V10-11: Robotic Ureterolysis and Skeletonization of the Renal Hilum for Severe Case of Intractable Chyluria

Video

Introductions and Objectives
Chyluria is thought to be caused by the rupture of lymphatic channels into the urinary collecting system. Disturbances in lymphatic flow can result in increased pressure of retroperitoneal lymphatic drainage. This increased pressure can result in dilatation, proliferation, and valvular incompetence of lymphatic channels and can ultimately lead to fistulous communications with the urinary tract. Possible causes of chyluria, then, share in common the ability to cause lymphatic obstruction. These include filariasis, trauma, neoplasm, congenital lymphatic malformation, infection, and iatrogenic (usually after partial nephrectomy)._x000D_ _x000D_ Chyluria is a rare entity in the United States. However, in regions where Wuchereria bancrofti is endemic, as many as 10% of the population can be infected and 2-10% of these individuals on average experience chyluria._x000D_ _x000D_ Presenting symptoms generally include intermittent or persistently milky white urine, flank pain, weight loss, anemia, and urinary hesitancy due to chyle clot formation. More severe symptoms can include nutritional deficiency, fatigue, and immunosuppression from protein wasting._x000D_ _x000D_ Treatment options include dietary modifications, endoscopic fulgaration, open vs. laparoscopic lymphatic disconnection, autotransplantation, and nephrectomy.

Methods
The Intuitive da Vinci Si System was used to perform a robotic-assisted laparoscopic right sided ureterolysis and skeletonization of the right renal vessels on a 54 year old woman with chyluria which did not respond to endoscopic attempts at fulgaration of lymphatic fistulae.

Results
Total operative time was 83 minutes. Robotic console time was 68 minutes. Patient had complete resolution of chyluria immediately following surgery. Result was durable at three month follow up.

Conclusions
Prior research has shown a benefit of laparoscopic approach in achieving lymphatic disconnection for chyluria in terms of operative time, blood loss, duration of postoperative ileus, and hospital days as well as the suggestion of possible improved durability of response (Zhang et al, "Renal Pedicle Lymphatic Disconnection for Chyluria Via Retroperitoneoscopy and Open Surgery"). These authors have postulated that the higher long term recurrence rates after open compared to laparoscopic approach may be related to better visualization in laparoscopic approach. Robotic technology provides significant potential benefits in lymphatic disconnection in terms of magnification of small lymphatic connections which might otherwise be missed on open or pure laparoscopic approaches.

Funding: none