|LETTER TO THE EDITOR
|Year : 2018 | Volume
| Issue : 6 | Page : 307-310
The effect of dextrose instillation on a man with chylous hematuria: A case report
Yu Liang Liu1, Shun Chen Huang2, Hao Lun Luo1
1 Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
2 Department of Anatomic Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
|Date of Web Publication||22-Nov-2018|
Hao Lun Luo
Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, No.123, Da-Pi Road, Niaosong Dist., Kaohsiung
Source of Support: None, Conflict of Interest: None
Chyluria is a morbid condition and sclerotherapy is a minimally invasive treatment modality in treatment of chyluria. The benefit of sclerosing agents have been analyzed in previous studies; however, our patient has iodine allergy and silver nitrate is not available at our institution. So we chose 50% dextrose as sclerosing agents. We found that chyluria was cured without any complication. This result might offers a simple and safe modality of treatment.
Keywords: Chyluria, slecrotherapy, dextrose
|How to cite this article:|
Liu YL, Huang SC, Luo HL. The effect of dextrose instillation on a man with chylous hematuria: A case report. Urol Sci 2018;29:307-10
| Introduction|| |
Chyluria is the presence of chyle in urine that is prevalent in tropical countries such as India, Africa, and South America. Efficacy of renal pelvic instillation sclerotherapy (RPIS) using silver nitrate for chyluria has been demonstrated in various studies, but the silver nitrate instillation is not a harmless therapy. The complications including severe perinephric hematoma, arterial hemorrhage, acute necrotizing ureteritis with obstructive uropathy, and ureteral stenosis have been reported.,,, Cases of death also have been reported after silver nitrate instillation. We report a case of chyluria from left kidney in a 51-year-old man treated by retrograde instillation of 50% dextrose water. No complication was recorded during the follow-up of 6 months. We suggest that urothelial sclerotherapy using 50% dextrose water in chyluria offers a simple and safe modality of treatment.
| Case Report|| |
A 51-year-old male without relevant comorbidities came to our clinic because of milky urine in the recent 2 weeks. The urine was getting thicker associated with blood clot passage. He denied traveling history or trauma history in the recent 1 year. Physical examination revealed low-abdominal distension and obvious tenderness. Urinary retention was impressed, and catheterization showed strawberry milk-like content [Figure 1]. [Table 1] shows the patient's initial laboratory testing. Urine analysis showed obvious proteinuria and hematuria [Table 2]. Computer tomography found no retroperitoneal lesions. Cystoscopic removal of intravesical content was performed, and no obvious intravesical lesion was noted. Bilateral ureteral catheter was placed, and retrograde pyelography found left renal pyelolymphatic backflow [Figure 2]. The collected urine was stained by Sudan III to confirm triglyceride content [Figure 3]. We performed 50% dextrose 20 cc instillation twice daily for 3 days and repeated retrograde pyelography. The left pyelolymphatic backflow was much regressed, and urine was gradually getting clear [Figure 4].
|Figure 2: Retrograde pyelogram showing fistulous connection between urinary collecting system and lymphatic system|
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|Figure 3: Photomicrograph of patient's urine stained with Sudan III showing triglyceride content (×400)|
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|Figure 4: Retrograde pyelogram showing pyelolymphatic backflow was much regressed|
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| Discussion|| |
Chyluria is described as the passage of milky white chylous urine due to the leakage of chylous material into the pelvicalyceal system. The causative factors have been divided into two groups: parasitic and nonparasitic. In tropical countries, more than 90% of parasitic chyluria is caused by Wuchereria bancrofti infestation. The parasite is spread by mosquitoes. Other parasites such as Taenia echinococcus, Taenia nana, ankylostomiasis, trichiniasis, and malarial parasites can also cause chyluria. Nonparasitic chyluria is rare and commonly occurs secondary to trauma, tumors, abscesses, pregnancy, congenital conditions, and following surgery. Most of these causes can result in lymphatic obstruction, leading to dilatation and proliferation of reno-lumber lacteals. Thus, a fistulous connection with the collecting system was developed. The severity of chyluria can be graded into (1) Grade I: Milky white urine passage; (2) Grade II: With whitish clots or episodes of clot retention; and (3) Grade III: Hematochyluria passage. The duration of chyluria symptoms may vary from 2 to 11 years. The disease is significantly higher in males (86%) compared to females (14%) and occurs more frequently on the left side.
