Lymphatic Interventional Treatment for Chyluria via Retrograde Thoracic Duct Access.

Chyluria is the leakage of intestinal lymph (chyle) into the urine. Novel lymphatic intervention techniques, such as interstitial lymphatic embolization, proved to be a useful treatment option for chyluria. However, one of the challenges of this approach is the difficulty in identifying connections between the lymphatic system and kidney collecting system. Here, embolization of the abnormal lymphatic connection through retrograde thoracic duct access in 3 chyluria patients is introduced.

Blunt force trauma as a rare mechanism for chyluria.

Chyluria is an uncommon clinical entity outside of the tropics. We present a rare case of blunt force trauma leading to the formation of a lymphorenal fistula. This was successfully managed via conservative endoscopic and dietary treatment.

Bedside diagnosis of lymphorrhea after kidney transplantation surgery: A clinical study.

The aim of our study is to evaluate the role of pyridium (phenazopyridine) in the early bedside differential diagnosis of urine leak and lymphorrhea. Twenty-five kidney recipients (15 males and ten females, aged between 14 and 62 years) with persisting post-operative fluid drainage from the drain for more than two weeks were enrolled in this study. Creatinine and urea of three samples, namely serum, urine and the drain fluid, were measured. A single dose of 300 mg of pyridium (phenazopyridine) was then administered to all patients. One physician and one nurse who were unaware of the aim of the study checked and evaluated the color of the samples of urine and drain fluid of each patient. In seven patients, the level of creatinine in the urine and drain fluid was similar and in them the color of both samples became orange to red, indicating urine leak from the ureteric anstomotic site. The remainder of the 18 patients did not show any changes in the drain fluid color and the level of creatinine was nearly same in the serum and drain fluid. In a kidney transplant recipient, pyridium can be used as an easy, safe and easily available indicator for diagnosing urine leak in the drain fluid.

Chyluria: a scourge of our region.

Chyluria is endemic in the Gangetic belt of India with an average of 90 cases treated annually at our institute. It is almost exclusively caused by Wuchereria bancrofti in tropical areas. Chylomicrons and triglycerides are lost in the urine from an abnormal lymphourinary fistula due to obstructive lymphatic stasis, most commonly at the renal pelvis. It is a distressingly recurrent condition with multiple exacerbations and remissions over years. Severe weakness, weight loss and haematuria occur in some patients. Diagnosis can be made by visual examination of milky urine along with the ether test of urine for chylomicrons. Intravenous urography is used to locate the site of the fistula, although the detection rate is poor. Treatment starts with conservative measures such as a high-protein low-fat diet and diethylcarbamazine therapy. In cases where conservative measures fail, endoscopic sclerotherapy (renal pelvic instillation of silver nitrate, povidone iodine or others) and surgical therapy are used.

Modified retroperitoneoscopic renal pedicle lymphatic disconnection for intractable chyluria.

INTRODUCTION: To describe a modified retroperitoneoscopic renal pedicle lymphatic disconnection (MRRPLD) and to compare the efficacy and safety of MRRPLD with traditional retroperitoneoscopic renal pedicle lymphatic disconnection (RRPLD). TECHNICAL CONSIDERATIONS: From September 2008 to July 2012, RRPLD and MRRPLD were performed respectively on 18 and 14 patients at our center. Comparison was conducted including operative time, intraoperative blood loss, postoperative time of bed rest, hospital stay, postoperative urine chyle test, and complications. All operations were completed without conversion to open surgery. The mean operative time, intraoperative blood loss, postoperative time of bed rest, and hospital stay from MRRPLD group were all decreased compared with data from RRPLD group. There was significant difference in operative time, postoperative time of bed rest, and hospital stay (P <.05). Complications occurred only in 1 patient receiving RRPLD. Chyluria disappeared in all patients after the operation. No recurrence was observed during the follow-up. CONCLUSION: MRRPLD has a good effect and safety for chyluria. It is a simpler, more minimally invasive, and more economic surgical therapy compared with traditional RRPLD.

Chyluria: is retrograde pyelogram mandatory prior to endoscopic sclerotherapy?

Chyluria is the passage of milky urine due to a lymphourinary fistula secondary to lymphatic stasis caused by obstruction of the lymphatic flow. This can be caused by parasitic or non-parasitic infections. Though chyluria is a commonly encountered entity in clinical practice particularly in developing countries like India, it is rarely discussed in English literature. We report a case of chyluria with right bifid ureter in a 50-year-old male patient who was treated with intrarenal pelvic instillation of 1% silver nitrate (AgNO3) and emphasis on the diagnostic implication of retrograde pyelography prior to endoscopic sclerotherapy in managing chyluria particularly in renal anomalies.

A rare case of milky urine.

Chyluria is an uncommon condition characterized by lymphatic fluid excretion into the urinary tract. Most common causes of chyluria are infections by parasites e.g. filariasis, echinococcosis, or cysticercosis. Nonparasitic chyluria is a very rare condition and possible etiologies include granulomatous disease (e.g. tuberculosis, leprosy, and fungal infection), malignomes, inherited and acquired malformation (posttraumatic), pregnancy, or aortic aneurysm. We present a case of a 73-year-old man, born and raised in Taiwan, but living in Austria for the past 5 years. He was admitted in our department by a general practitioner due to milky urine, whose turbidity increased after meal. All tests for infectious diseases or other above-mentioned causes remained negative. Additionally, although flexible cystoscopy yielded in a clear diagnosis of a milky urine jet out of the right urether, CT urography and bipedal lymphangiography failed to locate the lymphorenal fistula. Due to a stable renal function and absence of lipid metabolism disorders, a conservative management of the patient was chosen.

