More Related Content
What's hot
What's hot (20)
Similar to CHYLURIA SEMINAR (1).pptx
Similar to CHYLURIA SEMINAR (1).pptx (20)
Recently uploaded
Recently uploaded (20)
CHYLURIA SEMINAR (1).pptx
- 1. CHYLURIA
- 3. •“Chyluria is a state of chronic lymphourinary reflux via fistulous communications secondary to lymphatic stasis caused by obstruction of the lymphatic flow”. •GU tract lymphatics are damaged, resulting in lymph passage into the urine and massive fat and protein loss. DEFINTION & INTRODUCTION
- 4. ETIOLOGY
- 5. •India – 45 million suffer from filiariasis •Chyluria – late manifestation of filariasis •2- 10% of pts with filariasis develop chyluria •10 – 20 yrs after filarial infection THE FILARIAL FACTOR
- 6. •Lymphatic drainage of the kidney occurs in a trilaminar fashion. •First lamina lies within the renal parenchyma •Second lies at a sub-capsular level •Third lies within the perinephric fat ANATOMY OF RENAL LYMPHATICS
- 7. intrarenal lymphatics 4-7 trunks join the 2 nd and 3 rd level lymphatics lateral aortic nodes lumbar trunks BASIC LYMPHATIC PATHWAY
- 8. LYMPHATIC ANATOMY OF THE RETROPERITONEUM
- 9. Parasitic infestation OBSTRUCTIVE THEORY Obliterative lymphangitis Lymphatic hypertension Varicosity & collateral formation Failure of valve system
- 10. Toxins from dying filarial worms REGURGITATIVE THEORY Lymphectasis/direct inflammatory damage to the valves (weakness of lymphatic wall) Failure of valve mechanism Rupture into renal calyces /pelvis
- 11. It is believed that chyluria occurs because of retroperitoneal lymphatics receiving lymph flow from the intestinal lymphatics become obstructed secondary to fibrosis produced by parasitic infestation thus short-circuiting chyle from the intestinal lymphatics to renal lymphatics, which rupture subsequently. IN SHORT
- 12. •Milky urine •Mostly Unilateral •Common on left side •Chyluria alone or • Associated with - dysuria -hematuria( hematochyluria) -pain due to clot -UTI -pedal lymphangitis and pedal odema -weight loss -cachexia MANIFESTATION
- 13. Lymphatic anatomy of the retroperitoneum patterns of lymphatic drainage
- 14. WHY CHYLURIA IS MOSTLY UNILATERAL? The manifestation of chyluria depends upon the site of involvement and the anastomotic variation of lymphatic system in the individual patient. The anastomotic variation primarily occurs at the cisterna chyli where the lumbar trunks and the intestinal trunks join. The classical cisterna chyli as described above is seen in only about 47% of normal individuals, and the intestinal trunk in such cases drains in the lumbar trunks of one side or directly in the thoracic duct either as a single trunk or as multiple smaller ones. This may explain the presence of unilateral chyluria. The unilateral findings are more common on the left side
- 15. PROPERTIES OF CHYLOUS URINE
- 16. Grading Chyluria is graded according to the mode of presentation: • grade 1 is milky white urine • grade 2 is white clots or episodes of clot retention •grade 3 is haematochyluria. •Ref: Suri A, Kumar A. Chyluria—SGPGI experience. Indian J Urol 2005;21:59–62 GRADING
- 17. BASIC APPROACH Detection and confirmation of Chyluria Location of Lympho-urinary fistula Specific investigations INVESTIGATIONS
- 18. STEP 1
- 19. Studied immediately Prior Fatty diet enhances diagnosis Gross examination Milky urine Semisolid gel Blood & fibrin clots Settles down into 3 layers Fat- top layer Fibrin clots – middle layer Cells & debris – bottom layer URINARY INVESTIGATIONS
- 20. Ether test Equal parts of urine & ether Vigourously shaken for few minutes Complete clearing of opacity Slight turbidity in the lower non ether zone Microscopy of sediment (modified Wright stain (Hansel's stain) Erythrocytes & lymphocytes Sudan III staining Sudan III ingestion 10gm butter with 100mg of Sudan red III Orange pink coloration in 2-6 hrs URINARY INVESTIGATIONS
