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The Treatment of Chyluria Secondary to Advanced Carcinoma of the Prostate

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Prostate Cancer and Prostatic Diseases (2008) 11, 102–105

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CASE REPORT

The treatment of chyluria secondary to advanced carcinoma of the prostate

SA Cluskey, A Myatt and MA Ferro

Department of Urology, Huddersfield Royal Infirmary, Huddersfield, UK

Chyluria has not been previously reported as being associated with carcinoma of the prostate. The most common cause is lymphatic filariasis, a parasitic disease. Non-parasitic chyluria is rare. We describe a case of chyluria associated with carcinoma of the prostate. We describe our successful management in this case and highlight how urologists may overcome problematic chyluria in patients with advanced carcinoma of the prostate.

Prostate Cancer and Prostatic Diseases (2008) 11, 102–105; doi:10.1038/sj.pcan.4500994; published online 31 July 2007

Keywords: chyluria; androgen blockade; TURP

3-week history of back pain. He had not opened his bowels for 3 days but reported passage of flatus. He

Introduction

Chyluria occurs as a result of abnormal communication between lymphatics and the urinary tract. It may be associated with flank pain, fever, dysuria, haematuria and chylous clot retention.1–3 Worldwide, the most common cause is lymphatic filariasis, a mosquito-borne parasitic disease endemic to tropical and subtropical areas. Wuchereria bancrofti is implicated in most cases. The adult worms inhabit peripheral lymphatics, ultimately leading to lymphangiectasia. Chyluria is thought to result from the rupture of small lymphatics of the collecting duct.4 Non-parasitic causes of chyluria are rare. Cases associated with structural lymphatic abnormalities,5 lymphatic tumours6 and tuberculosis7 have been described. Chyluria has also been observed after trauma, including intravascular catheterization8 and open surgery.9,10 was referred to the acute surgical team for further investigation. At the time of admission, his symptoms included general malaise, back pain and poor mobility. He was indeed bed bound. He reported no difficulty in passing urine, although he had been treated for a suspected urinary tract infection 3 weeks earlier. Clinical examination found his general condition to be very poor but revealed no specific signs to indicate a cause. He was afebrile and his cardiovascular and respiratory systems were normal. His abdomen was soft and non-tender, but distended. A fullness of the right lower quadrant, but no expansile aortic pulsation, was detected. He had audible bowel sounds. Digital rectal examination revealed hard faeces and a malignant feeling prostate. Clinically, his prostate was adenocarcinoma stage T3. Anal tone and perianal sensation were normal as was neurological examination of the lower limbs. Abdominal radiograph showed moderate gaseous distension of the large bowel but no abnormal small bowel dilatation. A contrast CT of the abdomen and pelvis (Figure 1) confirmed marked faecal loading of the caecum but no inflammatory process or obstructing large bowel lesion. Extensive retroperitoneal lymphadenopathy was identified, commencing just above the level of the right renal vein. A nodal mass measuring 6 cm in maximum diameter, intimately related to the inferior vena cava and right common iliac vein, extended into the right external iliac nodal group. A large prostate was noted. Prostate-specific antigen (PSA) measured 2962 mg/l, his alkaline phosphatase was mildly raised to 204 IU/l. There were no other relevant abnormal blood results. The patient was referred to urology with a working diagnosis of metastatic prostate cancer.
We describe a case of chyluria as the presenting feature of advanced prostate adenocarcinoma. This association has not been previously reported in the literature. The management of problematic chylous material causing retention of urine and catheter blockage, and resolution of chyluria after androgen blockade is described.

Case report

A 75-year-old Guyanese man, residing in the United Kingdom, with type II diabetes mellitus and ischaemic heart disease presented to his general practitioner with a

Correspondence: SA Cluskey, Department of Urology, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield, West Yorkshire HD3 3EA, UK. E-mail: [email protected]

On the day of admission, a 12Ch urethral catheter was inserted to monitor his urine output. There was no

Received 3 December 2006; revised 28 March 2007; accepted 6 April 2007; published online 31 July 2007

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chyluria after relief of his bladder outflow obstruction with a channel transurethral resection of his prostate (TURP). This was undertaken 10 weeks after treatment initiation. A normal bladder was observed on cystoscopic examination and no chylous material was evident at the ureteric orifices. Thirty-three grams of tissue was resected to create a good channel. His recovery was unremarkable, postoperatively. Following the removal of his catheter, the patient established normal micturition and was able to void the chylous urine with only 38 ml of residual urine. Histological examination of TURP chippings failed to identify neoplasia. To confirm our clinical diagnosis of prostatic adenocarcinoma, we elected to collect further tissue for histological examination. Transrectal biopsies of the peripheral prostatic tissue had the histological features of poorly differentiated prostate adenocarcinoma, Gleason grade 4 þ 5 in 50% of one core out of five from the right side of the prostate and grade 4 þ 5 in up to 70% of all five cores from the left side of the prostate. When reviewed 17 weeks after commencing antiandrogen therapy, the patient reported a good urinary flow. Most importantly, he reported that his urine was clear, with no apparent chylous material. Repeat midstream urine specimen was negative for triglyceride. Serum PSA was 234 mg/l and alkaline phosphatase was 187 IU/l. The patient continues to improve steadily and is under regular outpatient review at the time of writing this report.

