Retroperitoneoscopic Renal Pedicle Lymphatic Disconnection for Chyluria in Presence of Complex Renal Vasculature

Imaging of Perirenal and Intrarenal Lymphatic Vessels: Anatomy-based Approach

The lymphatic system (or lymphatics) consists of lymphoid organs and lymphatic vessels. Despite the numerous previously published studies describing conditions related to perirenal and intrarenal lymphoid organs in the radiology literature, the radiologic findings of conditions related to intrarenal and perirenal lymphatic vessels have been scarcely reported. In the renal cortex, interlobular lymphatic capillaries do not have valves; therefore, lymph can travel along the primary route toward the hilum, as well as toward the capsular lymphatic plexus. These two lymphatic pathways can be opacified by contrast medium via pyelolymphatic backflow at CT urography, which reflects urinary contrast agent leakage into perirenal lymphatic vessels via forniceal rupture. Pyelolymphatic backflow toward the renal hilum should be distinguished from urinary leakage due to urinary injury. Delayed subcapsular contrast material retention via pyelolymphatic backflow, appearing as hyperattenuating subcapsular foci on CT images, mimics other subcapsular cystic diseases. In contrast to renal parapelvic cysts originating from the renal parenchyma, renal peripelvic cysts are known to be of lymphatic origin. Congenital renal lymphangiectasia is mainly seen in children and assessed and followed up at imaging. Several lymphatic conditions, including lymphatic leakage as an early complication and acquired renal lymphangiectasia as a late complication, are sometimes identified at imaging follow-up of kidney transplant. Lymphangiographic contrast material accumulation in the renal hilar lymphatic vessels is characteristic of chylo-urinary fistula. Chyluria appears as a fat-layering fluid-fluid level in the urinary bladder or upper urinary tract. Recognition of the anatomic pathway of tumor spread via lymphatic vessels at imaging is of clinical importance for accurate management at oncologic imaging. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Chyluria: the state of the art

Chyluria is the passage of chyle in the urine. The cause seems to be the rupture of retroperitoneal lymphatics into the pyelocaliceal system, giving urine a milky appearance. This communication is caused by the obstruction of lymphatic drainage proximal to intestinal lacteals, resulting in dilatation of distal lymphatics and the eventual rupture of lymphatic vessels into the urinary collecting system.This condition, if left untreated, leads to significant morbidity because of hematochyluria, recurrent renal colic, nutritional problems due to protein losses and immunosuppression resulting from lymphocyturia.In this review, we summarize the state of the art of this condition and the newest treatments available.

It is unnecessary to completely mobilize the kidney in retroperitoneoscopic renal pedicle lymphatic disconnection for intractable chyluria

PURPOSE

To compare the efficacy and safety of two approaches in retroperitoneoscopic renal pedicle lymphatic disconnection (RRPLD) for intractable chyluria: completely or partly mobilize the kidney.

MATERIALS AND METHODS

Retrospectively reviewed the clinical data of 77 patients, who underwent RRPLD because of intractable chyluria in our institution. We mobilized the whole affected kidney in 22 patients during the operation, but only dissected the lower part in other 55 patients. Operative time, blood loss, visual analog scale (VAS) score, postoperative bed rest, postoperative hospital stay, recurrence, intraoperative and postoperative complications were compared between the two groups.

RESULTS

All operation was successful, and none convert to open. The chyluria was resolved immediately after surgery. Compared with completely mobilized RRPLD (CMR), partly mobilized RRPLD (PMR) was superior in terms of operative time (132.91 ± 35.65 vs. 91.73 ± 24.14 min), blood loss (35.68 ± 8.21 vs. 25.09 ± 7.41 ml), VAS score (4.63 ± 0.44 vs. 2.34 ± 0.80), postoperative bed rest (3.36 ± 0.49 vs. 1.80 ± 0.85 days) and hospital stay (6.77 ± 1.57 vs. 4.98 ± 1.89 days). Compilations occurred in three patients in CMR group and two in PMR. Recurrence was confirmed by cystoscopy in three patients during 3-103-month follow-up, CMR group with 1 and PMR with 2.

CONCLUSION

In our study, we found PMR was equally effective and safe as CMR. Moreover, it is more minimally invasive, painless and economical. Therefore, we believe it is unnecessary to completely mobilize the kidney in RRPLD for intractable chyluria.

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.

Transperitoneal laparoscopic renal denervation for the management of loin pain haematuria syndrome

OBJECTIVES

To assess the role of laparoscopic renal denervation as a surgical option in loin pain-haematuria syndrome (LPHS), refractory to conservative treatment.

MATERIAL AND METHODS

Nine patients between 2000 and 2010 with a diagnosis of LPHS following extensive investigations. The data collection from medical records and electronic databases included demographic details, details of surgical procedures, perioperative outcomes, pain recurrences and ongoing analgesia requirements. A telephone follow-up was conducted after at least one year after the procedure for each patient using the Pain Impact Questionnaire (PIQ-6TM) to assess impact of pain on their quality of life.

RESULTS

Nine patients (nine women; median age 37 years) underwent 11 laparoscopic denervations. The median follow-up was 28 months. The median operative time was 150 min. There were no significant postoperative complications. In four patients (44%) laparoscopic denervation procedures were curative (median follow-up 70.5 months). The analgesic requirement was significantly reduced in 22% of patients. Telephone follow-up confirmed that 66.66% of the patients had better quality of life after the procedure.

CONCLUSIONS

Laparoscopic renal denervation is a feasible and safe alternative to open procedures in patients with refractory LPHS, producing good outcomes in terms of pain-free rates and quality of life impact.