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Chyluria

Case contributed by Abdallah Al Khateeb
Diagnosis certain

Presentation

New-onset hematuria and lower urinary tract irritative symptoms.

Patient Data

Age: 60 years
Gender: Male

Initial CT

ct

Small exophytic left renal cortical solid enhancing lesion, with central irregular calcification. The solid portion measures 25 HU on the non-enhanced scan and 101 HU on the cortical phase.

Other findings: left nephrolithiasis, gallbladder sludge.

The patient underwent surgical resection and histopathological diagnosis was established. A few years later, the patient developed colon adenocarcinoma and was treated surgically.

Surveillance CT 10 years later

ct

Exophytic lobulated solid peripherally enhancing mass at the surgical resection site of the previous lesion. It measures 40 HU on the non-enhanced phase and 75 HU on the excretory phase.

Other findings: left nephrolithiasis, few small left cortical scars, cholelithiasis, sigmoidectomy, and prostatomegaly.

The patient underwent re-resection of the renal lesion.

Surveillance CT 11 years later

ct

Postoperative left perinephric fat stranding.

Fluid-fluid level in the urinary bladder, with the superior fluid of fat density (measuring -112 HU) and the inferior fluid (12 HU) representing urine.

Multiple urinary bladder stones.

Other chronic findings: left nephrolithiasis, few small left renal cortical scars, cholelithiasis, sigmoidectomy, and prostatomegaly.

Case Discussion

The histopathological diagnosis for this patient's primary left renal mass was renal cell carcinoma (RCC), chromophobe subtype. This subtype has the best prognosis, but is uncommon (~5% of all RCC). Open partial nephrectomy was performed for tumor removal. 

The patient developed local recurrence of RCC 10 years after resection. The recurrent mass was surgically removed.

One of the uncommon complications of partial nephrectomy is chyluria, the presence of chyle in urine. In this setting, it results from fistulous communication between the perinephric lymphatics and the pelvicalyceal system.

A much more common cause of an intravesical fluid level is intravesical gas, which should always be confirmed by using a lung window setting, or a direct measurement of its density. Other possible mimics are benign intramural fat occasionally seen incidentally, or an intramural lipoma.

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