Endoscopic Management of Chyluria Caused by Pyelolymphatic Fistula After Robot-Assisted Laparoscopic Pyeloplasty

Background: Chyluria is a rare diagnosis classically associated with milky-appearing urine. It involves the leakage of chyle into the urinary tract. Although the most common cause of chyluria worldwide is infectious in nature, other noninfectious etiologies have been described. Classically chyluria resolves spontaneously or with conservative management. Surgical treatments have been described but are not often required. We present a case of iatrogenic pyelolymphatic fistula after robot-assisted laparoscopic dismembered pyeloplasty that was treated with endoscopic electrocautery of the fistulous tract. Case Presentation: A 50-year-old Caucasian man underwent a robot-assisted laparoscopic dismembered pyeloplasty with stent insertion for radiographically demonstrated left ureteropelvic junction obstruction. His postoperative course was uneventful until 4-week follow-up at which time he began to notice intermittent passage of milky-appearing urine. Urinalysis was notable for large protein and elevated urine triglycerides. He was initially managed conservatively dietary modifications without success. He then underwent endoscopic management with cystoscopy and ureteroscopy with fulguration of suspected pyelolymphatic fistula. He was maintained on a low-fat medium-chain triglyceride diet and octreotide injections while inpatient for 1 week postoperatively. His postoperative course was unremarkable and no return of chyluria was observed. His chyluria remained resolved at 9 months postoperatively. Conclusion: Pyelolymphatic fistula after robot-assisted laparoscopic pyeloplasty is a theoretical complication of perirenal dissection and has not been previously described in the literature. It should be considered as a rare iatrogenic cause of chyluria. Endoscopic management with fulguration is technically feasible and may obviate the need for more invasive surgical management.