|Year : 2005 | Volume
| Issue : 1 | Page : 27-30
Complications and precautions of sclerotherapy for chyluria
Department of Urology, SSG Medical College and Hospital, Baroda, India
11, Kasturbanagar Bunglows, Near Nutan School,New Sama Road, Baroda - 390008,Gujarat
| Abstract|| |
Chyluria is a debilitating illness seen in 1-2% of patients of filariasis after 10-20 years of initial infection. The obstructed retroperitoneal lymphatics rupture into pelvicalyceal system and leads to patient passing milky white chylous urine with haematuria and chylous clots. Sclerotherapy as a minimally invasive treatment modality has been used for last 35 years. Hypertonic saline, hypertonic glucose, contrast (15-25% Na iodide and Na diatrizoate), silver nitrate (0.1, 0.5, 1, 3, and 5%) and povidone-iodine (0.2%) have all been used as sclerosants with varying results. The various complications and lessons learned due to the most widely used sclerosant, silver nitrate, have been discussed in detail. The prerequisites and precautions, both preoperative and intraoperative, especially when using 1% silver nitrate instillations for sclerotherapy have been outlined to make it a safe, effective and minimally invasive treatment for chyluria.
Keywords: Chyluria; Complications; Sclerotherapy
|How to cite this article:|
Desai R. Complications and precautions of sclerotherapy for chyluria. Indian J Urol 2005;21:27-30
Chyluria represents the chronic stage of filarial disease and is seen in 1-2% of patients of filariasis after 10-20 years of initial infection. It results from obstruction of retroperitoneal lymphatics causing renal lymphatics to rupture into pelvicalyceal system and leads to patient passing milky white chylous urine with haematuria and chylous clots. It is a debilitating but not life threatening condition. It leads to weight and protein loss and immunological deficiency. Hence, any treatment of chyluria must be minimally invasive, safe, and effective. Can sclerotherapy, as a minimally invasive treatment modality, be justified as the first option when conservative modalities fail? A review of literature over last 35 years seems to justify this.
Many sclerosants with different concentrations have been used over last 35 years. These sclerosants are hypertonic saline, hypertonic glucose, contrast (15-25% Na iodide and Na diatrizoate), silver nitrate (0.1, 0.5, 1, 3, and 5%) and povidone-iodine (0.2%). As maximum experience is with silver nitrate instillations with maximum literature being published from India, Japan and Taiwan and it is discussed in detail.
| Mechanism of sclerosants|| |
After retrograde instillation through a ureteral catheter these sclerosants cause a chemical lymphangitis in renal lymphatics. After instillation the resulting inflammatory reaction causes edema of lymphatic channels and their early blockage results in immediate relief in form of clear urine. Permanent remission occurs when renal lymphatic inflammation heals by fibrosis.
| Protocols and complications|| |
The safety, efficacy and complications were directly proportional to the protocol of instillation and concentration of silver nitrate used.
Experience with silver nitrate 0.1-0.5%
Okamoto and Ohi, Japan and Tan et al, Taiwan described their experiences of silver nitrate, progressively increasing concentration from 0.1 to 0.5%. Using simple ureteral catheter, bilateral instillations 2-3 times/week were given for 10 weeks. Complications like fever, flank pain, nausea and vomiting in 20-30% were described with an efficacy of only 40-50%.
Experience with silver nitrate 1%
Sabnis et al. described their experience with instillation of 1% silver nitrate in 62 patients over 8 years with a follow up of 7 years. Using simple ureteral catheter, unilateral instillations of 10-15 ml of 1% AgNO3 were done every half an hour for four times (one course) and repeated if required after 6 weeks. In bilateral cases, opposite side instillations were done after 6 weeks. The efficacy was high with 80-85% permanent remission with only minor complications like flank pain, haematuria, nausea, and vomiting for 24-48 h in all and no major complications.