Figure 1 Contrast CT abdomen and pelvis. Axial image demonstrating the right paracaval nodal mass (arrow).

comment regarding the appearance of the 500 ml residual volume of urine. However, within 24 h, the catheter had blocked and was subsequently changed to a 22Ch three-way catheter with irrigation. Blood-stained, thick, ‘creamy’ urine was observed. Initial therapy was bicalutamide 150 mg o.d., followed by subcutaneous goserelin 10.8 mg after 3 weeks and at 12-week intervals. The patient remained clinically stable and afebrile. Oral ciprofloxacin 500 mg b.d. was started empirically and continued for 7 days; however, urine cultures did not grow significant colonies of bacteria. Further analysis of the urine identified a triglyceride concentration of 2.01 mmol/l but no cholesterol. Following centrifugation, a layer of chylomicrons formed on the top of the urine consistent with the presence of lymphatic material.11 A radionuclide bone scan showed widespread abnormal areas of tracer uptake throughout the ribs, pelvis and thoracic spine. No definite renal uptake was demonstrated and the appearance was that of a superscan.12 Further diagnostic tests ruled out myeloma. The patient’s back pain was managed effectively with oral analgesics. Isotope lymphoscintigraphy performed 8 weeks after the onset of symptoms did not positively identify a connection between the lymphatic and genitourinary systems. His PSA fell to 567 mg/l within 4 weeks of starting androgen blockade therapy, although problematic chyluria persisted. By this time, his constipation had been treated successfully with conservative measures. A trial without catheter was unsuccessful and smaller calibre urethral catheters rapidly blocked leaving this patient resident in hospital with continuous bladder irrigation through a 22Ch three-way catheter. The patient’s general condition improved with the continued androgen blockade therapy. His back pain subsided and his mobility improved. He was no longer confined to his bed. He was deemed ready for surgical intervention for his persistent chyluria. We thought that he might void this thick

Discussion

A number of existing reports described cases of intermittent chyluria, which was not associated with biochemical disturbance and had little impact on the patient’s well-being.3,5,8 Conversely, the persistent loss of lipid and protein in the urine can lead to hypoproteinaemia, weight loss and malnutrition, warranting definitive treatment.11 Optimum management of this condition is likely to depend on symptom severity, biochemical derangement and the underlying cause of chyluria. The urinary lipids have been shown to originate from dietary fat. Absolute lipid content therefore varies between fasting and postprandial samples; indeed, this is often evident clinically.11,13 One conservative management strategy is to restrict dietary fat or consume only medium-chain triglycerides, as these are transported directly to the liver by the portal venous system.14 However, dietary restriction of a patient with advanced malignancy would have been undesirable in this case. Anti-filarial agents such as diethylcarbamazine and ivermectin kill circulating microfilariae, although adult worms may be resistant. The major role of drug therapy is to interrupt disease transmission through the mosquito vector.15 Treatment can result in lasting symptomatic relief, although recurrence of chyluria after medical therapy has been reported.2 Reliable diagnosis of lymphatic filariasis can be problematic. Chyluria and other chronic manifestations of filariasis, including lymphoedema and hydrocele, may occur many years after the death of the adult worm.4,16 Furthermore, reliable detection of microfilariae in a thick blood film

