Lymphangiography and Lymphatic Embolization for the Management of Pelvic Lymphocele After Radical Prostatectomy in Prostatic Cancer

The role and controversy of pelvic lymph node dissection in prostate cancer treatment: a focused review

Pelvic lymph node dissection (PLND) is commonly performed alongside radical prostatectomy. Its primary objective is to determine the lymphatic staging of prostate tumors by removing lymph nodes involved in lymphatic drainage. This aids in guiding subsequent treatment and removing metastatic foci, potentially offering significant therapeutic benefits. Despite varying recommendations from clinical practice guidelines across countries, the actual implementation of PLND is inconsistent, partly due to debates over its therapeutic value. While high-quality evidence supporting the superiority of PLND in oncological outcomes is lacking, its role in increasing surgical time and risk of complications is well-recognized. Despite these concerns, PLND remains the gold standard for lymph node staging in prostate cancer, providing invaluable staging information unattainable by other techniques. This article reviews PLND's scope, guideline perspectives, implementation status, oncologic and non-oncologic outcomes, alternatives, and future research needs.

Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions

ABSTRACT

Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.

A comparison of lymphatic embolization and sclerotherapy in the management of iatrogenic abdominopelvic lymphoceles following oncological surgery

PURPOSE

To compare the safety and efficacy of sclerotherapy and lymphatic embolization (LE) in the treatment of symptomatic iatrogenic lymphoceles following the placement of a percutaneous drainage catheter.

METHODS

This is a retrospective study of 46 patients who underwent sclerotherapy (17 patients) or LE (29 patients) for the management of symptomatic iatrogenic lymphoceles following percutaneous drain placement between January 2017 and December 2021. The demographic characteristics, time between surgery and lymphatic intervention, clinical presentation, number of procedures, drain output pre- and post-intervention, time from intervention to drain removal, and adverse events were collected and compared for both groups. The clinical success rate, defined as the successful removal of the drain after one procedure, was calculated. Adverse events were reported according to the Society of Interventional Radiology classification. A statistical analysis was conducted using SPSS, and the P value for statistical significance was set at 0.05. The Mann-Whitney U test was used to compare differences in the scale variables, and Fisher's exact test was used to compare the categorical and ordinal variables between both groups.

RESULTS

A total of 46 patients with 49 lymphoceles met the inclusion criteria of the study. Of these patients, 17 patients (19 lymphoceles) underwent sclerotherapy, and 29 patients (30 lymphoceles) underwent LE as their initial procedures. The clinical success after one procedure was significantly higher (83% vs. 47%, P = 0.011), and the median time between the first intervention and drain removal was significantly shorter in the LE group (median duration of 6 vs. 13 days, P = 0.018) compared with the sclerotherapy group. No statistically significant difference in adverse events was noted between both groups (0.26 vs. 0.10, P = 0.11).

CONCLUSION

This study found that LE had a higher clinical success rate after the first procedure and a shorter time to drain removal compared with sclerotherapy. There was no difference in the rate of adverse events between both groups. Although LE is a safe and promising technique, a prospective study is needed to further compare the efficacy of both treatment modalities.

The Effect of a Peritoneal Iliac Flap on Lymphocele Formation After Robotic Radical Prostatectomy: Results From the PLUS Trial

OBJECTIVE

To assess the effectiveness of a peritoneal flap on the formation of lymphoceles after robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

METHODS

We conducted a single surgeon, assessor blinded prospective randomized controlled trial (the Prospective Lymphocele Ultrasound Study) in men undergoing robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. At the conclusion of the node dissection, patients were block randomized 1:1 to either standard of care (no bladder peritoneal flap) or to the creation of a bladder peritoneal flap. Lymphocele formation was assessed by pelvic ultrasound postoperatively. The primary outcome was lymphocele formation. Rates of lymphocele formation and complications were analyzed using chi-square. Other outcomes, including length of stay, number of lymph nodes removed, lymphocele volume, and quality of life measures, were analyzed by t-tests or Wilcoxon Ranked Sum Tests, as appropriate. An a priori power calculation was performed using O'Brien-Fleming alpha sharing for the interim analyses. Two preplanned interim analyses were performed when 45 and 90 patients per group had follow-up ultrasounds.

