This study compared the efficacy and safety of single versus multiple instillations of povidone iodine and urographin as a sclerosing agent for the treatment of chyluria. The study involved 54 patients randomized into single or multiple instillation groups. Results found no significant difference in chyluria recurrence rates or disease-free duration between groups. Both approaches achieved over 85% success rates with minimal adverse effects. The study concluded that a single instillation protocol is as effective as multiple instillations but is more cost-effective due to a shorter hospital stay.

1. Single versus multiple instillation of povidone iodine &
urographin in the treatment of chyluria | A prospective
randomised study
Presented by:
Dr. Tapendra Koirala
21st Nov. 2016
Arab J Urol. 2016 Jun; 14(2): 131–135.

2. Chyluria | Introduction
Chyluria is a condition characterized by the
passage of milky urine.
It is due to abnormal communication between
the lymphatic system and pyelocalyceal system.
Chyle = Albumin + Emulsified fat + Fibrin in varying proportions that
are absorbed by intestinal lacteals.

3. Epidemiology
• Prevalent in Africa & Indian
subcontinent
– Mostly d/t filariasis
• Rare in Western countries
– Mostly d/t post-operative
• Common in 2nd to 3rd decade
• M:F= 6:1
• Mostly left sided

4. • Prout (1841)
• Ackerman (1863)
• Wucherer (1869)
• Manson-Bahr (1954)
• Sen & Elappan (1968)
Pathophysiology | Hypotheses
Recent Theories:
1. Obstructive theory (1975)
2. Regurgitative theory (1977)

5. Clinical presentation
• Passage of milky urine– most common
• Clot colicky/passage of chylous clots
• Passage of bloody & milky urine
• Dysuria, frequency, urgency
• Acute urinary retention (chylous clot retention)
• Constitutional symptoms
– Fever, wt. loss, back pain
• Filarial manifestations
– Filarial scrotum & penis
– Filarial lower limb

6. Chyluria | Grading
Mild
• Intermittent milky
urine.
• No clot colic/ AUR/
wt. loss.
• Involvment of single
calyx on RGP.
Moderate
• Intermittent milky
urine.
• Occasional clot colic
• No AUR or wt.loss.
• Involvement of 2 or
more calyces on RGP.
Severe
• Continuous milky
urine.
• Presence of clot
colic/AUR/wt. loss.
• Involvement of most
of calyces with or
without involvement
of ureter on RGP.

7. Approach & investigations
1. Urinalysis
2. Blood examination
3. Cystourethroscopy
4. Retrograde pyelography
5. Lymphangiography
6. Lymphangioscintigraphy
7. USG/IVU/CT scan/ MRI

8. Management | Outline
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
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
AgNO3: ADRs!
• Interstitial nephritis
• Ureteric stricture
• Papillary necrosis
• Renal failure
• Even death

9. Management | Outline
Surgical management
• INDICATION:
– Refractory chyluria (Failed
conservative/medical therapy)
– Significant weight loss
– Hypoproteinemia
– Anasarca, and/or severe
anemia
– Recurrent clot retention and
hematochyluria
– Recurrent UTI
• PROCEDURES:
– Surgical lymphovenous
disconnection
– Renal auto transplantation
– Lymphangiovenous
anastomosis
– Lymphonodovenous
anastomosis
– Micro surgery
– Nephrectomy

10. Single versus multiple instillation of povidone iodine &
urographin in the treatment of chyluria | A prospective
randomised study
Arab J Urol. 2016 Jun; 14(2): 131–135
Authors:
Mohammed M. Seleem, Ahmed M. Eliwa, Ehab R. Elsayed, Hamdy
Desouky, Hazem El Galaly, Khalid Abdelwahab, Salem Khalil, and Mahmoud El Adl
Received: 5 December 2015,
Accepted: 12 January 2016
Available online: 26 April 2016

11. Contents
• Objective of the study
• Methodology
• Results and findings
• Discussion
• Limitation of the study
• Conclusion
• Similar studies
• Take home messages

12. Objective of the study
• To compare the safety, efficacy and
complications of:
– Single vs multiple instillation of povidone iodine
& urographin as a sclerosing agent in the treatment
of chyluria

13. Methodology
• Study design:
– Prospective randomized study
– From 2006 to 2013 AD
Inclusion criteria
– Severe attacks of chyluria
• (continuous chyluria with clots and or
considerable weight loss)
– Patients with mild-to-moderate
chyluria and failed response to
conservative treatment
• (in the form of a fat-restricted high-protein
diet and diethylecarbamazebine 100 mg
three times a day/21 days)
Exclusion criteria
– Bilateral cases
– Mild-to-moderate cases
with good response to
conservative treatment
– Cases with secondary
chyluria