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from an infected individual may depend on the time of day that the specimen was obtained.16 Ultrasound scanning is utilised in some endemic regions to identify adult worms in the lymphatic vessels around the spermatic cord.17 Detection of antibodies against the adult worm is considered to be a reliable test for infection,18 although this was not available to us. We could not definitely exclude lymphatic filariasis in our patient who had emigrated from a geographic area with a high prevalence of filarial infection. However, in the absence of other stigmata of infection and in the context of the confirmed diagnosis of metastatic prostate cancer, together with his response to androgen blockade therapy, specific diagnostic tests to confirm filarial infection were not undertaken. Demonstration of the anatomical site of lymphaticourinary communication can direct the management of nonparasitic or intractable chyluria. Lymphoscintigraphy has gained popularity as a safe, rapid and reproducible method to assess structural and functional lymphatic transport pathways. This involves peripheral subcutaneous injection of a technetium 99m-labelled macromolecule, which enters the lymphatic vessels and is transported towards the thoracic duct. A high-resolution scintiscan camera produces an anatomical image of lymphatic transport, identifying abnormal nodes and delayed transport suggestive of lymphatic obstruction.19 Lymphoscintigraphy has been used to demonstrate lymphaticourinary fistulae in previously reported cases of chyluria. Such fistulae are indicated by accumulation of the tracer in the renal collecting system.14,20 The number of cases investigated in this way is small. In our case, lymphoscintigraphy did not reveal lymphaticourinary connection. Haddad et al.21 reported that lymphoscintigraphy failed to identify a lymphocalyceal fistula, which had been shown by conventional lymphangiography. Pui and Yeuh14 reported normal lymphoscintigraphic findings in 5 of 11 patients with chyluria and a history of filariasis. Dilution of tracer in the bloodstream, uptake of radioisotope in the liver, kidney and spleen and poor camera resolution are proposed explanations for the failure of lymphoscintigraphy to identify fistulae Passage of chylous material is known to be intermittent and is affected by fasting status; this could explain why chylous efflux was not observed at either ureter at the time of cystoscopy. freedom from the catheter, although chyluria persisted. The complete resolution of chyluria, in response to androgen blockade, paralleled the fall in serum PSA and supports the suggestion that his prostate malignancy was the causative factor of his chyluria, particularly because no other medical treatments or interventions were adopted. It is probable that a reduction in the tumour bulk and retroperitoneal lymph node mass alleviated lymphatic obstruction, which had led to chyluria.

Conclusion

TURP has not been described previously as part of the management of chyluria. In this case, it was a useful treatment modality in managing the problematic chylous material causing retention of urine and catheter blockage. The resolution of chyluria, in response to androgen blockade, suggests that prostatic adenocarcinoma was the causative factor of chyluria in this case. This is an important observation for urologists who might encounter similar cases.

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Previously reported treatment strategies, which target lymphaticourinary fistulae involving the renal collecting system, include renal pelvic instillation sclerotherapy

  • with povidone iodine or silver nitrate solutions.22,23
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novel application of the tissue sealant N-butyl-2-cyanoacrylate was to successfully close a fistula between the ureteric stump and a lymphatic fluid collection, which developed post nephrectomy and lymphadenectomy.10 Surgical procedures for intractable chyluria include renal decapsulation, renal pedicle lymphatic disconnection, which has successfully been achieved using minimal access techniques, and nephrectomy.24 The objectives of treatment in our patient were to manage advanced prostatic malignancy, and secondly to address the problem of recurrent chylous clot retention, which rendered our patient hospitalized and dependant on continuous bladder irrigation. We surmised that passage of thick, chylous material was impeded by a large, malignant prostate. In this case, TURP permitted

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Prostate Cancer and Prostatic Diseases

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    Urinalysis: A Comprehensive Review JEFF A. SIMERVILLE, M.D., WILLIAM C. MAXTED, M.D., and JOHN L PAHIRA, M.D. Georgetown Utiiversity School of Medicine, Washington, D.C. A complete urinalysis includes physical, chemical, and microscopic examinations. Midstream clean collection is acceptable in most situations, but tbe specimen sbould be examined within two hours of collection. Cloudy urine often is a result of precipitated phosphate crystals in alka- line urine, but pyuria also can be tbe cause. A strong odor may be the resuh of a concentrated specimen rather than a urinary tract infection. Dipstick urinalysis is convenient, but false-posi- tive and false-negative results can occur. Specific gravity provides a reliable assessment of the patient's hydration status. Microhematuria has a range of causes, from benign to life tbreatening. Glomerular, renal, and urologic causes of microbematuria often can be differentiated by otber elements of the urinalysis. Although transient proteijiuria typically is a henign condition, persis- tent proteinuria requires further work-up. Uncomplicated urinary tract infections diagnosed by positive leukocyte esterase and nitrite tests can be treated without culture. {Am Fam Physician 2005;71:1153-62. Copyright© 2005 American Academy of Family Physicians.) Seepage 1046 for rinalysis is invaluable in the ors (Table 1).^ Cloudy urine often is a result strength-of-fecommenda- diagnosis of urologic conditions of precipitated phosphate crystals in alkaline tion labels. such as calculi, urinary tract urine, but pyuria also can be the cause. Uinfection (UTI), and malig- The normal odor of urine is described as nancy. It also can alert the physician to the urinoid; this odor can be strong in concen- presence of systemic disease affecting the trated specimens but does not imply infec- kidneys.
  • Analysis of Case Series of Milky Urine