RESULTS

A statistically significant difference in lymphocele formation was seen on the second interim analysis for 183 patients (4.3% vs. 15.6%, p = .011) stopping enrollment; this remained significant in the final analysis of 216 patients (3.6% vs 14.2%, p = .006). No other significant differences were observed.

CONCLUSION

This prospective randomized trial supports the implementation of this simple modification for robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

Intranodal Glue Embolization for Postoperative Lymphatic Leaks in the Groin and Pelvis: Comparison with Sclerotherapy

PURPOSE

To compare the effectiveness of and adverse events related to intranodal glue embolization (IGE) with those of intracavitary sclerotherapy for the treatment of postoperative groin and pelvic lymphatic leaks.

MATERIALS AND METHODS

From November 2015 to July 2021, IGE for postoperative pelvic or groin lymphocele or lymphorrhea was performed in 33 patients. From January 2010 to July 2021, 28 patients with postoperative pelvic or groin lymphocele were treated with sclerosis alone. Clinical success was defined as resolution of drainage within 3 weeks of the last intervention performed without recurrence. Patients presenting >1 year after surgery or with <30 days of follow-up were excluded. Patients with lymphorrhea treated with IGE were not statistically compared with those in the sclerosis group because they were not eligible for sclerosis.

RESULTS

Clinical success was similar between the groups (lymphocele IGE, 15/18, 83.3%, vs sclerosis, 15/23, 65.2% [P = .29]; lymphorrhea IGE, 8/9, 88.9%). The mean number of interventions performed to successfully treat a lymphocele was significantly higher in the sclerosis group (2.5 for sclerosis vs 1.3 for IGE; P = .003; lymphorrhea IGE, 1.0). The mean time to resolution was significantly longer for sclerosis than for IGE (27 vs 7 days; P = .002; 4 days for lymphorrhea IGE). There were no sclerosis-related adverse events and 2 IGE-related adverse events: (a) 1 case of mild lymphedema and (b) 1 case of nontarget embolization resulting in deep vein thrombosis.

CONCLUSIONS

For treatment of postoperative pelvic and groin lymphoceles, IGE results in faster resolution with fewer interventions compared with sclerosis. IGE is also an effective treatment for postoperative groin lymphorrhea.

Technical Outcome, Clinical Success, and Complications of Low-Milliampere Computed Tomography Fluoroscopy-Guided Drainage of Lymphoceles Following Radical Prostatectomy with Pelvic Lymph Node Dissection

To evaluate the technical outcome, clinical success, and safety of low-milliampere CT fluoroscopy (CTF)-guided percutaneous drain (PD) placement in patients with lymphoceles following radical prostatectomy (RP) with pelvic lymph node dissection (LND). This retrospective analysis comprised 65 patients with PD placement in lymphoceles following RP under low-milliampere CTF guidance. Technical and clinical success were evaluated. Complications within a 30-day time interval associated with CTF-guided PD placement were classified according to SIR. Patient radiation exposure was quantified using dose-length products (DLP) of the pre-interventional planning CT scan (DLPpre), of the sum of intra-interventional CT fluoroscopic acquisitions (DLPintra) and of the post-interventional control CT scan (DLPpost). Eighty-nine lymphoceles were detected. Seventy-seven CT-guided interventions were performed, with a total of 92 inserted drains. CTF-guided lymphocele drainage was technically successful in 100% of cases. For all symptomatic patients, improvement in symptoms was reported within 48 h after intervention. Time course of C-reactive protein and Leucocytes within 30 days revealed a statistically significant (p < 0.0001) decrease. Median DLPpre, DLPintra and DLPpost were 431 mGy*cm, 45 mGy*cm and 303 mGy*cm, respectively. Only one minor complication (self-resolving haematoma over the bladder dome; SIR Grade 2) was observed. Low-milliampere CTF-guided drainage is a safe treatment option in patients with lymphoceles following RP with pelvic LND characterized by high technical and good clinical success rates, which provides rapid symptom relief and serves as definite treatment or as a bridging therapy prior to laparoscopic marsupialisation.

