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SUMMARY |
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| Year : 2005 | Volume
: 21
| Issue : 1 | Page : 66 |
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Summary
Deepak Dubey, Anant Kumar
, India
Correspondence Address:
Deepak Dubey
,
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-1591.19556
How to cite this article:
Dubey D, Kumar A. Summary. Indian J Urol 2005;21:66 |
From the articles in this issue it is apparent that India has made significant contributions to the understanding and management of lymphatic filariasis.
Lymphatic filariasis is a disease which is endemic in almost 80 (tropical and sub-tropical) countries around the world. In India, it is a major health problem and the country contributes to about 40% to the global clinical burden. The disease is predominantly caused by the parasite Wuchereria Bancrofti and mainly affects young adult males from poor socio-economic backgrounds. The common clinical manifestations of lymphatic obstruction by microfilaria are hydrocoele, lymphedema and chyluria (passage of milky urine). The pathology associated with lymphatic filariasis results from a complex interplay of the pathogenic potential of the parasite, the immune response of the host, and external ('complicating') bacterial and fungal infections. Histologically, dilatation and proliferation of lymphatic endothelium can be identified, and the abnormal lymphatic function associated with these changes can be readily documented by lymphoscintigraphy. Filarial hydrocoele is the commonest manifestation of lymphatic obstruction. Medical management with Diethyl carbamazepine citrate (DEC and conservative management with aspiration sclerotherapy are ineffective for management of filarial hydrocoeles. The recommended procedure is subtotal excision of the sac as it can be performed with an acceptable rate of complications and the least chance of recurrence. Jaboulay's operation (eversion of sac) is not preferred due to higher recurrence rates and chances of leaving a residual scrotal swelling in large sacs. Filarial lymphedema usually affects adolescent girls and ranges from mild lymphedema to elephantiasis. Mild lymphedema should be managed conservatively whereas higher grades require surgical treatment. Surgical procedures have been divided into physiologic (drainage) procedures or excisional procedures. Amongst the drainage procedures, microscopic Lymphatico-venous anastomosis appears to give the best results. Excisional procedures are associated with greater morbidity and currently do not find favour. Scrotal elephantiasis and ram horn penis are best managed by excision with split skin grafting.
Chyluria results from obstruction of the lumbar lymphatics and short circuiting of chyle from the intestinal lacteals to the renal lymphatic channels. Biochemical analysis of urine and demonstration of small lymphocytes and chylomicrons are required for the confirmation of the diagnosis of chyluria. Recently electrophoretic studies of urine and demonstration of urinary triglycerides has shown to be diagnostic of chyluria. An intravenous urogram is usually normal cystoscopy is required to confirm the side involved. The medical treatment of filariasis and chyluria is based on dietary modification, i.e. a diet excluding fat, supplemented by medium chain triglycerides (MCT) and high protein content. A recent study has demonstrated that fat restriction can diminish urinary losses of fatty acid, triglyceride, cholesterol and phospholipid with their concomitant fall in serum levels. The cornerstone of management of chyluria Renal Pelvic instillation sclerotherapy (RPIS). Sclerosants act by inducing an inflammatory reaction in the lymphatic vessels and blockade of the communicating lymphatics by fibrosis. Various protocols have been described in literature but the most commonly followed regime is 8 hourly instillations (9 doses) for 3 days. Silver nitrate (0.1-1%) is effective in 60-84%. A recently conducted randomized prospective trial has demonstrated similar results with the use of 0.2%povidone-iodine solution. Recurrent chyluria can occur in upto15-20% patients following RPIS. It is of utmost importance that the silver nitrate solution is freshly prepared and its concentration should not exceed 1%. It should be remembered that normal saline should not be mixed with silver nitrate as it could cause precipitation of the chemical which can cause renal obstruction and scarring. Early recuurence could be due to inadequate sclerotherpay, release of chyle from the contralateral unit, communication between lower ureteral /bladder collateral release of chyle due to increased lymphatic pressure. Late recurrence is usually due to recanalisation of obstructed lymphatics in the treated kidney. Recurrences are treated with an alternative sclerosant and if this fails surgical treatment is required. Surgical alternatives include open or laparocopic chylolymphatic disconnection. Retroperitoneoscopic pyelo-lymphatic disconnection is a minimally invasive technique that provides success in about 70-80% patients. Microsurgical lympho-venous anastomosis and autotransplantation are rarely performed procedures for recurrent chyluria.
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