    Analysis of Case Series of Milky Urine

    [Downloaded free from http://www.urologyannals.com on Tuesday, November 18, 2014, IP: 197.132.255.244] || Click here to download free Android application for this journal Original Article Analysis of case series of milky urine: A single center and departmental clinical experience with emphasis on management perspectives: A prospective observational study Sham Sunder, Rajesh Jayaraman, Himanshu Sekhar Mahapatra, Satyanand Sathi, K. Venkataramanan, K. Prabhu, Anurag Gupta, Suman Sethi Department of Nephrology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India Abstract Background: Milky urine can be due to chyluria or lipiduria due to nephrotic syndrome. Filarial chyluria usually responds to medical management while non-filarial cases may require surgical intervention. Aim: To perform a prospective observational study in patients presenting with milky urine in our centre over a period of one year from July 2011 to June 2012, a complete biochemical work up and imaging to find out the site of leakage of lymph if it is a case of chyluria, its response to medical management and the requirement of surgical intervention. Materials and Methods: Routine blood and urine investigations, 24 hour urine protein excretion, USG abdomen, serum lipid profile and rapid filarial antigen test were done in all. MRI abdomen was done in affordable patients. Renal biopsy was done in some chyluria patients for academic purpose and in milky urine with negative urine ether test. Sclerotherapy was done with 50% dextrose and 0.2% povidone iodine. Patients were followed up with 24 hour urine protein and triglyceride estimation. Results: 18 cases of milky urine were encountered.
  • The Role of Urine Investigations in Urology Practice

    The Role of Urine Investigations in Urology Practice

    Open Journal of Orthopedics, 2015, 5, 90-99 Published Online April 2015 in SciRes. http://www.scirp.org/journal/ojo http://dx.doi.org/10.4236/ojo.2015.54012 The Role of Urine Investigations in Urology Practice Muhammad Ujudud Musa Urology Unit, Department of Surgery, Federal Medical Centre Katsina, Katsina, Nigeria Email: [email protected] Received 6 February 2015; accepted 9 April 2015; published 14 April 2015 Copyright © 2015 by author and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/ Abstract Urine examination is one of the important armamentarium in the practice of urology and it is a fundamental test that is usually carried out for urology patients, it can be as simple as dipstick analysis to a complex hormonal assays. Urine examination is done worldwide as an extension of physical examination which provides a lot of information about the pathology, and both physical and chemical analysis of urine are highly informative. There are several types of urine investiga- tions, some of which include urinalysis, urine microscopy culture and sensitivity, urine micros- copy for ova or cyst of parasites, urine cytology, urine tumour antigens assays, urine hormonal assays, urine toxicology, urine quantitative measurement and urine acid fast bacilli. Uses of urine examinations in urology could be diagnostic, such as renal function test, evaluation of heamaturia, stone diseases, urinary tract infections, urologic cancers and infertility or monitoring and for prognosis. Uses of urine investigations in practice of urology cannot be over emphasized as it has many revealing information of the physiology and pathology of urologic organs.

  • The Case of a 15-Year-Old with Non-Parasitic Chyluria

    Open Access Case Report DOI: 10.7759/cureus.17388 Review began 07/20/2021 Review ended 08/12/2021 The Case of a 15-Year-Old With Non-Parasitic Published 08/23/2021 © Copyright 2021 Chyluria Lovrec Krstić et al. This is an open access 1 1 1 1 article distributed under the terms of the Tina Lovrec Krstić , Kristijan Šoštarič , Primož Caf , Matija Žerdin Creative Commons Attribution License CC-BY 4.0., which permits unrestricted 1. Radiology, University Medical Centre Maribor, Maribor, SVN use, distribution, and reproduction in any medium, provided the original author and source are credited. Corresponding author: Tina Lovrec Krstić, [email protected] Abstract Chyluria is defined by the presence of chyle in urine, and is caused by a communication between the lymphatic and urinary system. Commonly, it is characterised by the excretion of milky white urine, which is present in up to 70% of chyluria cases. The prevalent cause for chyluria in Asia is filariasis with Wuchereria bancrofti. Non-parasitic chyluria is more common in western countries and is usually subsequent to traumatic factors, infections, or tumours. The occurrence of non-parasitic chyluria in the absence of trauma, iatrogenic or other, is exceedingly rare. The lymphatic system is rather challenging to visualize. Herein, we present a case of non-parasitic chyluria and our approach of combining different complementing imaging modalities, such as contrast-enhanced ultrasound (CEUS) retrograde pyelography and magnetic resonance (MR) lymphography. Categories: Radiology, Urology, Nephrology Keywords: chyluria, non-parasitic, ceus retrograde pyelography, mr lymphangiography, urinary retention Introduction Chyluria is a condition in which chyle is present in urine.