Urological Science 25 (2014) 77e78
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Practical uroradiology CME Credits
Chyluriaq Jia-Hwia Wang a, b, c, * a
Department of Radiology, Cheng Hsin General Hospital, Taipei, Taiwan Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan c School of Medicine, National Yang-Ming University, Taipei, Taiwan b
a r t i c l e i n f o Article history: Received 10 February 2014 Accepted 10 February 2014 Available online 2 June 2014 Keywords: chyluria computed tomography lymphangiography magnetic resonance imaging
and low serum albumin. Lymphangiography (Fig. 1) and follow-up noncontrast computed tomography after lymphangiography (Fig. 2) revealed an anomalous lymphatic connection between the retroperitoneal lymphatic vessels and the bilateral kidneys: the contrast medium was present in the collecting system of the bilateral kidneys, which indicated chyluria. Parasite examination for Wuchereria bancrofti (Bancroft’s filaria) was negative. We subsequently performed renal pedicle lymphatic disconnection. The postoperative course was uneventful. The patient was discharged in a stable condition after 10 days in hospital. Outpatient follow-up was recommended. 3. Discussion
1. Introduction Chyluria is a rare condition characterized by the presence of chyle in the urinary tract. Chyluria can be either tropical or nontropical. It may be a complication of radical nephrectomy, partial nephrectomy, and radiofrequency ablation of renal tumors. The presence of milky urine suggests chyluria, and the clinical diagnosis is confirmed by microscopic urine analysis. Imaging examinations may play a role in detecting the site of chyle leakage.
Chyluria is a rare condition characterized by the presence of chyle (milky lymphatic fluid) in the urinary tract through an anomalous lymphatic connection. Tropical chyluria usually occurs secondary to infection with W. bancrofti.1e3 Nontropical chyluria is
2. Case Report A 62-year-old woman experienced gross hematuria and milky urine 14 months ago. She visited another hospital for treatment. Cystoscopy was performed, and milky urine was observed exiting from the left ureteral orifice. A diagnosis of chyluria was made. Silver nitrate was retrogradely injected into the left renal pelvis. At the time of discharge, no hematuria or milky urine was noted. However, 1 year later, the patient again experienced hematuria and milky urine. She was admitted to our hospital for further evaluation and management. On admission, physical examination was unremarkable. Laboratory examination revealed hematuria, proteinuria, * Department of Radiology, Cheng Hsin General Hospital, Number 45, Cheng Hsin Street, Beitou, Taipei 112, Taiwan. E-mail address:
[email protected]. q There are 3 CME questions based on this article.
Fig. 1. Lymphangiography revealed an anomalous connection between the retroperitoneal lymphatic vessels and bilateral kidneys.
http://dx.doi.org/10.1016/j.urols.2014.02.002 1879-5226/Copyright Ó 2014, Taiwan Urological Association. Published by Elsevier Taiwan LLC. Open access under CC BY-NC-ND license.
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Fig. 2. Follow-up noncontrast computed tomography after lymphangiography revealed the presence of contrast medium in the collecting system of bilateral kidneys.
relatively uncommon, and can be caused by the obstruction of the upper retroperitoneal lymph drainage; the obstruction can be secondary to tumors, chronic inflammatory diseases such as tuberculosis, abscess, pregnancy, trauma, or congenital abnormality.1e5 Recent studies have suggested that chyluria may be a complication of surgical interventions such as radical nephrectomy, partial nephrectomy, and radiofrequency ablation of renal tumors as a result of the disruption of renal lymphatics.3e6 The presence of milky urine suggests a clinical diagnosis of chyluria, which can be confirmed by microscopic urine analysis. Computed tomography4,7,8 and magnetic resonance imaging9,10 can detect fat-fluid levels in the urinary tract, but they have difficulty determining the exact site of chyle leakage. Lymphangiography1,2,11e14 and ureteroscopy may determine the leakage site. In general, chyluria is self-limiting and resolves spontaneously.3e5,7,15,16 However, persistent chyluria can lead to a loss of proteins, lipids, fat-soluble vitamins, malnutrition, and immunosuppression.5 In such conditions, a restricted-fat diet and nutritional therapy with mediumchain triglycerides may be successful.1e4 More chronic and severe cases often require surgical intervention. The recommended methods include retrograde or percutaneous sclerotherapy of renal lymphatics by instillation of silver nitrate or povidone iodine,1,3,16 or laparoscopic renal pedicle lymphatic disconnection.17e19 Conflicts of interest The author declares that he has no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript. Source of funding None.
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