Retrospective analysis and a case report: Chyluria

C. Sherlin agnes1, S. Senthil Kumar2, Sasikumar3

1DNB Resident, Department of Urology, Kauvery Hospital, Trichy, Tamil Nadu

2Consultant Urologist, Kauvery Hospital, Trichy, Tamil Nadu

3Consultant Urologist, Kauvery Hospital, Trichy, Tamil Nadu

Case Presentation

A 65-year-old male presented to our OPD with c/o passing cloudy urine on and off since 10 months.

  • H/o hematuria with cloudy urine associated with difficulty in passing urine on and off
  • H/o loss of weight + (5 kg lost in 6 months)
  • No H/o lower limb edema / puffiness of face/ abdomen pain or distension / dysuria/ fever/ chills.
  • H/o similar episode of passing cloudy urine in the past (5 years ago ) recovered spontaneously without treatment.
  • H/o being treated as recurrent UTI with pyuria and proteinuria for the past 8 months in a private hospital.

Comorbidities: K/C/O T2DM on treatment

Lab evaluation

Urine analysis

  • RBC – 10 – 15
  • WBC – 25 – 30
  • Proteinuria – +++
  • TGL – 175 mg/dl
  • USG – no clots or any other abnormality detected.

Cystoscopy

Retrograde Pyelogram

Endoscopic Sclerotherapy

Pyelolymphatic efflux of contrast is noted in left upper calyx of renal pelvis. 10 ml of urograffin + 10 ml of 10% povidone iodine injected into left renal pelvis using 5 Fr ureteral catheter

Contrast with povidone iodine noted entering into lymphaticourinary communication.

Tab. DEC (Diethylcarbamazine) 100 mg 1-1-1 for 3 weeks started.

Post-operative period

  • On CBD clear urine was drained on POD -1
  • Urinalysis showed absence of TGL and proteinuria postoperatively.
  • On follow up after 1 month, there was no episode of passage of cloudy urine

Our experience

We have treated about more than 20 cases of chyluria in our hospital in the past 15 years.

In our experience, Povidone iodine is a better option for endoscopic sclerotherapy which is easily available, affordable and stable. There was no recurrence with usage of povidone iodine as sclerotherapy agent in our setup.

Out of twenty patients, one patient had past history of THR and another patient has history of vertebral implant surgery.

Chyluria – Discussion

  • Chyle – contains albumin, emulsified fat and fibrin
  • Regurgitation theory – valvular insufficiency of lymphatics.
  • Obstructive theory – obliterative lymphangitis, buildup of toxic metabolites or an inflammatory immune reaction – lymph ectasia and varicosities.

The location of lymphaticourinary fistula is most commonly at the calyceal fornix in the renal pelvis, but can also occur at the level of the ureter or urinary bladder.

When left to settle urine separates into 3 layers

  • Top layer – chylomicrons
  • Middle layer – proteins
  • Bottom layer – fibrin clots and cellular elements

Dipstick test

  • Non – selective proteinuria (>3 gm) +
  • Leukocyte esterase is usually negative
  • Blood

Cloudy/Milky urine: DD

  • Most common cause – Phosphaturia (intermittent, may occur after meals) Microscopic analysis and acidification of urine with acetic acid
  • Pyuria – WBC- neutrophils, pungent odour, urine microscopy, urine dipstick – leucocyte esterase.
  • Chyluria
  • Spermaturia
  • Funguria
  • Lipiduria
  • Hyperuricosuria
  • hyperoxaluria

Parasitic vs Non – parasitic chyluria

  • More common in ages 20-40 years
  • Can have a relapsing and remitting course.
  • Non – parasitic etiology can occur at any age.
  • If complication of surgery can occur upto 2 years post-surgery.

Symptoms and Signs

  • Milky white urine
  • Dysuria
  • Urgency
  • Urinary retention
  • Chylous clot hematuria
  • Clot colic
  • Weight loss
  • Peripheral edema

Investigations

  • Urinary chylomicrons most specific and sensitive test for chyluria.
  • Levels > 15 mg/dl indicative of chyluria.
  • Urinary TGL level >110 mg/dl
  • Filarial antigen detection in urine using immunochromatography or ELISA testing.
  • USG – clot or any other abnormality.
  • IVP – not helpful.
  • CT urogram – clot within bladder and possible dilated lymphatics.
  • MRI – fistula in lower ureter or bladder.

