| Chyluria is common in urology department. The pathogenesis of chyluria is related to renal lymphatic circumfluence obstacle. The current protocol of surgical treatment for chyluria is the ligation of all the lymphatic vessels surrounding renal pedicle. Generally speaking, the affected kidney should be dissociated entirely. All the lymphatic vessels within the perirenal fascia should be ligated, including the lymphatic vessels surrounding renal pedicle, between the renal artery and vein, surrounding the upper part of ureter. The disadvantage is excessive retroperitoneal trauma, damage to the normal perinephric structure, possibility of causing some postoperative complications, such as kidney sagging, hematuria and renal pedicle torsion. Traditional lymphatic ligation lacks supporting of pathological evidence. Moreover, the enlarged surgical field and excessive damage are considered to be the disadvantage of this operation. The rationality of the current protocol is questionable. The existing literature focuses on the effect and complication, but is unable to clarify its mechanism theoretically. To investigate the distribution and morphological features of lymphatic vessels in the fat tissue surrounding kidney and ureter of patients with chyluria, the lymphatic vessel density (LVD), diameter and luminal area of lymphatic vessel in the fat tissue surrounding the renal pedicle, upper part of ureter, adrenal and perinephric fat were detected by hematoxylin and Eosin (HE) staining and immunohistochemistry staining with lymphatic endothelial marker oncofetal antigen M2A Monoclonal antibody (D2-40). It might help to provide some evidence to modify the protocol of surgical treatment for chyluria. Moreover, the effect of the modified protocol is compared to the traditional one in patients with chyluria in this study.Objective The aim of this study was to compare the effect of different protocol and marker in the detection of perinephric lymphatic vessels, to investigate the distribution and morphological features of lymphatic vessels in the fat tissue surrounding kidney and ureter of patients with chyluria and to initially provide the anatomical and pathological supports for the modification of the surgical management of chyluria, to modify the protocol of surgical treatment for chyluria according to the former study and to evaluate the feasibility and effect of the modified protocol of surgical treatment for chyluria.Methods1. The lymphatic vessels in the fat tissue surrounding renal pedicle obtained from8patients with chyluria were shown by hematoxylin and Eosin (HE) staining, enzyme histochemistry staining for5’-Nase, and immunohistochemistry staining with lymphatic endothelial marker oncofetal antigen M2A Monoclonal antibody (D2-40).2. The fat tissue surrounding the renal pedicle, upper part of ureter, adrenal and perinephric fat were obtained from6adult cadavers and15patients with chyluria. The lymphatic vessels were shown by hematoxylin and Eosin (HE) staining and immunohistochemistry staining with lymphatic endothelial marker oncofetal antigen M2A Monoclonal antibody (D2-40). The lymphatic vessel density (LVD), diameter and luminal area of lymphatic vessel were compared between cadavers and patients with chyluria.3.25cases of patients who were diagnosis as chyluria in Zhongnan hospital of wuhan university from December2011to February2014were analyzed. The operation time, intraoperative bleeding volume, postoperative hospital stay, postoperative intestinal function recovery time, retroperitoneal drainage time, postoperative complications, recurrence rate were compared between16case of patients undergone traditional laparoscopic renal pedicle lymphatic vessel ligation and16cases of patients underwent traditional laparoscopic renal pedicle lymphatic vessel ligation9cases of patients undergone modified laparoscopic renal pedicle lymphatic vessel ligation.Results Fat tissue, connective tissue, and a small amount of luminal structures were observed by HE staining, but blood vessel and lymphatic vessels cannot be distinguished. A clear background was obtained by D2-40immunohistochemical staining, and the relationship between the lymphatic vessels and surrounding tissue can be clearly shown. The background was light yellow by5’-Nase staining, but the surrounding structure of lymphatic vessels cannot be observed. The LVD in5’-Nase group was significantly lower than D2-40group(2.28±0.99vs3.88±0.98; P<0.05)Lymphatic vessels were observed in the fat tissue surrounding the renal vessels, ureter and adrenal. In the control group, the LVD of the up-mentioned districts was1.98±0.73,2.14±0.73and2.04±0.56respectively; the diameter was32.13±13.28um,28.25±7.67um and27.56±7.91um respectively; the luminal area was107854±75897um2,98647±36131um2and89791±34911um2respectively. The LVD (2.97±0.91、3.10±0.88、2.87±0.74), diameter(75.05±39.75um、64.02±41.92um、40.00±12.05um) and luminal area (222776±106624um2、205551±114578um2、173823±89559um2) of lymphatic vessel in the patients with chyluria were significantly higher than those in the cadavers. The tortuous and dilated lymphatic vessels were commonly seen in the patients with chyluria. However, there was no significant difference in the LVD (1.56±0.41vs1.46±0.22), diameter (18.02±6.65vs15.77±5.03um) and luminal area (71648±50677vs50223±32796um2)of the perinephric fat between the patients with chyluria and the cadavers. Among the patients with chyluria, the LVD, diameter and luminal area of lymphatic vessels in the sub-group of perinephric fat were significantly lower than those in the sub-group of the renal vessels, ureter and adrenal (p<0.05)The operations were completed as expected in all the25patients. The chyluria was disappeared, the chyluria qualitative test was negative and the nutritional status of the patients was improved after the management in all cases. Among the patients undergone traditional laparoscopic ligation of renal pedicle lymphatic vessels, the subcutaneous emphysema was observed in4cases. Nephroptosis was diagnosed in1case and hematuria accompanied with osphyalgia was observed in1case at a1year follow-up. Among the patients undergone modified protocol, the subcutaneous emphysema was observed in1case. No complication was observed in all cases at a1year follow-up. There was no recurrence in both groups. The operation time, intraoperative bleeding volume, postoperative hospital stay, postoperative intestinal function recovery time, retroperitoneal drainage time, postoperative complications were significantly lower in patients undergone modified laparoscopic renal pedicle lymphatic vessel ligation than those in patients undergone traditional laparoscopic renal pedicle lymphatic vessel ligation (p<0.05).Conclusion The morphological and density changes of the lymphatic vessels the fat tissue surrounding the renal pedicle, ureter and adrenal may play a role in the etiology of chyluria. It might be a feasible surgical management for chyluria by lymphatic disconnection in the up-mentioned sites. However, the current procedure of surgical management of chyluria may not be appropriated. High selective ligation of the lymphatic vessels in the fat tissue between the renal artery and vein, upper part of ureter and adrenal for is safe and effective the treatment of chyluria. The modified procedure might alleviate the retroperitoneal injury and avoid the complications such as nephroptosis. |
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