Microsurgical treatment of chyluria: a preliminary report

Chyluria: the state of the art

Chyluria is the passage of chyle in the urine. The cause seems to be the rupture of retroperitoneal lymphatics into the pyelocaliceal system, giving urine a milky appearance. This communication is caused by the obstruction of lymphatic drainage proximal to intestinal lacteals, resulting in dilatation of distal lymphatics and the eventual rupture of lymphatic vessels into the urinary collecting system.This condition, if left untreated, leads to significant morbidity because of hematochyluria, recurrent renal colic, nutritional problems due to protein losses and immunosuppression resulting from lymphocyturia.In this review, we summarize the state of the art of this condition and the newest treatments available.

RENAL PEDICLE LYMPHATIC DISCONNECTION FOR CHYLURIA VIA RETROPERITONEOSCOPY AND OPEN SURGERY: REPORT OF 53 CASES WITH FOLLOWUP

PURPOSE

We present our experience with retroperitoneoscopic renal pedicle lymphatic disconnection. We compared the clinical efficacy of this treatment for chyluria with that of open surgery.

MATERIALS AND METHODS

From January 1998 to June 2004, 53 patients (55 renal units) with chyluria underwent renal pedicle lymphatic disconnection via the retroperitoneoscopic and conventional open approaches. The diagnosis of chyluria was confirmed by the ether test and the side of chylous reflux was determined by cystoscopy. Operative time, intraoperative blood loss, postoperative intestinal recovery and hospital stay were evaluated. Increases in hemoglobin and serum albumin were compared before and after surgery during followup.

RESULTS

Retroperitoneoscopic renal pedicle lymphatic disconnection or open surgery was performed successfully in all patients. In terms of operative time, intraoperative blood loss, postoperative intestinal recovery and hospital stay retroperitoneoscopy was superior to conventional open surgery. During retroperitoneoscopy the inferior vena cava was injured in 1 case but repaired successfully by laparoscopy without conversion to open surgery. Postoperative gross hematuria in 1 case disappeared 4 days later. In the open surgery group the renal segmental artery was inadvertently injured in 1 case and anastomosis was performed successfully. Wound healing was delayed in 1 case due to hypoalbuminemia. Recurrence developed in 2 patients during the 6 to 84-month followup.

CONCLUSIONS

Retroperitoneoscopic renal pedicle lymphatic disconnection for chyluria has the advantages of minimal invasion and rapid recovery compared with open surgery.

Filarial chyluria: Long-term experience of a university hospital in India

BACKGROUND

Filariasis is an endemic problem in various Indian states. We evaluated the results of long-term follow up (10-20 years) of patients with filarial chyluria.

METHODS

We conducted a retrospective analysis of 160 patients treated for filarial chyluria who presented to the Banaras Hindu University Hospital from 1982 to 1992. Eighty-four patients (52.5%) were treated using diethylcarbamazine (DEC) and a fat restricted diet and 76 patients (47.5%) underwent surgery. To examine the long-term effects of filarial chyluria we analysed data on post-treatment recurrence, weight gain, dietary freedom, chyluria free period and a number of other associated factors.

RESULTS

Previous history of filariasis or its complication was documented in 19% of patients. In 71% of cases, cystoscopy showed that chylous efflux was predominant in the left ureteric orifice. The long-term remission rate was 62% in the conservatively managed group (DEC + fat restricted diet), whereas 90% of patients in the operated group were cured. 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.

CONCLUSIONS

Definitive surgical ablation of lymphatic urinary fistula is better than conservative medical management because it has a higher success rate, more dietary freedom and, therefore, better patient acceptability.

Comparison of open surgery versus retroperitoneoscopic approach to chyluria

PURPOSE

We compared the clinical effectiveness of renal pedicle lymphatic disconnection for chyluria performed by retroperitoneoscopy and by open surgery.

MATERIALS AND METHODS

Three male and 4 female patients 33 to 68 years old (mean age 49) with chyluria underwent retroperitoneoscopic renal pedicle lymphatic disconnection. Chyluria was on the left side in 5 cases and on the right side in 2. Open renal pedicle lymphatic disconnection was performed in 4 men and 2 women 33 to 61 years old (mean age 45.8). Chyluria was on the left and right sides in 3 cases each. Mean operative time, intraoperative blood loss, postoperative intestinal function recovery time, intraoperative and postoperative complications, postoperative hospital delay and operative outcome were compared in these 2 groups.

RESULTS

Compared with the open surgery group results in the retroperitoneoscopic group were superior in terms of operative time (42 to 90 minutes, mean +/- SD 65.0 +/- 18.8 versus 120 to 220, mean 156.7 +/- 38.8), intraoperative blood loss (20 to 50 ml., mean 29.3 +/- 10.2 versus 60 to 250, mean 171.7 +/- 76.5), postoperative intestinal function recovery time (24 to 48 hours, mean 36.0 +/- 6.9 versus 24 to 72, mean 54.0 +/- 21.1), intraoperative and postoperative complications, and postoperative hospital stay (3 to 6 days, mean 4.7 +/- 0.7 versus 7 to 9 days, mean 7.8 +/- 1.0). In the open surgery group primary anastomosis was performed in 1 case due to injury to a renal artery branch during the operation. Chyluria resolved the day after surgery in the 2 groups. No obvious complications developed postoperatively. The followup of 2 to 12 months (mean 6.7 +/- 4.0) showed no recurrence of chyluria.

CONCLUSIONS

Retroperitoneoscopic renal pedicle lymphatic disconnection completely ligates the lymphatic vessels with minimal invasion, less blood loss, rapid recovery and a good short-term outcome.

Retroperitoneoscopic nephrolympholysis and ureterolysis for management of intractable filarial chyluria

PURPOSE

To evaluate the feasibility of retroperitoneoscopic lymphatic disconnection in patients with intractable filarial chyluria with the aim of reducing the morbidity of the surgery.

PATIENTS AND METHODS

Two patients presented to us with intractable chyluria. They did not respond to conservative measures and endoscopic sclerotherapy. In view of the severe lipid and protein loss associated with recurrent bouts of chyluria, they merited surgical correction by lymphatic disconnection. Because this operation requires extensive mobilization within the retroperitoneum over a large area, it necessitates a large flank or midline incision. In order to reduce the incision-related morbidity, it was decided to undertake the procedure laparoscopically. The retroperitoneal route was chosen for its obvious advantages.

RESULTS

Surgery was carried out uneventfully in both patients, with a mean operating time of 2 hours. The patients stayed in the hospital for an average of 2.5 days. Chyluria resolved in the immediate postoperative period, and they have been asymptomatic over a follow-up of 30 and 18 months. One patient had drainage of lymph for 5 days, which resolved spontaneously.

CONCLUSIONS

The objectives of open surgery can be achieved by the minimally invasive approach of retroperitoneoscopy. The new approach significantly reduces the incision-related morbidity without compromising the principles of open surgery. We propose five important steps necessary to avoid recurrence and reduce postoperative morbidity.

Laparoscopic nephrolysis for chyluria: case report of long-term success

Laparoscopic nephrolysis was performed in an 81-year-old man with recurrent chyluria. A total of five trocars were used for approaching the lymphatic ducts over the right ureter and renal hilum. The lymphatic ducts identified were easily ligated under laparoscopic magnification. The recovery of this patient was quick and uneventful. The follow-up urinalysis for chyle was negative, and his serum albumin concentration increased from 3.0 g/dL to 4.2 g/dL at 2 years postoperatively. This case report attests to the long-term efficacy of a laparoscopic approach to ligation of lymphatic fistulas for the treatment of recalcitrant chyluria.