14. Methodology (Contn’d…)
• Clearance from Local Ethics Committee
• Consent
• Randomization
– Randomized 1:1
– One patient was allocated to Group A and the next
one to Group B
Group A
– Single instillation of a combination
of PI 0.2% and the contrast-agent
urographin 76%
Group B
– Multiple instillations of the same
combination twice daily for 3 successive
days

15. Methodology (Contn’d…)
Steps:
• Heavy fatty meal the night before the procedure (250 mL
full cream milk)
• Routine prophylactic antibiotic pre-procedure
• Diagnostic cystoscopy done ↓LA
• 6-F ureteric stent (open tip catheter) was inserted under
fluoroscopy into the effluxing side
• Diluted contrast injected to
– delineate the pelvicalyceal system
– detect pyelolymphatic fistula
– adjust the tip of the catheter at the renal pelvis of the affected site

16. • Sclerosing agent: 5 mL PI 0.2% and 5 mL
diluted contrast (2.5 mL urographin
76% + 2.5 mL distilled water)
• Injected via drip method under fluoroscopy
• The combination was retained in the
pelvicalyceal system for 5 min (by closing the
ureteric catheter)

17. • All patients were observed for loin pain, fever,
haematuria and disappearance of milky urine
after the procedure
Group A
– Catheter was removed
immediately after the
procedure
Group B
– It was left for 3 days
– Patients received another 5
instillations of the same agent every
12 h from the first instillation

18. Follow ups
• Patients were followed up
– Every 3 monthly for 2 years
– History, routine urine analysis and ether test
• The disease-free duration (DFD) was
calculated for recurrent cases only during the
follow-up period
• Data analysis using SPSS v16

20. RESULTS

21. Variable
Group A
(one instillation)
Group B
(six instillations)
P value
Mean (SD) age, years 38.22 (10.67) 37.9 (10.86) 0.929
Sex, n (%)
Male 19 (70.4) 16 (59.3) 0.393
Female 8 (29.6) 11 (40.7) 0.392
Table 1 Participants characteristicsP atients’ characteristics and outcomes.

22. • Chyluria severity
• Pyelolymphatic communications in RGP
– 11 patients (40.7%) in Group A
– 13 (48.1%) in Group B
21
25
8
0 10 20 30
Mild
Modera…
Severe
No. of Pt.
Group A,
40.7
Group B,
48.1
35 40 45 50%

23. • Immediate disappearance of the milky urine
– In 100% of patients
• The success rate
– Single instillation = 85.2%
– Multiple instillations = 88.9%

24. Chyluria recurrence
• Recurrence of chyluria during follow-up
– Group A = 4 (14.8%)
– Group B = 3 (11.1%)
• DFD [mean (SD; range)]
– Group A = 9.25 weeks (4.79; 4–15)
– Group B = 11.33 weeks (6.11; 6–18)
P = 0.685
(P = 0.632)

25. Adverse effects (ADRs)
• 6 patients developed loin pain
– Requiring parenteral analgesics
• 4 developed fever
• 1 developed hematuria

26. Conclusion
• Combination of PI and urographin as a
sclerosing agent had a high success rate
• No significant difference in outcome was
detected between single vs multiple
instillations
• Single-instillation protocol is more cost
effective with a shorter hospital stay

27. Limitation of the study
• Appropriate sample size
• Short follow up period
• Single centered study
• Blinding
• Biases
• Statistical tests used are not disclosed

28. Similar study: 1
Department of Surgery, Urology Unit
National Academy of Medical Sciences,
Bir Hospital, Kathmandu
2014
N = 41 (27 Male,14 Female)
Mean follow up of 20 months

29. Results
• Immediate clearance was seen in all patients
• Recurrence = 7 (17%)
• Mean DFD = 18 months
• Two patients had moderate to severe flank pain
Conclusion: Single dose 0.2% povidone iodine sclerotherapy
is safe and effective treatment for chyluria.

30. Similar study: 2
Chitale Clinic Pvt. Ltd
Solapur, Maharashtra, India
2008
N = 40 (24 Male,16 Female)
Mean follow up was 12 months
International
Brazilian Journal Of
Urology
Fluoroscopy guided instillation therapy in chyluria using
combination of povidone iodine with contrast agent. Is a
single instillation sufficient?
Sharma G1, Chitale V, Karva R, Sharma A, Durug AB.

31. Results
• Immediate clearance was seen in 39 patients
• Success rate = 87.5%
• Recurrence = 5 (12.5%)
• Some patients had moderate to severe flank
pain
Conclusion: RPIS of chyluria using a single instillation a
combination of povidone iodine with contrast agent is safe
and effective.

32. Thank you