Lymphocytes associated with renal transplantation. Report of 15 cases and review of the literature

Management of lymphocele following anterior lumbar interbody fusion, case report and review of literature

While anterior lumbar interbody fusion (ALIF) is known as an established and safe procedure for treatment of degenerative disc disease, albeit rare, the development of postoperative intra-abdominal or retroperitoneal collection of lymph warrants timely diagnosis and management. This study presents the case of a 62-year-old male who underwent L4-L5 and L5-S1 ALIF and developed a persistent left-sided fluid collection, resulting in a symptomatic retroperitoneal lymphocele confirmed by computed tomography (CT). After percutaneous drainage by interventional radiology (IR), output remained high at 1 liter (L) per day, necessitating sclerotherapy with doxycycline and ethanol. In the absence of improvement, a lymphangiogram demonstrating a persistent lymph leak and glue embolization was performed. Due to refractory symptoms, retroperitoneal exploration with methylene blue dye was utilized for lymphatic mapping, and a lymphatic capillary leak in proximity to the left iliac artery was identified and successfully ligated with resolution of symptoms. With suspected fluid collections following ALIF, confirmation with CT or ultrasound (US) imaging followed by percutaneous drainage and testing of fluid is necessary. In mild cases, drainage alone or nonsurgical chemical sclerotherapy may suffice. In symptomatic refractory cases, localization of the site with lymphangiogram or US-guided injection of methylene blue dye allows for easier identification and definitive management with either transabdominal laparoscopic fenestration or retroperitoneal surgical exploration and ligation.

Various Techniques and Outcomes of Arterial Anastomosis in Live Renal Transplant: An Institutional Experience

Introduction

Renal transplantation with multiple arteries is associated with a major index of surgical complications. Relevant papers and meta-analyses have shown relatively more vascular and urological complications in transplant of donor kidneys with multiple arteries. In live donor grafts due to the unavailability of a carrel patch, several techniques for bench and in situ reconstruction have been described in order to reduce the incidence of these vascular complications. In this study, the short and long-term results of living donor kidney transplants with multiple renal arteries (MRAs) versus single renal artery (SRA) were compared retrospectively.

Methods

This is a retrospective study done on patients who received a living donor kidney between January 2012 and January 2018 at the Institute of Urology, Madras Medical College, Chennai. We have excluded deceased donor kidney transplants and ABO-incompatible cases done in the same time period. The study was approved by the Institutional Ethics Committee (Approval No: IES-MMC-008) and performed in accordance with the guidelines of the Declaration of Helsinki. Open live donor nephrectomy was performed through an extra-peritoneal flank incision in all cases. In the SRA group, the renal artery was anastomosed end to end to the Internal iliac artery, while the renal vein was anastomosed to the external iliac vein in the end to side fashion. Urinary tract reconstruction was accomplished by the Gregoir technique in both groups. We looked at recipient complications, baseline and postoperative serum creatinine, total ischemia time, mean operating time, and short- and long-term graft and patient survival as postoperative outcomes.

Results

In a six-year period (2012-2018) at our institute, 256 living donor transplantations were performed; 36 (14%) kidneys had two or more renal arteries which were anastomosed using various techniques. Cold ischemia time was relatively longer in the MRA group (45 mins vs 28 mins in the SRA group) (p-value <0.05). while warm ischemia time was comparable in both groups (2.5 vs 2.9 mins) serum creatinine was comparable in both groups at the 30th postoperative day (1.4 in SRA group vs 1.2 in MRA group) (p-value >0.05). Incidence of surgical complications in SRA and MRA groups was: vascular - 3.6% and 2.7%; urological - 3.2% and 2.7%; the incidence of lymphocele was 4.5% and 5.5% and delayed graft function 4.5% and 5.5% respectively.

Conclusion

Multiple renal arteries are no longer a relative contraindication with advanced surgical techniques. in renal grafts with multiple arteries, all techniques of vessel anastomosis are comparable in terms of post-surgical complications.

Evidence to support a drain-free strategy in kidney transplantation using a retrospective comparison of 500 consecutively transplanted cases at a single center

Introduction

Routine placement of surgical drains at the time of kidney transplant has been debated in terms of its prognostic value.

Objectives

To determine whether the placement of a surgical drain affects the incidence rate of developing wound complications and other clinical outcomes, particularly after controlling for other prognostic factors.

Methods

Retrospective analysis of 500 consecutive renal transplant cases who did not (Drain-free, DF) vs. did (Drain, D) receive a drain at the time of transplant was performed. The primary outcome was the development of any wound complication (superficial or deep) during the first 12 months post-transplant. Secondary outcomes included the development of superficial wound complications, deep wound complications, DGF, and graft loss during the first 12 months post-transplant.