Site Identification

  • Lymphangiography –information on the site, size and the number of fistulous communications sensitivity 90%
  • Invasive but not routinely used.
  • Lymphangioscintigraphy – pre-op imaging of choice road mapping of lymphatic transport and drainage system uses Tc99 human albumin sulphur colloid. Safe noninvasive. Assess degree of reflux.
  • Endoscopy – more therapeutic than diagnostic. Split urinalysis.
  • Retrograde pyelography – identify lymphatic backflow specificity – low – contrast injected under pressure

Medical Management

  • Conservative treatment – more than 70% success rate.
  • High fluid intake
  • High protein diet
  • Fat restriction < 25g/day
  • Low fat medium chain TGL diet

TPN intractable chyluria

Chylous clot – manual bladder washout.

Suspected filariasis:

  • DEC (Diethylcarbamazine and Chlorpheniramine Maleate) – 6mg/kg/day for 21 days,
  • Ivermectin – 6 – 12 mg as a single dose repeated after 3 weeks,
  • Albendazole – 14-day course of 400 mg/day,
  • Benzathine penicillin for 12 weeks 1.2 million units weekly.

DEC given with antihistamine. Endoscopic sclerotherapy should be suggested if not responding to conservative or medical therapy.

Minimally invasive therapy – Sclerotherapy

  • Agents Used – Silver nitrate 0.1 – 3%, 0.2% povidone iodine, 1-25% sodium iodide, 10-25% potassium bromide, 50% dextrose, hypertonic saline.
  • Instilled into renal pelvis – induces chemical lymphangitis with edema blockage of lymphatics and immediate relief – fibrosis of lymphatics – lasting relief.
  • Ureteric catheter into renal pelvis 8-10 ml injected with 3 days of instillation occurring every 8 hours or once weekly instillation for 6 weeks.
  • Do only one side at a time due to risk of ATN. Waiting period 2 months recommended.
  • Sclerosing and obliterating inflammatory reaction. Sclerotherapy given with antibiotic cover.
  • Success rate is around 80 %.
  • As per Goel et al 50% dextrose if poor success rate. There is no difference b/w Povidone iodine and Silver nitrate injection

Silver Nitrate – Disadvantages

Susceptibility to light, freshly prepared each time, water insolubility and need for autoclaving- water evaporation difficult to maintain concentration.

Povidone Iodine: Non – ionic water soluble surfactant polymer, cheap, readily available, easy to reconstitute and stable at room temperature.

Study shows that in DMSA – relative renal function does not decrease more than 5 %.

Complications of Sclerotherapy

Adverse effects of sclerotherapy

  • Nausea, flank pain, hematuria, renal failure, anuria with pelvicalyceal cast formation and acute necrotising ureteritis.
  • These symptoms usually resolve within 48 hrs.
  • Usaually the treatment failure will be – 10-20%

Invasive

Medical or minimally invasive failed patients– failed 2 or more courses of sclerotherapy. Excessive weight loss, hypoproteinemia, edema, recurrent clot retention 95% success rate

  1. Chylolymphatic disconnection (modified – only medial lymphatic disconnection)
  2. Lymphovenous anastomosis
  3. Auto transplantation
  4. Simple nephrectomy

Chylo – lymphatic disconnection

Retroperitoneal laparoscopic ligation of renal lymphatic vessels.

Success rate – 98%

Postoperative complications: lymphocele, recurrence, fibrosis,

LV anastomosis

Diverting lymph flow – 14% failure rate

Retroperitoneal lymphovenous anastamosis, transinguinal spermatic lymphovenous anastamosis or inguinal lymph node saphenous venous anastomosis.

Most common site – retroperitoneal and inguinal region.

Take upto 6 months for full effects to become apparent.

Recurrence

  • Conservative treatment – recurrence: 80%
  • Sclerotherapy – recurrence rate: 13–41 %
  • Primary treatment failure with sclerotherapy: 10–20%
  • Post-surgical recurrence mostly due to incomplete stripping, reflux from c/l side, reflux from bladder.

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