Lymphatic Interventions in the Cancer Patient

PURPOSE OF REVIEW

The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks.

RECENT FINDINGS

Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.

Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients

PURPOSE

 Report of experience from a single institution in treating postoperative lymphatic leakage (PLL) applying conventional transpedal lymphangiography (TL).

MATERIALS AND METHODS

 453 patients with the initial diagnosis of PLL receiving TL between 03/1993 and 09/2018 were identified in the database. Only patients with confirmed PLL were included in the study. The technical success, safety, and treatment success of TL were evaluated. Independent predictors of TL treatment failure were examined using univariate and multivariate logistic regression analysis.

RESULTS

 355 consecutive patients (218 men, 137 women; median age of 62 years) who underwent TL for PLL (e. g., chylothorax) after ineffective conservative treatment were included. The median time between causal surgery and TL was 27 days. The median technical success rate of TL was 88.5 %, with a median volume of Lipiodol of 10.0 ml. No complication of TL was recorded. Three groups were defined according to the different clinical courses: group A (41/355, 11.5 %) - TL with technical failure; group B (258/355, 72.7 %) - "therapeutic" TL alone with technical success; and group C (56/355, 15.8 %) - "diagnostic" TL with simultaneously invasive treatment (incl. surgical revision and percutaneous sclerotherapy). Treatment success rate and median time to treatment success were higher in group C than in group B, but without significant differences (64.3 % vs. 61.6 %, p = 0.710; six vs. five days, p = 0.065). Univariate and multivariate logistic regression analyses for group B confirmed drainage volume (> 500 ml/d) and Lipiodol extravasation as independent predictors of TL clinical failure (odds ratios [ORs] of 2.128 and 2.372 [p = 0.005 and p = 0.003, respectively]).

CONCLUSION

 TL is technically reliable, safe, and effective in treating PLL. When conservative treatment fails, TL can be regarded as the next treatment option.

KEY POINTS

  · TL is technically reliable, safe, and effective for treating PLL.. · When conservative treatment fails, TL can be regarded as the next treatment option.. · Drainage volume > 500 ml/day is an independent predictor of clinical failure after TL.. · Lipiodol extravasation is an independent predictor of clinical failure after TL..

CITATION FORMAT

· Pan F, Richter GM, Do TD et al. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1717-2467.

Transvaginal lymphatic embolization of the fistula between a pelvic lymphocele and the vaginal stump following radical hysterectomy and sentinel pelvic lymph node biopsy in a patient with cervical cancer: A case report

A lymphocele is a common complication that occurs following pelvic lymph node dissection. However, the complication of lymphoceles following sentinel pelvic lymph node biopsy has not been previously reported, to the best of our knowledge. A 49-year-old female patient had undergone radical hysterectomy and pelvic lymph node biopsy for stage IB1 cervical cancer 5 months previously and presented with a profuse watery vaginal discharge of ~2 liters per day. A fistula connecting the lymphocele and the vaginal stump was identified using lymphoscintigraphy and single photon emission CT/CT. Transvaginal lymphatic embolization was successfully performed through the vaginal fistulous tract, resulting in immediate reduction of the vaginal discharge. In conclusion, the case of fistula formation between pelvic lymphocele and vaginal stump was encountered at our department and was reported with a literature review. To the best of our knowledge, there are no previous reports on lymphoceles with direct communication to the vaginal mucosa, particularly following sentinel pelvic lymph node biopsy. The present study reported the case of a patient who was successfully treated for a pelvic lymphocele with direct communication to the vaginal mucosa.

Lipiodol Lymphangiography and Glue Embolization for Vulvar and Vaginal Lymphorrhea

A 26-year-old woman patient had an 18-year long history of vulvar and vaginal lymphorrhea and multiple millet-like lesions on her vulva. On magnetic resonance image, multiple T2 high signal intensities were noted at the bilateral vulvar areas and pelvic cavity. Conventional lipiodol lymphangiography showed lymphatic reflux to the vulvar areas, possibly originating from prominent tubular lymphatics in the right lower abdominal wall. After percutaneous puncture of this tubular lymphatic structure, its distal portion was embolized using microcoils to prevent upward glue propagation; this was followed by glue embolization of the tubular lymphatic structure. The patient was without skin lesions or symptoms at follow-up of 1 year after the procedure.