- 21. •Inaccuracy of tests in mild cases •Electrophoresis • Estimation of urinary triglycerides • Invariably detected in morning samples in chylurics • 100% sensitive and specific •Estimation of Chylomicrons, TGs, Cholesterol • Point the level of abnormal communication URINARY INVESTIGATIONS
- 23. STEP 2
- 24. •Cystourethroscopy -Milky efflux from ureteric orIfices -Split urinalysis for chyle in cases with mild chyluria •Retrograde Pyelography -5-6F uretric catheter / flouroscopy -20* Trendelenberg position -Gravity filling -Pyelolymphatic backflow monitored LOCATION OF LYMPHO-URINARY FISTULA
- 25. Mild – Involvement of one calyx Moderate – Involvement of 2/3 calyces Severe – Most of the calyces are involved Hemal AK, Kumar M, Wadhwa SN. Retroperitoneoscopic nephrolympholysis and ureterolysis for management of intractable filarial chyluria. J Endourol 1999;13:507–11. RGP GRADING
- 26. Hemal AK, Kumar M, Wadhwa SN. Retroperitoneoscopic nephrolympholysis and ureterolysis for management of intractable filarial chyluria. J Endourol 1999;13:507–11.
- 27. Lymphography Lymphourinary fistula Lymphectasia beaded thoracic duct Lymphoscintigraphy IVU Mostly normal Poor sensitivity Recommended before AgNO3 instillation LOCATION OF LYMPHO-URINARY FISTULA
- 30. •IVU •Mostly normal , poor sensitivity LOCALIZATION
- 31. STEP 3
- 32. •Microfilaria in urine / blood •ELISA for filariasis -Sensitivity- 85%, specificity – 95% •Renal biopsy -Research purposes -Mesangioproliferative nephropathy -Membranous nephropathy -endothelial cell proliferation SPECIFIC TESTS
- 34. Dietary modification Prevent malnutrition Mininize chyle production Fat restriction Medium chain TG – absorbed by portal system directly Intractable chyluria – TPN & total enteric rest Anti-filarial DEC- 2mg/kg – 3 divided doses after food for 10-14 days Reduces microfilarial rate by 80-90%, kills some adults too Ivermectin - 400microgm/ kg single dose Albendazole – 400mg twice daily for 21 days MEDICAL MANAGEMENT
- 35. •Indication 1.Weight loss, hypoproteinemia, anasarca 2.Recurrent clot retention 3.Hematochyluria 4.Recurrent urinary tract infection because of Chyluria 5.Refractory chyluria (defined as failure of conservative treatment with adequate dietary modification, medical management and two or more instillations of sclerosants) 6.Altered immune status, marked psychological disturbance. 7. Duration of more than 1 year SURGICAL TREATMENT
- 36. Indication failed conservative management Mild/ moderate pyelolymphatic fistula Agents used AgNO3 (0.1-1%) 0.2% Povidone Iodine 15-25% Sodium iodide 10-25% Potasium Bromide 50% Dextrose 76% Urograffin 3% saline Combination therapy SCLEROTHERAPY
- 37. Method -Cystoscopic visualization -Ureteric catheter placement -Renal pelvis capacity measurement -Instillation of sclerosant RPIS( Renal pelvis instillation of sclerotherapy)
- 39. Instillation Schedule • 8 hrly instillation for 3 days • 12 hrly instillation for 2 days • Weekly for 6-8 weeks • Other protocols • Single dose instillation • 2-3/week for 10 weeks RPIS PROTOCOLS
- 40. RESULTS
- 41. RESULTS
- 42. •1 % AgNO3 – safe, effective •Prior fatty meal -must to identify affected side •Bulbureterogram- mandatory to identify affected side / predict success •IV diuresis – must to produce chyluria / washout AgNO3 •AgNO3 instillation – Done under LA •Unilateral instillation only •Bilateral -Contralateral 6 wks later •Maximum of 2 courses only SCLEROTHERAPY – TO REMEMBER
- 43. Indications 1. Weight loss 2. Hypoproteinemia 3. Anasarca 4. Recurrent clot retention 5. Hematochyluria 6. Recurrent UTI 7. Refractory Chyluria 8. Altered immune status OPEN SURGERY
- 44. Pre operative investigations -IVU -Pedal lymphangiography -Lymphoscinitigraphy OPEN SURGERY
- 45. Chylolymphatic dissconetion – standard procedure Ureterolympholysis – Patna Operation Cockett and Goodwin procedure Diversion of hilar lymphatics to spermatic or gonadal vein in end to side fashion Microsurgical Procedures -Lymphangiovenous anastamosis -Lymph node- saphenous vein anastamosis SURGICAL PROCEDURES