Experience with silver nitrate 3%
Many authors have reported severe to fatal complications with 3% silver nitrate instillations. Mandhani et al. asked a question 'Can silver nitrate instillation for the treatment of chyluria be fatal?' They reported a case where bilateral simultaneous 3% AgNO3 instillation was done elsewhere and patient presented with anuria and ATN with S. creatinine 6.5 mg% requiring hemodialysis. Patient developed bilateral multiple ureteral strictures with obstructive uropathy and was treated with bilateral PCN + right Davis intubated ureterotomy with D/J stenting and left ileal replacement. On table both ureters were cordlike with black deposits confirmed on HP to be silver deposits with stricture formation. She died 15 days postop of septicemia. Their conclusion was that higher concentrations of silver nitrate cause chemical cauterization of urothelium lining ureter and pelvicalyceal system leading to fibrosis and stricture formation.
Gulati et al. reported a pelvicalyceal cast formation following AgNO3 injection for chyluria. Here also patient had anuria following bilateral instillation of 3% AgNO3. Srivasta et al. reported a case of massive haematuria due to arterial hemorrhage following 3% AgNO3 instillation requiring coil embolization of the resulting intrarenal aneurysm which had ruptured. Another case of acute renal failure and renal papillary necrosis following 3% AgNO3 was also reported in 1996.
Experience with silver nitrate 5%
Mohan Kumar and Bhat first reported their experience with 5% AgNO3 instillation in eight patients. Pandey reported his experience in over 200 patients with 80-85% permanent remission. He used unilateral instillation of 10-15 ml of 5% silver nitrate using ureteral balloon catheter to block PUJ under LA followed by aspiration of AgNO3 and giving distilled water washouts. He also reported major complications like (1) anaphylactic reaction when AgNO3 entered blood stream through pyelovenous backflow requiring iv fluids and steroids (2) renal cortical and perinephric abscess due to improper placement of ureteral catheter into renal parenchyma requiring drainage, and (3) ureteral stricture formation and chemical cystitis if 5% AgNO3 slipped into ureter and bladder due to defective ureteral balloon catheter.
Precautions and prerequisites
The current consensus strongly favors use of 1% silver nitrate as the sclerosant of choice in treatment of chyluria provided following precautions and prerequisites are fulfilled. Silver nitrate (1%) is a colorless, odorless crystalline material highly soluble in water. It is light sensitive and is darkened by sunlight and hence is dispensed in amber colored bottles. It is highly resistant to growth of bacteria. Its boiling point is 444°C at which it decomposes and hence is not affected when sterilized by autoclaving. It is stable at room temperature and is prepared by reaction of nitric acid with silver and purified by recrystallization.
1. Only freshly prepared 1% silver nitrate dispensed in amber color bottle should be used;
2. High fat meal on evening prior to sclerotherapy is desired as chyluria is intermittent. Patient must ingest 50 g butter with 250 ml of creamy milk;
Instillation is under LA (95%) as it facilitates instillation of correct amount of silver nitrate. Some apprehensive patients may require caudal block (5%). Patients have to be NBM for 5 h because of possible nausea and vomiting; intraoperative
1. A IV access is a must for iv antibiotics, iv diuresis and SOS steroids in case of anaphylactic reaction;
2. C arm fluoroscopy with IITV/portable X-ray for bulb ureterography is required;
3. Cystoscopy: observe for chylous efflux to identify affected side; chyluria is unilateral in 85% and bilateral in 15%;
4. Do a bulb ureterography with bulb tip catheter to demonstrate pyelolymphatic communication and identify side of instillation. It also predicts response to treatment by assessing severity of pyelolymphatic communication [Figure - 1][Figure - 2];
5. Pass a 6F simple ureteral catheter on the affected side and estimate renal pelvis capacity using water for injection till patient experiences mild flank pain (same amount is to be used for sclerosant injection);
6. Initiate iv lasix diuresis;
7. Only unilateral sclerosant instillation. Instill 10-15 ml of 1% silver nitrate every half an hour for 2 h. This comprises one course.