Percutaneous Lymphatic Embolization as Primary Management of Pelvic and Retroperitoneal Iatrogenic Lymphoceles

PURPOSE

To evaluate the efficacy of lymphatic embolization (LE) in decreasing catheter output and dwell time in iatrogenic lymphoceles after percutaneous catheter drainage.

MATERIALS AND METHODS

Retrospective review of patients who underwent intranodal lymphangiography (INL) with or without LE for management of iatrogenic lymphoceles between January 2017 and November 2020 was performed. Twenty consecutive patients (16 men and 4 women; median age, 60.5 years) underwent a total of 22 INLs and 18 LEs for 15 pelvic and 5 retroperitoneal lymphoceles. Lymphatic leaks were identified in 19/22 (86.4%) of the INLs. Three patients underwent INL only because a leak was not identified or was identified into an asymptomatic lymphocele. One patient underwent repeat INL and LE after persistent high catheter output, and 1 patient underwent repeat INL with LE after the initial INL did not identify a leak. Catheter output was assessed until catheter removal, and changes in output before and after the procedure were reported. The patients were followed up for 2-30 months, and procedural complications were reported.

RESULTS

The median catheter output before the procedure was 210 mL/day (50-1,200 mL/day), which decreased to a median of 20 mL/day (0-520 mL/day) 3 days after the procedure, with a median output decrease of 160 mL (0-900 mL). The median time between INL with LE and catheter removal was 6 days, with no recurrence requiring redrainage. Four patients experienced minor complications of low-grade fever (n = 2) and lower limb edema (n = 2).

CONCLUSIONS

Lymphangiogram and LE are safe and effective methods for the management of lymphoceles.

Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles

PURPOSE

 Lymphoceles often occur within several weeks or even months after surgery. Mostly asymptomatic and therefore undiagnosed, they may be self-healing without any treatment. A small percentage of postoperative lymphoceles are symptomatic with significant pain, infection, or compression of vital structures, thus requiring intervention. Many different treatment options are described in the literature, like drainage with or without sclerotherapy, embolization of lymph vessels, and surgical approaches with laparoscopy or laparotomy. Inspired by reports stating that postoperative suction drainage can prevent the formation of lymphoceles, we developed a simple protocol for vacuum-assisted drainage of symptomatic lymphoceles, which proved to be successful and which we would therefore like to present.

MATERIALS AND METHOD

 Between 2008 and 2020, 35 patients with symptomatic postoperative lymphoceles were treated with vacuum-assisted suction drainage (in total 39 lymphoceles). The surgery that caused lymphocele formation had been performed between 8 and 572 days before. All lymphoceles were diagnosed based on biochemical and cytologic findings in aspirated fluid. The clinical and imaging data were collected and retrospectively analyzed.

RESULTS

 In total, 43 suction drainage catheters were inserted under CT guidance. The technical success rate was 100 %. One patient died of severe preexisting pulmonary embolism, sepsis, and poor conditions (non-procedure-related death). In 94.8 % of symptomatic lymphoceles, healing and total disappearance could be achieved. 4 lymphoceles had a relapse or dislocation of the drainage catheter and needed a second drainage procedure. Two lymphoceles needed further surgery. The complication rate of the procedure was 4.6 % (2/43, minor complications). The median indwelling time of a suction drainage catheter was 8-9 days (range: 1-30 days).

CONCLUSION

 The positive effects of negative pressure therapy in local wound therapy have been investigated for a long time. These positive effects also seem to have an impact on suction drainage of symptomatic lymphoceles with a high cure rate.

KEY POINTS

  · Suction drainage of lymphoceles is an easy and successful method to cure symptomatic lymphoceles at various locations.. · We believe this to be due to the induction of cavity collapse and surface adherence.. · In most cases rapid clinical improvement could be obtained..

CITATION FORMAT

· Franke M, Saager C, Kröger J et al. Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1586-3652.