- 46. Renal autotransplantation Omental wrapping – non-filarial origin Nephrectomy – life saving / nonfunctional kidneys SURGICAL PROCEDURES
- 47. Nephrolympholysis- kidney dissected of its perirenal fascia Hilar stripping-skeletonisation of renal vessels and clipping of renal lymphatics Ureterolympholysis-downward mobilization of ureter and strippng the lymphatics till iliac vessels Fasciectomy-removal of perirenal fat Nephropexy-fixation of renal capsule to psoas muscles at upper, middle and lower poles CHYLOLYMPHATIC DISSCONETION PROCEDURES
- 48. RESULTS
- 50. Ref: Singh I, Dargan P, Sharma N. Chyluria - a clinical and diagnostic stepladder algorithm with review of literature. Indian J Urol 2004;20:79-85
- 51. •Evaluation of urine for chyle, lipids and cholesterol and thereafter to be checked 6-monthly. •Ref: Singh I, Dargan P, Sharma N. Chyluria - a clinical and diagnostic stepladder algorithm with review of literature. Indian J Urol 2004;20:79-85 FOLLOW UP
- 52. Two types – Parasitic & Non parasitic Two theories – Obstructive & Regurgitative Management – Detection & localization Maximum of 2 sclerotherpies permitted Indications for open/ lap sugery Dietary management plays an important role Preferred surgical treatment – Chylolymphatic disconnection SUMMARY
- 54. •Contrast material within the perinephric collection space and fat in the bladder on CT after partial nephrectomy suggest the presence of chyluria. • Conservative treatment is non-invasive and should thus be attempted first. However, this treatment is less effective than surgical management. If patients have symptoms as a result of chyluria or have long-term asymptomatic chyluria, surgical management might be worth consideration. Renal pedicle lymphatic disconnection might be invasive and difficult, because adhesion around the preserved kidney after partial nephrectomy is expected. We believe that endoscopic sclerotherapy is an optimal therapy in these cases
- 55. HEMATOCHYLURIA •The mechanism of hematuria in lymphatic filariasis is unclear. It may be related to presumed venolymphatic fistulae and increased pressure in the lymphatic vessels. •Only a few reports of gross chylohematuria due to filariasis have been reported in literature, and in most cases, microfilariae were detected only in peripheral blood smears rather than in the urine.
- 56. THANK YOU
Editor's Notes
- The intrarenal lymphatics emerge as 4-7 trunks, which emerge at the renal hilum to join the 2 nd and 3 rd level lymphatics. These then eventually converge along the renal vessels to the lateral aortic nodes. The efferents from the lateral aortic glands form the lumbar trunks. The intestinal trunks comprise the large vessels, which receive lymph from stomach, intestine, pancreas, spleen and from the lower and the anterior part of the liver. The lumbar trunks and the intestinal trunks drain into the cisterna chylii. The intestinal trunks comprise the large vessels, which receive lymph from stomach, intestine, pancreas, spleen and from the lower and the anterior part of the liver.
- he third-stage infective nematode larvae (L3i) enter the blood through the wound made by the mosquito. They then migrate to the nearest lymph gland where they mature into the thread like adult worms about 3 months to 1 year later. The average incubation time before patency is about 15 months. The mature adults can survive for 5 to 10 years and the damage of the lymphatic vessels they cause and the immune system's response to their presence (and that of microfilaria and newly inoculated L3i) can result in the various symptom 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
- Unless complications are present renal function in usually unaffected. Microfilaria may or may not be demonstrated in urine and/or blood. Although eosinophilia is an accepted feature, most of investigators have not observed absolute eosinophilia in their patients. Leukocytosis has been reported in acute filarial manifestations.