Almost all patients will have nausea, vomiting, flank pain and haematuria for 24-48 h requiring treatment. Patients should be counseled about this preoperatively. Sabnis et al. have reported that 70% patients have permanent remission after one course. In 30% patients there is recurrence of chyluria within 1 year. These undergo a second course of instillation and half of these will have permanent remission thus having an 85% permanent remission rate. Even when the remaining 10-15% undergo a third course only an occasional patient may have permanent remission. These usually have severe pyelolymphatic communications as seen on the bulb ureterogram [Figure - 3] and will fail with 1% silver nitrate. They should be offered pyelolymphatic disconnection surgery at the outset.
01. One percent silver nitrate is a safe, effective and minimally invasive sclerosant for chyluria;
2.Fatty meal on evening prior to sclerotherapy is a must to identify affected side;
3.Bulb ureterogram mandatory to identify affected side and predict success with sclerotherapy;
4.IV diuresis is must to produce chyluria and washout silver nitrate;
5.Silver nitrate instillations must be done under LA to decrease complications by preventing over instillations;
6.Unilateral instillation only. In bilateral cases, contra lateral instillation should be done after 6 weeks;
7.Preoperatively warn patient about postop flank pain, nausea, vomiting, and haematuria;
8.Maximum of two courses of instillations only. If chyluria persists offer patients pyelolymphatic disconnection surgery.
| Is there anything better than silver nitrate?|| |
Shanmugan et al., have reported their experience with povidone iodine as a sclerosant in the treatment of chyluria. A single instillation of 8-10 ml of 0.2% povidone iodine using ureteral catheter were used in five patients with 6 months follow up produced success in all with no postoperative complications. In addition to advantages of being nontoxic, nonirritating, and antibacterial, povidone iodine is cheap and easily available. Goel et al. have also shown 0.2% povidone iodine to be equally efficacious as 1% silver nitrate instillations for chyluria. Its long-term results are awaited before recommending it as sclerosant of first choice for chyluria.
| Conclusion|| |
Several sclerosants with different concentrations have been used over last four decades to treat chyluria. So far the maximum experience available is with that of silver nitrate instillations. One percent silver nitrate instillation is a safe and effective treatment for chyluria as concentration above this can result in more serous complications. Recently, use of 0.2% povidone iodine has been reported to be equally efficacious and safe in the treatment of chyluria.
| References|| |
|1.||Okamoto & Ohi. Recent distribution and treatment of filarial chyluria in Japan. J Urol 1983;129:64-7. |
|2.||Tan. Experience in treatment of chyluria in Taiwan. J Urol 1990;144:710-3. |
|3.||Sabnis RB, Punekar SV, Desai RM, Bradoo AM, Bapat SD. Instillation of Silver Nitrate in Treatment of Chyluria. BJU 1992;70:660-2. |
|4.||Mandhani A, Kapoor R, Gupta RK, Rao HS. Can silver nitrate instillation for the treatment of chyluria be fatal? BJU 1998;82:926-7. |
|5.||Gulati MS, Sharma R, Kapoor A, Berry M. PC cast formation following AgNO3 injection for chyluria. Austral Radiol 1999;43:102-3. |
|6.||Srivasta DN, Yadav S, Hemal AK, Berry M. Arterial hemorrhage resulting in massive haematuria following AgNO3 instillation. Austral Radiol 1998;42:234-5. |
|7.||Dash SC, Bhargav Y, Saxena S, Agarwal SK, Tiwari SC, Dinda A. Acute renal failure & renal papillary necrosis following AgNO3. Nephrol Dial Transplant 1996;11:1841-2. |
|8.||Kumar M, Bhat HS. Experience with 5% AgNO3 instillation in chyluria. Indian J Surg 1975;37:335. |
|9.||Pandey AP. In Oxford Textbook of Surgery, Chyluria; 1985. |
|10.||Shanmugan TV, Prakash JV, Sivashankar G. Povidone Iodine used as a sclerosing agent in the treatment of chyluria. Br J Urol 1998;82:587. |
|11.||Goel S, Mandhani A, Srivastava A, Kapoor R, Gogoi S, Kumar A, et al. Is povidone iodine an alternative to silver nitrate for renal pelvic instillation chemotherapy in chyluria. BJU Int 2004;94:1082-5. |
[Figure - 1], [Figure - 2], [Figure - 3]