Silver nitrate sclerotherapy for chyluria: evaluation for the optimal instillation regime.

OBJECTIVE: To compare the efficacy of the 3-instillation regime with the 9-instillation regime of 1% silver nitrate solution for renal pelvic instillation sclerotherapy in patients with chyluria. PATIENTS AND METHODS: 59 Patients with chyluria were prospectively evaluated and randomized into two groups. The study group received 3 instillations (n = 29) while the control group received 9 instillations (n = 30). 1% silver nitrate was used. RESULTS: In the study group of the 29 patients given sclerotherapy, 28 (96.5%) had complete symptomatic relief while symptoms persisted in 1 (3.44%). None of the patients had hematuria or any other severe complication. In the control group of the 30 patients given sclerotherapy, 29 (96.66%) had complete symptomatic relief while chyluria persisted in 1 (3.33%), 5 patients developed hematuria (16.66%) and 1 patient developed fever with UTI (3.33%). The results of the 3-instillation regime match the results of the more commonly used 9-instillation regime. With this shorter regime, the hospital stay, morbidity and overall complication rate is less and it is more cost effective. CONCLUSION: We recommend the 3-instillation regimen in patients with chyluria refractory to conservative treatment.

Recombinant alpha-2b interferon in patients with malignant carcinoid tumour.

Seventeen patients with malignant carcinoid tumour, ten of whom had the malignant carcinoid syndrome, were treated with recombinant alpha-2b interferon by subcutaneous injection (3 MU per dose) three times per week for a median of 12 weeks (range 4-48). No objective tumour responses were observed; however, there was a greater than 50% reduction in 24-hour urinary 5-hydroxyindolacetic acid (5-HIAA) excretion in four of ten patients (40%) with elevated pretreatment levels. Five of ten patients (50%) with flushing, five of seven patients (71%) with diarrhoea and both patients with wheezing experienced relief of symptoms. Three of four patients (75%) with weight loss as their only problem experienced weight gain. Responses occurred within the first eight weeks of treatment, but were generally of short duration. Toxicity occurred in all patients, and consisted mainly of fever, chills, anorexia, fatigue and weight loss. Four patients ceased therapy due to toxic reactions. Although interferon has activity against carcinoid tumours, its benefits are short-lived and toxicity limits its use with increasing dose. Patients with carcinoid syndrome appear to achieve the best therapeutic response, and it is likely that low doses (9-20 million IU weekly) are as effective as higher doses (36-72 million IU weekly).

Altered excretion of modified nucleosides and beta-aminoisobutyric acid in subjects with acquired immunodeficiency syndrome or at risk for acquired immunodeficiency syndrome.

Urinary excretion of modified nucleosides and beta-aminoisobutyric acid, subsequently referred to as markers, was determined in populations of patients with acquired immunodeficiency syndrome (AIDS) or at risk for development of AIDS. Our results show that asymptomatic adult male homosexuals excreted elevated amounts of markers as compared to male heterosexuals. This aberrant excretion was more pronounced in asymptomatic adult male homosexuals with antibodies to HTLV-III. Significantly greater excretion of 1-methylinosine, N4-acetylcytidine, and N2-methylguanosine was observed in asymptomatic adult male homosexuals with antibodies to HTLV-III than in asymptomatic male homosexuals without antibodies to HTLV-III. Increased amounts of markers were also excreted by subjects with the generalized or chronic lymphadenopathy syndrome, AIDS related complex (ARC), or AIDS. In these subjects, the most pronounced differences between groups were between subjects with chronic lymphadenopathy syndrome and those with ARC; subjects with ARC excreted greater amounts of seven of the ten urinary markers. There were few differences between subjects with ARC and those with AIDS, Kaposi's sarcoma, or AIDS with opportunistic infections. This observation may be useful for identifying subjects who are at risk of developing AIDS. A prospective study to test this hypothesis is under way.

Neopterin in AIDs, other immunodeficiencies, and bacterial and viral infections.

An increase in total urinary neopterin was observed in 12 of 13 patients with acquired immunodeficiency syndrome (AIDS), seven of 13 patients with lymphadenopathy, one of six healthy homosexual males, seven of ten adult patients with staphylococcal pneumonia, 11 of 12 children with viral infections, four of seven children with bacterial infections, and 12 of 13 children with various immune defects. Extremely high values of total urinary neopterin and monapterin were observed in severely ill patients with AIDS and those with familial hemophagocytic lymphohistiocytosis. Neopterin excretion was normal in two AIDS patients with Kaposi's sarcoma, but without opportunistic infections at that time. On reexamination of one of these patients later on, elevated neopterin values were noted. Parallel increases in neopterin and monapterin were found, whereas biopterin was usually normal. The increase in total neopterin was mainly due to 7,8-dihydroneopterin and was accompanied by an increase in 3'-hydroxysepiapterin. Increased neopterin in urine is assumed to reflect the increase in GTP pool and GTP cyclohydrolase I activity as observed in stimulated monocytes. Thus, neopterin, as a measure of the activation of the nonspecific cellular immune system, may be used diagnostically to detect allograft rejection after transplantations and to follow-up HTLV-III positive patients.