Results

388 and 112 recipients had DF/D, respectively. DF-recipients were significantly more likely to be younger, not have pre-transplant diabetes, receive a living donor kidney, receive a kidney-alone transplant, have a shorter duration of dialysis, shorter mean cold-ischemia-time, and greater pre-transplant use of anticoagulants/antiplatelets. Wound complications were 4.6% (18/388) vs. 5.4% (6/112) in DF vs. D groups, respectively (P = 0.75). Superficial wound complications were observed in 0.8% (3/388) vs. 0.0% (0/112) in DF vs. D groups, respectively (P = 0.35). Deep wound complications were observed in 4.1% (16/388) vs. 5.4% ((6/112) in DF vs. D groups, respectively (P = 0.57). Higher recipient body mass index and ≥ 1 year of pre-transplant dialysis were associated in multivariable analysis with an increased incidence of wound complications. Once the prognostic influence of these 2 factors were controlled, there was still no notable effect of drain use (yes/no). The lack of prognostic effect of drain use was similarly observed for the other clinical outcomes.

Conclusions

In a relatively large cohort of renal transplant recipients, routine surgical drain use appears to offer no distinct prognostic advantage.

Fistula formation between infected pelvic lymphocele and sigmoid colon: A rare complication of pelvic lymphadenectomy

Lymphocele formation following pelvic lymphadenectomy is a well-known complication. In this article, we report a 56 years old female patient with a pelvic infected lymphocele fistulised in the sigmoid discovered in imaging 2 months after pelvic surgery. Lymphocele complications are rare and their diagnosis is based on imaging. However, lymphocele as a potential cause for fistula in the bowel as a particular new case has not been found in literature search.

Comparison of Postoperative Benign Pelvic Cysts Occurred after Gynecologic or Gyne-oncologic Surgery Treated with Percutaneous Transcatheteric Sclerosant Alcohol Therapy

Objectives:

Here, we compare the success of percutaneous transcatheter sclerosant alcohol therapy (PTSAT) for the postoperative treatment of benign pelvic cysts that occurred after gynecologic surgery.

Materials and Methods:

The study is a retrospective case–control trial. Gynecological patients who had symptoms due to postoperative pelvic cysts and received PTSAT after gynecologic surgery, between October 2008 and January 2018, were examined in a single training and research hospital in Turkey. Some factors were investigated for associations with postoperative pelvic cyst formation in patients who underwent gynecologic operations for malignancies or benign conditions. Statistical analysis used: The association between two independent and nonnormally distributed continuous variables was analyzed with the Mann–Whitney U-test. Spearman's rho correlation analysis was conducted to determine the correlation of two nonnormally distributed variables. Chi-square (or Fisher's exact test, when more suitable) was used to examine the correlation between categorical variables.

Results:

Statistically significant differences were found in terms of the average age was higher in patients with malignancies, and the average postoperative pelvic cyst detection time was higher in patients with benign pelvic cysts. While all patients were treated with PTSAT, repetitive PTSAT was required for seven benign and ten malign cases.

Conclusion:

Patients with pelvic cysts that occurred after gynecologic surgery for malignant conditions, large volume pelvic cysts and patients with benign cysts who underwent more than one surgery required recurrent PTSAT.

Analysis of Risk Factors and Long-Term Outcomes in Kidney Transplant Patients with Identified Lymphoceles

The collection of lymphatic fluids (lymphoceles) is a frequent adverse event following renal transplantation. A variety of surgical and medical factors has been linked to this entity, but reliable data on risk factors and long-term outcomes are lacking. This retrospective single-center study included 867 adult transplant recipients who received a kidney transplantation from 2006 to 2015. We evaluated for patient and graft survival, rejection episodes, or detectable donor-specific antibodies (dnDSA) in patients with identified lymphoceles in comparison to controls. We identified 305/867 (35.2%) patients with lymphocele formation, of whom 72/867 (8.3%) needed intervention. Multivariate analysis identified rejection episode as an independent risk factor (OR 1.61, CI 95% 1.17–2.21, p = 0.003) for lymphocele formation, while delayed graft function was independently associated with symptomatic lymphoceles (OR 1.9, CI 95% 1.16–3.12, p = 0.011). Interestingly, there was no difference in detectable dnDSA between groups with a similar graft and patient survival in all groups after 10 years. Lymphoceles frequently occur after transplantation and were found to be independently associated with rejection episodes, while symptomatic lymphoceles were associated with delayed graft function in our cohort. As both are inflammatory processes, they might play a causative role in the formation of lymphoceles. However, development or intervention of lymphoceles did not lead to impaired graft survival in the long-term.

Lymphovenous anastomosis (LVA) for treatment of iatrogenic lymphocele in the thigh

BACKGROUND

Lymphocele is a collection of lymphatic fluid within the body. It is caused by an impairment of lymph drainage and often occurs after a surgical intervention. In this setting conservative treatment is usually ineffective. The aim of this report is to share the outcomes of 11 patients with iatrogenic lymphocele in the thigh area treated by supermicrosurgical lymphovenous anastomosis.

PATIENTS AND METHODS

Eleven patients presenting iatrogenic lymphocele in the thigh were referred for surgery after an unsuccessful conservative therapy. Patients' mean age was 56 years old, two males and nine females. All of them presented a moderate-to-severe lymphocele in the medial thigh after a surgical intervention that damaged the rich lymphatic pathway present there. Indocyanine green (ICG) lymphography was always performed to visualize the lymphatic vessels and to make the preoperative marking.

