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- 2nd or 3rd 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
1. 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)

24. 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

25. 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

26. Mechanism

27. • 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.

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

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

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

31. 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.

33. 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.
• .

34. Thank you