The urinary sample is like milk, usually containing fibrin and blood clots. A fatty diet before voiding can enhance the phenomenon. Erythrocytes and lymphocytes may appear in a microscopic examination and chyluria can be confirmed by ether test, methylene blue test, and Sudan III test. Abnormal pyelolymphatic channels can be confirmed by intravenous urography, retrograde pyelography, and lymphangiography. The preoperative findings of retrograde pyelography may not affect the outcome but help plan treatment. The lymphangiography is the most powerful diagnostic modality, but it is not routinely done because it is a technically demanding, time-consuming, and invasive procedure. Other noninvasive techniques such as magnetic resonance imaging and lymphangioscintigraphy also can provide detailed anatomical information about the source of chyluria.
Conservative treatment may include watchful waiting and treatment with high protein and medium-chain triglyceride-rich diets(coconut oil). Antifilarial drugs (diethylcarbamazine, ivermectin, and albendazole) are useful against lymphatic filariasis. RPIS which causes sclerosis of the fistulous connection is a minimally invasive treatment for chyluria resistant to conservative treatment. Sclerosing agents including silver nitrate (0.1%–3.0%), 0.2% povidone-iodine, 15%–25% sodium iodide, 10%–25% potassium iodide, 50% dextrose, 76% hypertonic saline, and combination therapy are used. The patient was placed in the head-down (20°) position and 7–10 ml sclerosant was instilled through an ureteric catheter. The following edema, inflammatory reaction, and fibrosis will lead to symptoms remission.
Silver nitrate is the most commonly used agent with a high success rate and a relative low recurrent rate. Silver nitrate has sensitivity to light, so the solution must be freshly prepared each time and stored in a dark bottle. In addition, when the silver nitrate and normal saline are mixed, insoluble silver chloride salt forms and can lead to ureteric obstruction. Side effects caused by silver nitrate instillation include severe perinephric hematoma, arterial hemorrhage, acute necrotizing ureteritis, and ureteral stenosis. Even a 30-year-old woman death has been reported following bilateral simultaneous 3% silver nitrate instillation.
Povidone-iodine is another safe and effective agent with similar success rate to silver nitrate. Goel et al. reported that 0.2% povidone-iodine is as effective as 1% silver nitrate with no side effects. Nandy et al. mentioned about the combination sclerotherapy using 5% povidone-iodine and 50% dextrose of chyluria which caused 87% complete remission. In other study, a combination of 10% povidone-iodine plus 10% dextrose solution was used in two patients, and recurrence was noted in one patient after 6-month follow-up. Sclerotherapy with povidone-iodine is an alternative therapy in addition to silver nitrate, but the long-term efficacy is still unclear. Although povidone-iodine is an alternative and a relatively safe agent, patients still have the risk of allergic reaction. Goel et al. found a relatively high recurrent rate of sclerotherapy with 50% dextrose alone. However, for patients with povidone-iodine allergy history, it should be considered as a safe and alternative treatment choice. Fifty percent dextrose is a hypertonic solution that may cause thrombosis when infused through peripheral veins. Fifty percent dextrose infusion is thought to induce an inflammatory reaction and then fibrosis within the pyelolymphatic fistula, leading to the closure of lymphatic pelvic channel.
In this case, a 51-year-old male developed chylous hematuria due to unknown etiology for 2 weeks. The patient has a history of contact dermatitis on povidone-iodine, and silver nitrate is not available at our institution. Hence, we chose 50% dextrose as sclerosing agents. A ureteral catheter was placed in the left renal pelvis, and six instillations of 50% dextrose solution were performed at 12-hourly intervals. Each dextrose instillation was stopped until this patient felt intolerable flank soreness. After treatment, the strawberry milk-like urine was cured completely. A repeat retrograde pyelography showed complete disappearance of the pyelolymphatic backflow. Postoperative follow-up about 1 year found no recurrence in such patients allergic to povidone-iodine. Although long-term follow-up is not reached, we present our experience of successful dextrose retrograde instillation in the management of chyluria.
| Conclusion|| |
Sclerotherapy using 50% dextrose is an alternative technique for the treatment of pyelolymphatic fistula. This case illustrates a role for this sclerosing agent in treating chyluria. The dextrose is safe, cheap, and easy to obtain. However, further randomized controlled studies are needed to evaluate the long-term effectiveness of this sclerosing agent.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]