- Urinary investigations Chylous urine - studied immediately after it has been voided. A fatty diet a day or night before has been used to enhance chyluria. On gross inspection, classic chylous urine is like milk, frequently containing a semisolid gel. Blood and fibrin clots are frequently observed in most of the samples. When kept in the test tube, it usually settles down into three layers, the fat being lighter gets deposited as the top layer, the fibrin clots from the middle layer and cells together with debris settle in the bottom layer
- When equal part of the milky urine and ether are vigorously shaken for a few minutes, there is almost complete clearing of opacity with slight turbidity remaining in the lower nonether zone. Under the microscope the sediment is found to contain variable number of erythrocytes and lymphocytes. The latter when stained fresh with one or two drops of 1:1500 aquous solution of methylene blue reveals small lymphocytes floating single or in clumps. Fat droplets of varying size can be seen. Casts and cylindroids are usually absent. Chylomicrons can be seen directly under microscope with dark ground illumination or stained with Sudan III. Oral ingestion of fat labelled with Sudan III (10 gm of butter with 100 mg of Sudan red III) causes orange pink colouration of urine in chylurics with in 2-6 h, but Sudan III being expensive is not freely available. Chloroform extraction of fat globules from chyluria. (a) To an aliquot of milky urine, an equal volume of chloroform is added. (b) Result of mixing and agitation of the mixture. (c) After centrifugation of the agitated mixture, there is clearing of milky urine with extraction of fat globules in the chloroform layer (bottom). (d) Chloroform extraction after the addition of Sudan III to the milky urine. Note the appearance of red-stained fat globules in the bottom chloroform layer and clearing of the milky urine.
- Estimation of urinary triglycerides is 100% sensitive and specific test for chyluria. It is noninvasive and cost effective and is independent of manual error urine albumin has been found in varying ranges from mild to nephrotic range and immunoelectrophroresis has shown globulins of various types and apolipoprotein A 48 of intestinal origin in the urine
- -Urine albumin -Mild to nephrotic range -Apolipoprotein A 48 of intestinal origin
- retrograde pyelography Retrograde pyelography with fluoroscopic control and spot films often demonstrates pyelolymphatic backflow. Earlier studies demonstrated this in most of the cases and believed it to be diagnostic of chyluria. Later studies revealed that it is not specific of chyluria and may be seen in normal kidneys particularly if contrast is injected under pressure. However, it is more likely to occur in chyluria and should be differentiated from pyelovenous reflux, which is rather rare The RGP film is taken with the patient in 20° trendelenberg position. The contrast is gently instilled into the pelvis allowing gravity propagated filling of the pelvis instead of pressurized instillation. The films are checked for the presence of pyelolymphatic fistulae . do not use force because sudden distension of renal collecting system is painful and may open up pyelovenous or pyelosinus channels, which may cause inadvertent reactions.
- Lymphography shows lymphaticourinary fistulae (lymphaticocalyceal and lymphaticoelvic). Numerous torurous dilated lymphatics around hilar region (lymphangiectasia) communicating with paravertebral lymphatics and contrast outling major/minor calyx. Contrast may enter pelvicalyceal system in 40% and may be followed into bladder Other associated findings may be; thoracic duct sometimes shows tortuosity and beading though mostly it is normal, round granular enlarged, nodes in para-aortic area, skipping of lymphatic chain in advance cases, dilated cisterna chylii may be demonstrated, abnormal lymphatics may be seen coursing down along line of ureter and transit of contrast medium from feet to thoracic duct is characteristically accelerated. Presently it is not recommended for routine use. Lymphoscintigraphy Lymphoscintigraphy being less invasive has been promulgated as investigation of choice but is not available at all centers.
- Elisa test for filariasis (fila test) The ELISA test for filariasis is based on humoral immune response of the host to filarial antigen. The filarial ES antigen, immobilized on membrane is allowed to react with patients serum, followed by incubation with anti IgG enzyme conjugate. The presence of antibody is detected using a color change indicator system. The specificity and sensitivity of this test has been reported to be 85 and 95%, respectively