Dıscussıon
Lymphatic ducts draining renal parenchyma and capsule which are rich in lymphatic ducts are drained via renal hilum into the lateral aortic and interaortacaval lymph nodes. Chyluria is a condition explained by Ackerman’s obstructive theory firstly in 1893 are generally benign but can cause serious morbidity. In this theory, it is proposed that lymphatic fluid is drained to urine by a fistula between renal lymphatics and pelvicaliceal system (1,2).
Chyluria is occurred in Southeast Asia, South America and Asia because of parasitic infections like filariasis, and cysticercosis echinococcus. On the other hand in Europe, North Asia and North America granulomatos infection, neoplasia, lymphatic malformations and kidney surgery and trauma are reasons for chyluria. All of these diseases can cause chyluria by lymph calyceal fistula because of obstruction in lymphatic ducts (2).
In chyluria cases which are treatment resistant or not treated for a long time, renal dysfunction, nephritic syndrome, immune deficiency, malnutrition, weighty lose and cachexia can occur because of hypoproteinemia occurred by lipidüri and proteinuria.(4). For example, in our case hypoalbuminemia was developed because of long time existence of chyluria and proteinuria while renal functions were normal.
In ongoing chyluria diet changes, injection of sclerosing substances endoscopically and disconnection of renal pedicul and lymphatic ducts can be applied in order (7). Diet rich in medium-chain fatty acids and protein is suggested to patients. In situations in which this treatment is inadequate, around 60-80% reported cure rate of injection of sclerosing substance can be applied. Recently 0.2% of povidone iodine cheaper and having less allergic side effects is used endoscopically because 1 % of silver nitrate has serious side effects like anaphylactic reactions, chemical cystitis, renal colic, urethral stricture, nausea and vomiting after instillation (7). Laparoscopic or open renal pedicul lymphatic disconnection operation is an alternative to these treatment options in cases of resistant chyluria. In our case we instillated 20 cc 0.2 % of povidone iodine via ureter catheter after taking retrograde urography. Improvement in post-treatment follow-up was identified.
Chyluria in non endemic regions is generally seen after renal surgery and trauma especially in partial nephrectomy and radiofrequency ablation treatment in renal cell carcinoma (6).
Today, SWL is commonly used successfully in treatment of urolithiasis. During SWL, shock waves are generated outside the body and focused on the stone in the renal collecting system. It is proposed that shock waves can cause fistula by trauma and obstruction on lymphatic ducts. Serious complications like renal rupture(8), colon perforation, acute pancreatitis(9) and spleen rupture(10) can develop after SWL while benign complications like hematuria renal colic and skin ecchymosis can be seen. In our literature review we didn’t find chyluria as a complication of SWL. We think that case could be a rare complication of SWL because it was observed after 2 weeks of SWL treatment and there was no history of parasitic infection or renal surgery.
As a result, patients should be informed about chyluria as a rare complication of SWL and also other complications of SWL which is a common treatment options in countries like our country where urolithiasis is high.
References
1. Hemal AK, Gupta NP. Retroperitoneoscopic lymphatic management of intractable chyluria. J Urol 2002; 167: 2473-6
2. Date A, John TJ, Chandy KG, Rajagopalan MS, Vaska PH, Pandey AP, et al. Abnormalities of the immun system in patients with chyluria. Br J Urol 1981; 53: 384-6
3. Brunkwall J, Simonsen O, Bergqvist D, Jonsson K, Bergentz SE: Chyluria treated with renal auto transplantation: A case report. J Urol 1990; 143: 793-6
4. Singh I, Dargan P, Sharma N. Chyluria a clinical and diagnostic stepladder algorithm with rewiew of literature. Indian J Urol 2004; 20:79-85
5. Goel S, Mandhani A, Srivastava A, Kapoor R, Gogoi S, Kumar A, et al.: Is povidone iodine an alternative to silver nitrat efor renal pelvic instillation sclerotherapy in chyluria? BJU Int 2004; 94: 1082-5
6. Ramani AP, Desai MM, Steinberg AP, et al.: Complication of laparoscopic partial nephrectomy in 200 cases. J Urol 2005; 173: 42
7. Shanmugam TV, Prakash JVS, Sivashankar G. Povidone iodine used as a sclerosing agent in the treatment of chyluria. Br J Urol 1998; 82: 587
8. Jeon BH, Jang JH, Oh JH, Oh SY, Lee SJ, Kim SE, Kim CW, Choe JW, Lee KJ.Kidney rupture after extracorporeal shockwave lithotripsy: report of a case. J Emerg Med 2009 ; 37(1): 13-4
9. Kurz W, Klein B, Rumstadt B. Colonic perforation after extracorporeal shock wave lithotripsy. Dtsch Med Wochenschr 2009; 134(9): 401-3
10. Kastelan Z, Derezic D, Pasini J, Stern-Padovan R, Skegro M, Mrazovac D, Sosic H. Rupture of the spleen and acute pancreatitis after SWL therapy: a rare complication. Aktuelle Urol 2005; 36(6): 519-21
