Renal pedicle lymphatic ligation

Chyluria is caused by lymphatic system damage caused by lymphatic reflux, causing increased pressure in the lymphatic vessels, forming a channel between the lymphatics and the urinary tract. The chyle in the lymphatics flows into the urinary tract, and is discharged from the urine. The urine is milky white or cheese-like. It is called chyluria, because chyluria is often accompanied by hematuria, called chyluria. Chyluria can be divided into parasitic and non-parasitic. Parasitic chyluria are often caused by filariasis, and most of the domestic infections are caused by worms. After invading the human body, the worms are parasitic in the deep lymphatic system of the human body (post-peritoneal and pelvic lymphatic system). The mechanical damage and inflammatory damage of the adult worms destroy the lymphatic vessels in the central part of the chyle pool and the lumbar and intestinal total lymph nodes. Wall and valve, these pathological changes affect lymphatic vessel elasticity and lymph flow velocity, loss of effective control of lymphatic pressure and lymphatic centripetal flow, so that lymphatic drainage is slow, retention, intraductal pressure increases, reflux falls, causing lymphatic sputum The kinetic changes, reflux into the renal lymphatics, and the rupture of the kidney near the nipple and the urine mixed with the urine to form chyluria. Because the renal pelvis is the most vulnerable, the renal parenchyma is the least supported by the surrounding tissues, so the renal pelvis is the most common. In addition to silkworms, hydatid, malaria parasites, hookworms, and trichomoniasis can also cause chyluria. Non-parasitic diseases such as tumor compression, tuberculosis, chest and abdomen trauma, surgical injury, congenital or primary lymphoid disease can also cause chyluria. Cystoscopy during the chyluria episode revealed that the chyle was ejected from the ureteral orifice. The diethylether test was performed on both sides of the renal pelvis. The renal pelvic regurgitation was observed by retrograde pyelography. Lymphatic angiography is an important means of diagnosing chyluria. It can show the extent of the lesion and the presence of lymphatic fistula. It is helpful to choose surgical treatment and is helpful for observing the pathological changes of lymph nodes. It is worth mentioning that the results of domestic lymphography showed that the thoracic duct, chylothorax, lumbosacral lymphatic vessels were not obstructed, and the clinical ascending renal pedicle lymphatic ligation did not cause the occurrence or aggravation of contralateral chyluria, negating filariasis chyluria. Lymphatic obstruction theory. Treatment of chyluria, early cases, symptoms are not serious, non-surgical treatment, including bed rest, avoid foods with high fat content, taking traditional Chinese medicine, anti-filaria and anti-inflammatory drugs and 1% to 2% silver nitrate solution Washing, etc., have a certain effect, but easy to relapse. For severe cases, non-surgical treatment can be used for surgical treatment. Common surgical methods include renal pedicle lymphatic ligation, spermatic lymphatic-venous anastomosis, inguinal lymph node-abdominal superficial venous anastomosis. Lymphangiography should be performed before surgery to determine the surgical plan. Renal pedicle lymphatic ligation is currently a widely used method for the treatment of chyluria. Lymphatic reflux of the kidney can be divided into three groups: perirenal fat, renal capsule and renal parenchyma. Three groups of lymph nodes were combined at the renal hilum to form several trunks, which were then refluxed through the waist. Therefore, ligation of lymphatic vessels at the renal pedicle blocks three groups of channels, which play a good role in improving lymphatic dysfunction. Treating diseases: urinary infections Indication Renal pedicle lymphatic ligation is applicable to: Recurrent chyluria, long-term unhealed, poorly treated by non-surgical treatment; longer course, progressive progression, accompanied by malnutrition, weight loss. Contraindications For severe malnutrition, patients with dyscrasia should be treated with non-surgical treatment. After the general condition is improved, surgery should be used. Preoperative preparation 1. Preoperative cystoscopy or lymphography should be performed to determine the source of chyluria; if it is bilateral chyluria, understand which side is serious, first make a more serious side. Unilateral lesions were performed on the lesion side only. Take 1 to 2 courses of anti-filaria drugs before surgery. 2. Improve the general condition, using a high protein, low fat diet. 3. Patients with urinary tract infection should control infection. Surgical procedure 1. Incision and exposure of the kidney Use a waist incision. According to the position of the kidney, the 12th rib incision or the 12th rib resection is taken. Cut the skin, subcutaneous, muscular layer, and lumbar fascia layer by layer, and cut the perirenal fascia to reveal the kidney. Be careful not to injure the peritoneum and pleura, and if it is damaged, treat it promptly. 2. Cut off the lymphatic vessels around the renal pedicle After the kidneys are exposed, the perirenal tissue is appropriately released, and the renal pedicle is required to be fully exposed. Carefully check the expansion of the renal pedicle and nearby lymphatic vessels, and completely separate the renal pedicle, renal pelvis, lymphatic vessels and loose tissues around the upper ureter, clamp and cut, and ligature. In particular, attention should be paid to the lymphatic vessel ligation and ligation between the renal artery and the vein. The adventitia of the artery is also peeled off, and the arteriovenous vein is lifted by a venous hook, which is thoroughly cleaned without leaving any fibrous tissue. It is generally required to clean the connective tissue around the trunk of the renal pedicle to 2 cm. Adhesions within 2 cm of the upper ureter were also removed, and all lymphatic vessels were cut and ligated one by one. For patients with ectopic blood vessels, they should be thoroughly cleaned in the same way as the lymphatic vessels around the main pedicle of the renal pedicle. 3. According to the situation, add lymphatic serosal (ovary) venous anastomosis The method is to carefully check the inside of the renal pedicle or the spermatic cord (ovary) blood vessels after revealing the renal pedicle, find a large lymphatic vessel, and separate it. Be careful not to damage the wall, cut off the lymphatic vessels, and distinguish the chyle. The proximal end of the fluid or bloody chyle flows out, the lymphatic vessels are temporarily clamped with a small blood vessel clamp, and the distal end is ligated with a silk thread. Free spermatic cord (ovarian) vein, cut the spermatic cord (ovarian) vein 6 to 8 cm from the inferior vena cava (right) or renal vein (left) entrance, the proximal cardiac vein is flushed with heparin isotonic saline to prevent clot blockage The vein is then clamped with a blood vessel clamp and properly dissociated around the vein. Do not damage the inner membrane when separating and treating the vein. The distal end of the vein is ligated with a silk thread. The lymphatic vessels were aligned with the spermatic cord (ovary) veins end-to-end or end-to-side with a 7-0 non-invasive line. Stitch with detached valgus. In order to ensure the success of the operation, it is necessary to operate under the operating microscope. After the anastomosis is completed, the small blood vessel clamp is released, and the liquid in the lymphatic tube can be seen to flow through the anastomosis to fill the vein, and the anastomosis is covered with the fat tissue. After completion of renal pedicle lymphatic ligation and lumbar lymphatic spermatic cord (ovary) venous anastomosis, the kidney was properly fixed. 4. Layer-by-layer suture There is no need to place drainage during the kidney week. complication 1. Hematuria: After the operation, the patient often has gross hematuria, which gradually stops in about 1 week. 2. Recurrence of chyluria: It is caused by incomplete lymphatic ligation during operation or only one side of bilateral lesions. During the operation, attention should be paid to the operation technique, and if necessary, bilateral surgery should be performed to reduce the recurrence rate.