Two cases of pelvic lymphocele after prostatectomy and dissection of obturator lymph nodes successfully treated by interventional radiology

INTRODUCTION

Postoperative refractory lymphocele is often difficult to treat. Recently, interventional radiology with N-butyl-cyanoacrylate has been used by urologists and radiologists to treat lymphocele. This modality is an effective treatment with fewer complications.

CASE PRESENTATION

Case 1. A 70-year-old man, who underwent retropubic radical prostatectomy and bilateral obturator lymph node dissection, developed postoperative lymphocele. Continuous drainage and multiple rounds of sclerotherapy to reduce lymphocele volume ended in failure. Subsequently, lymphangiography with lipiodol and N-butyl-cyanoacrylate was performed, and the lymphocele volume gradually decreased.Case 2. A 75-year-old man underwent retropubic radical prostatectomy and bilateral obturator lymph node dissection. After surgery, the patient developed a high-output lymphocele. The lymphocele volume decreased following lymphangiography with lipiodol.

CONCLUSION

Interventional radiology using lipiodol and N-butyl-cyanoacrylate could provide a new standard treatment for refractory lymphocele.

Lymphatic embolization for the management of symptomatic pelvic lymphocele after radical prostatectomy with lymph node dissection: Report of two cases

INTRODUCTION

Pelvic lymphocele is the most common complication of pelvic lymph node dissection after radical prostatectomy. Management of symptomatic pelvic lymphocele begins with percutaneous drainage, followed by sclerotherapy or surgical marsupialization and more recently, lymphatic embolization. In this article, we show the feasibility and results of two lymphatic embolization after prostatectomy with lymph node dissection.

CASE PRESENTATION

We decided to perform lymphatic embolization in two patients with persistent symptomatic pelvic lymphocele, after percutaneous drainage. This was done through inguinal lymph node puncture using Lipiodol and N-butyl cyanoacrylate glue injection. Drainage removal was done on the day after the procedure and clinical recovery was maintained at follow-up visits, 3 and 4 months later, in both patients. Computed tomography at 6 and 10 weeks after embolization showed the disappearance of the lymphocele.

CONCLUSION

Our two case reports support the promising results of lymphatic embolization in this pathology.

Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review

PURPOSE

A broad range of therapeutic options exists for symptomatic postoperative lymphoceles. However, no consensus exists on what is the optimal therapy. In this study, we aimed to compare the efficacy of currently available radiologic interventions in terms of number of successful interventions, number of recurrences, and number of complications.

METHODS

A systematic review was conducted with a pre-defined search strategy for PubMed, EMBASE, and Cochrane databases from inception until September 2019. Quality assessment was performed using the 'Risk Of Bias In Non-randomized Studies - of Interventions' tool. Statistical heterogeneity was assessed using the I² and χ² test and a meta-analysis was considered for studies reporting on multiple interventions.

RESULTS

37 eligible studies including 732 lymphoceles were identified. Proportions of successful interventions for percutaneous fine needle aspiration, percutaneous catheter drainage, percutaneous catheter drainage with delayed or instantaneous addition of sclerotherapy, and embolization were as follows: 0.341 (95% confidence interval [CI]: 0.185-0.542), 0.612 (95% CI: 0.490-0.722), 0.890 (95% CI: 0.781-0.948), 0.872 (95% CI: 0.710-0.949), 0.922 (95% CI: 0.731-0.981). Random-effects meta-analysis of seven studies revealed a pooled relative risk for percutaneous catheter drainage with delayed addition of sclerotherapy of 1.57 (95% CI: 1.17-2.10) when compared to percutaneous catheter drainage alone. The risk of bias in this study was severe.

CONCLUSIONS

This systematic review demonstrates that the success rates of percutaneous catheter drainage with sclerotherapy are more favorable when compared to percutaneous catheter drainage alone in the treatment of postoperative pelvic lymphoceles. Overall, percutaneous catheter drainage with delayed addition of sclerotherapy, and embolization showed the best outcomes.

Percutaneous afferent lymphatic vessel sclerotherapy for postoperative lymphatic leakage after previous ineffective therapeutic transpedal lymphangiography

BACKGROUND

To demonstrate the efficacy of percutaneous computed tomography (CT)-guided afferent lymphatic vessel sclerotherapy (ALVS) in the treatment of postoperative lymphatic leakage (LL) after ineffective therapeutic transpedal lymphangiography (TL).

