iodine was effective in immediate clearance of milky urine and well tolerated in patients with chyluria during 1-year follow-up.

Sclerotherapy with Povidone Iodine Instillation into the Renal Pelvis in the Management of Non-Parasitic Chyluria: Our Experience

Background & objective: To evaluate the effectiveness and safety of 0.2% povidone iodine renal pelvic instillation as minimally invasive therapy for chyluria resistant to conservative treatment.
 Materials & Methods: From July 2015 to December 2016, 9 patients with chyluria were treated. There were 2 males and 7 females ranging from 30-65 years age. Cystoscopic localization of chylous efflux was done. On a day care basis under local anesthesia a 5 Fr open-ended ureteric catheter was introduced on the affected side. Freshly prepared 10 ml 0.2% Povidone iodine solution was instilled as a sclerosing agent in the renal pelvis. A total of 3 doses were given at 8-hour intervals. Unilateral instillation was done in 8 cases, and bilateral instillation was done in 1 patient.
 Results: Eight of 9 patients showed complete clearance. In 1 patient, recurrence was noted and a repeat injection was given after 4 weeks, with success.
 Conclusion: Our experience shows that povidone iodine is a safe and effective sclerosing agent in the management of chyluria.
 Ibrahim Card Med J 2016; 6 (1&2): 41-44

The distribution and clinic relevance of lymphatic vessels in the perinephric space of patients with chyluria

Objective To investigate the distribution and morphological features of lymphatic vessels in the fat tissue surrounding the kidney and ureter of patients with chyluria and to initially provide the anatomical and pathological supports for the modification of the surgical management of chyluria.Methods The fat tissues surrounding the renal pedicle,kidney and ureter were obtained from 6 adult cadavers and 15patients with chyluria.The lymphatic vessels were shown by hematoxylin and eosin (HE) staining and immunohistochemical staining with lymphatic endothelial marker oncofetal antigen M2A monoclonal antibody (D2-40).The lymphatic vessel density (LVD),diameter and luminal area of lymphatic vessel were compared between cadavers and patients with chyluria.Results Lymphatic vessels were observed in the fat tissues surrounding the renal vessels,ureter and adrenal gland.In the control group,the LVD of the up-mentioned districts was 1.98 ±0.73,2.14 ±0.73 and 2.04 ±0.56 respectively; the diameter was (32.13 ±13.28),(28.25 ± 7.67) and (27.56 ± 7.91) μm respectively ; the luminal area was (107 854 ±75 897),(98647 ±36 131) and (897901 ±34911) μm2 respectively.The LVD (2.97 ±0.91,3.10 ±0.88,2.87 ± 0.74),diameter [(75.05 ± 39.75),(64.02 ± 41.92),(40.00 ± 12.05) μm] and luminal area [(222 776 ± 106 624),(205 551 ± 114 578),(173 823 ± 89 559) μm2] of lymphatic vessel in the patients with chyluria were significantly increased as compared with those in the cadavers.The tortuous and dilated lymphatic vessels were commonly seen in the patients with chyluria.However,there was no significant difference in the LVD (1.56 ±0.41 vs.1.46 ±0.22),diameter [(18.02 ±6.65) μm vs.15.77 ±5.03) μm] and luminal area [(71 648 ±50 677) μm2 vs.(50 223 ±32 796) μm2] of the perinephric fat between the patients with chyluria and the cadavers.Among the patients with chyluria,the LVD,diameter and luminal area of lymphatic vessels in the sub-group of perinephric fat were significantly reduced as compared with those in the sub-group of the renal vessels,ureter and adrenal gland (P ＜0.05).Conclusion The morphological and density changes of the lymphatic vessels in the fat tissues surrounding the renal pedicle,ureter and adrenal gland may play a role in the etiology of chyluria.It might be a feasible surgical management for chyluria by lymphatic disconnection in the up-mentioned sites.However,the current procedure of surgical management of chyluria may not be appropriated. Key words: Chyluria; Lymphatic vessels ; Morphology; Distribution

Open surgery for chyluria

The management of Chyluria is challenging. Various treatment options are available. Among them sclerotherapy has reasonable success but the problem is the recurrence. Surgery is an option in such refractory cases. This article looks at various surgical options and their success.

The Efficacy And Safety Of Povidone Iodine In The Management Of Chyluria

Aim: To assess the efficacy and safety of povidone iodine in the management of chyluria. Materials & Method: Twenty patients with chyluria who attended our department from January 2000 to December 2002 were studied. There were 14 males and 6 females, age ranging from 24 to 42. After confirming chyluria by relevant investigations and demonstrating chylous efflux at cystoscopy, all were treated with renal pelvic instillation of povidone iodine solution. Follow up was up to 3 years. Results: There was immediate disappearance of chyluria in all the 20 patients and 17 remained free of chyluria till their last follow up in June 2003. Three patients presented 1, 3, & 4 weeks later with recurrence. All 3 were retreated with povidone iodine. However, in 2 patients the chyluria persisted and these 2 patients were referred for laparoscopic management and lost for follow-up. Of the 20 patients, 2 patients had severe anaphylaxis which was appropriately treated. Conclusion: Povidone iodine is effective in curing chyluria. However, instillation of povidone iodine may be associated with serious anaphylactic reactions.

Acute Necrotizing Ureteritis with Obstructive Uropathy Following Instillation of Silver Nitrate in Chyluria: A Case Report

Chyluria occurs as a result of communication between the lymphatics and the renal pelvis. It is believed that instillation of silver nitrate into the renal pelvis is a safe, minimally invasive and effective treatment for chyluria. We report an unusual complication of acute necrotizing ureteritis following instillation of silver nitrate in a case of chyluria. It resolved completely with non-surgical intervention. The diagnosis and management of chyluria is discussed, with a brief review of the literature.

Use of lymphoscintigraphy in chyluria

The roentgenographic procedure of choice in delineating lymphatic channels has been lymphangiography. Recently, radionuclide lymphoscintigraphy has been used to outline lymphatics in patients with various lymphatic disorders. We present and compare the results of lymphangiography and lymphoscintigraphy in 2 patients with chyluria. Since the results of lymphoscintigraphy correlated with lymphangiography, the application of this less invasive technique in the diagnosis and management of chyluria may be warranted.