Etiopathogenesis

Chyluria may be classified as parasitic or nonparasitic (Table 2). Various theories have been suggested to explain the cause of chyluria. Prout postulated the theory of secretion of fat from blood through the kidney (9). Mollenbroch (1670) suggested abnormal connection between lymphatic and urinary system (10). Ackerman (1863) gave the "obstructive theory" and suggested that the obstruction of lymphatics anywhere between intestinal lacteals and the thoracic duct may give rise to chyluria (3). The theory of lymphatic obstruction appears to be most convincing and is well supported by the existing literature (11-13).

The lymph vessels of the kidneys form three plexi, one of them lies within the renal parenchyma, second beneath the capsule, and the third in the perinephric fat (Fig. 1). The second and third groups communicate freely with each other. The vessels emerging from the renal substance converge to form four to seven trunks. At the

Fasciectomy (Excision of Perinephric Fat and Fascia Gerota) Nephropexy

■ TECHNICAL TIPS TO AID LAPAROSCOPIC LYMPHATIC DISCONNECTION

■ POSTOPERATIVE CARE AND FOLLOW-UP

■ ADVANTAGES OF LAPAROSCOPY

■ RETROPERITONEAL VS. TRANSPERITONEAL LYMPHOLYSIS

■ REFERENCES

The most common cause of chyluria is parasitic infection secondary to filariasis caused by Wuchereria bancrofti.

Chyluria can occur anywhere in urinary tract, but the chyluria of renal origin is the most common and usually represents the chronic stage of the filarial disease. Chyle consists of lymphatic elements: albumin, fat (triglycerides), and fibrin due to a formation of coagulum if a urine is left standing for a long time.

The theory of lymphatic obstruction appears to be most convincing and is well supported by the existing literature.

TABLE 1 ■ Conditions Mimicking Chyluria TABLE2 ■ Classification of Chyluria

Gross pyuria Phosphaturia

Amorphous urate material in the urine Fungiuria

Heavy proteinuria (nephrotic range)

Parasitic

Nonparasitic

Filariasis (Wuchereria bancrofti)

Trauma

Echinococcosis (Cysticercus cellulose)

Tuberculosis

Ascariasis (Ascaris lumbricoides)

Diabetes

Ancylostomiasis

Retroperitoneal neoplasm

Trichiniasis

Retroperitoneal abscess

Malaria

Lymphatic aneurysm

Congenital disorders of lymphatic system

Congenital stenosis of thoracic duct

Pernicious anemia

Pregnancy

Source: From Refs. 7 and 8.

Chyluria occurs after the lymphatic vessel ruptures into the renal tubules. This is secondary to the obstruction in the draining lymphatic, which is usually due to an acquired cause. The obstruction in tropical countries is most commonly caused by filariasis, i.e., W. bancrofti infection. The dying worm provokes lymphangiolar dilatation and finally obstruction. The obstruction leads to high intralymphatic pressure and rupture of lymphatic in to urinary system.

hilum, these lymphatics join capsular and perinephric groups and traverse along the renal vessels to lateral aortic nodes. The perinephric group also drains in to the lateral aortic nodes. The renal pelvis and upper ureter lymphatics are connected to lymphatics around the renal vessels or lateral aortic nodes. Lymphatics from lower ureter pass to common iliac nodes. Lymphatics from the bladder originate in three sets: vessels from trigone, superior surface, and inferolateral surface all drain in to external iliac group (14).

Chyluria occurs after the lymphatic vessel ruptures into the renal tubules. This is secondary to the obstruction in the draining lymphatic, which is usually due to an acquired cause. The obstruction in tropical countries is most commonly caused by filariasis, i.e., W. bancrofti infection. The dying worm provokes lymphangiolar dilatation and finally obstruction. The obstruction leads to high intralymphatic pressure and rupture of lymphatic in to urinary system (3).

The reported incidence of chyluria is up to 2% in cases of filariasis, and in endemic areas about 10% of the population may be infected (15).

FIGURE 1 ■ Diagrammatic display of lymphatic system of kidney, ureter, and bladder.

FIGURE 1 ■ Diagrammatic display of lymphatic system of kidney, ureter, and bladder.

FIGURE2 ■ Retrograde ureteropyelograms (two different patients) showing dilated lymphatic channels (arrow heads) of right kidney (A) and upper ureter and fistulous communication with retroperitoneal lymphatics (B).

Chyluria can lead to considerable weakness and weight loss secondary to loss of proteins, cholesterol, and triglycerides.

Retrograde ureteropyelogram helps in establishing the connection between the lymphatics and urinary system.

Ultrasonography or computed tomography of the abdomen may be required in cases of nonfilarial etiology, e.g., malignant tumors.

Retrograde pyelography and sclerotherapy have been used with a success rate varying from 55% to 68% with a recurrence rate above 50% on a long-term basis.

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