METHODS

A retrospective review in this institute involving 201 patients was conducted from May 2011 to September 2018. Patients diagnosed with postoperative LL undergoing ineffective therapeutical TL before the performance of percutaneous CT-guided ALVS were involved. Technical success and clinical success of TL and ALVS were established. The technical success and efficacy of ALVS in the treatment of postoperative LL after ineffective therapeutic TL were assessed. The clinical success rate of ALVS is also assessed, and the complications are reviewed.

RESULTS

In total, nine patients were involved including three patients (33.3%) presented with chylothorax, three patients (33.3%) presented with inguinal lymphatic fistula/lymphocele, and three patients (33.3%) presented with lymphatic fistula in the thigh; 27 ± 18 days (mean ± standard deviation) after surgery, therapeutic TL was successfully performed and showed definite afferent lymphatic vessel and leakage site in all the patients. Due to clinical failure after TLs, the following ALVS was performed with a mean interval of 12 ± 8 days after TL. The technical success rate was 9/9 (100.0%, 95% confidence interval [CI] 63.1-100.0%). An average of 2.7 ± 1.3 mL 95% ethanol as sclerosant agent was injected during the procedure. The clinical success was observed in 8 of the 9 patients (88.9%, 95% CI 51.8-99.7%) with a time between ALVS and the LL cure of 8 ± 6 days. No complications were reported.

CONCLUSIONS

Our results showed the role of percutaneous CT-guided ALVS as a safe, feasible, and effective salvage treatment for postoperative LL after ineffective TL.

The roles of iodized oil-based lymphangiography and post-lymphangiographic computed tomography for specific lymphatic intervention planning in patients with postoperative lymphatic fistula: a literature review and case series

In the management of patients with postoperative lymphatic fistula (LF) in different locations, iodized oil-based lymphangiography (LAG) from trans-pedal or intranodal route is an established diagnostic approach with the potential to plan further interventional treatments. However, specific lymphatic interventions are indicated depending on different locations and morphologies of the LF. After a systematic literature review, four types of interventions can be considered, including direct leakage embolization/sclerotherapy (DLE/DLS), percutaneous afferent lymphatic vessel embolization (ALVE), percutaneous afferent lymphatic vessels disruption/sclerotherapy (ALVD/ALVS), and trans-afferent nodal embolization (TNE). In the iodized oil-based LAG, three potential lymphatic targets including confined leakage, definite afferent LVs, and definite closest afferent LNs should be comprehensively assessed. For optimal prospective treatment planning for LF, iodized oil-based post-lymphangiographic computed tomography (post-LAG CT) is a useful complement to the conventional iodized oil-based LAG, which can be performed easily after LAG. This review article summarized the current evidence of the specific lymphatic interventions in patients with postoperative LF and explored the potential benefits of post-LAG CT in the intervention planning from a case series.

Chylous Ascites and Lymphoceles: Evaluation and Interventions

Kinmonth introduced lymphangiography in 1955 and it became an important tool in the diagnosis and treatment of malignant disease. The technique, based on bipedal approach, was difficult and time-consuming which limited its use in clinical practice. Cope is the father of percutaneous lymphatic interventions and he was the first person to access and intervene on the lymphatic system. After his initial work published on 1999, there has been an expansion of the lymphatic embolization techniques, particularly since the development of intranodal lymphangiography and advance lymphatic imaging. This article is focused on the evaluation and management of postoperative chylous ascites and lymphoceles. Their incidence is growing due to longer survival of cancer patients and more radical surgical approaches, leading to an increased morbidity and mortality in this patient population. Minimally invasive percutaneous lymphatic embolization is becoming a first-line therapy in patients with postoperative lymphatic leakage.

Refractory Lymphatic Ascites After Radical Prostatectomy

Lymphatic ascites after pelvic lymphadenectomy is a rare complication and is rarely reported after urologic surgery. We report a case of delayed and refractory lymphatic ascites following robotic-assisted laparoscopic radical prostatectomy.