RESULTS

All the 11 patients were successfully treated by means of one or more (range: 1-3; mean: 1.5) lymphaticovenous anastomoses without complications. Three of them also received a pedicled sartorius flap for dead space obliteration. All the patients reached full range of motion (ROM) and no recurrences were observed during follow up (range: 6-12 months; mean: 8). Intra-operative ICG lymphography was performed in all cases to check the patency of the anastomoses.

CONCLUSIONS

Lymphaticovenous anastomosis confirmed to be a minimally-invasive and effective procedure for the treatment of postsurgical lymphoceles in the leg. For large lymphoceles a muscle flap may be indicated for volume restoration and prevention of recurrences.

Unusual lymphocele following radical cystectomy with orthotopic neobladder

A 65-year-old male patient, a known case of carcinoma bladder, underwent radical cystectomy with ileal neobladder in 2016. Eleven lymph nodes were identified in the specimen. Histopathology revealed reactive lymphadenitis with sinus histiocytosis. The patient presented with a swelling in the right thigh, associated with dull pain, about 6 months after the procedure. Ultrasound of the right thigh and computed tomography of the region showed an isolated, large, loculated, cystic collection measuring 15 cm × 6 cm with internal septation in the pectineus and adductor longus muscles. Complete aspiration of fluid from the right thigh was done with ultrasound guidance and sent for analysis. The fluid appeared to be lymph, and the lesion turned out to be a lymphocele. There was no recurrence or infection following the aspiration till last follow-up visit. We report this rare lymphocele presentation (in the thigh without any extension from pelvis or groin) after 6 months, following radical cystectomy with neobladder, which was treated by one-time aspiration.

Critical appraisal of consecutive 36 cases of post renal transplant lymphocele: a proposed algorithm

INTRODUCTION

Lymphyocele by definition is the collection of lymph that is contained by a pseudomembrane. Management of lymphocele varies from simple aspiration or aspiration with sclerothreapy to more invasive technique, such as internal/external drainage. We present the results of 36 patients who developed pelvic lymphocele after renal transplant.

MATERIALS AND METHODS

A total of 1720 patients underwent living related donor renal allograft transplant at our centre. Of the total 1720 transplants 36 patients developed symptomatic lymphocele and underwent definitive management. Retrospectively analysis of the clinical data of these 36 patients was done.

RESULTS

Thrirt six patients (2.09%) had a clinically significant lymphocele, which needed definitive management. All these patients underwent ultrasound guided drain placement and sclerosant injection. Fifteen out of 36 patients (41.6%) had successful treament with percutaneous drain placement. Laparoscopic marsupialization of lymphocele was done in 21 patients who failed percutaneous drain insertion therapy after diagnostic aspiration. Laparoscopic Marsupilization was successful in 18 out of 21 patients (85.7%). The 3 patients with failed laparoscopic marsupialization were managed with open surgical marsupialization.

CONCLUSION

Significant number of lymphocele post renal transplant may be asymptomatic but still cause deterioration of renal function even without causing obstructive uropathy. Lymphoceles causing renal deterioration or symptoms should be managed in a step ladder fashion starting from percutaneous drainage to laparoscopic marsupilization to open surgical approach. Asymptomatic recurrences post marsupialization are common and should be only closely observed unless they become symptomatic or cause deterioration of renal function. A systematic protocol may help in treating these patients better.

Lymphatic disorders after renal transplantation: new insights for an old complication

In renal transplanted patients, lymphoceles and lymphorrhea are well-known lymphatic complications. Surgical damage of the lymphatics of the graft during the procurement and of the lymphatic around the iliac vessels of the recipients has been associated with development of lymphatic complications. However, lymphatic complications may be related to medical factors such as diabetes, obesity, blood coagulation abnormalities, anticoagulation prophylaxis, high dose of diuretics, delay in graft function and immunosuppressive drugs. Consistently, immunosuppression regimens based on the use of mTOR inhibitors, especially in association with steroids and immediately after transplantation, has been associated with a high risk to develop lymphocele or lymphorrhea. In addition, several studies have demonstrated the association between rejection episodes and lymphatic complications. However, before the discovery of reliable markers of lymphatic vessels, the pathogenic mechanisms underlining the development of lymphatic complications during rejection and the influence of mTOR inhibitors remained not fully understood. The recent findings on the lymphatic systems of either native or transplanted kidneys together with the advances achieved on lymphangiogenesis shared some lights on the pathogenesis of lymphatic complications after renal transplantation. In this review, we describe the surgical and medical causes of lymphatic complications focusing on the rejection and immunosuppressive drugs as causes of lymphatic complications.

A case of continuous negative pressure wound therapy for abdominal infected lymphocele after kidney transplantation

Lymphocele is a common complication after kidney transplantation. Although superinfection is a rare event, it generates a difficult management problem; generally, open surgical drainage is the preferred method of treatment but it may lead to complicated postoperative course and prolonged healing time. Negative pressure wound therapy showed promising outcomes in various surgical disciplines and settings. We present a case of an abdominal infected lymphocele after kidney transplantation managed with open surgery and negative pressure wound therapy.

Bleomycin sclerotherapy for severe symptomatic and persistent pelvic lymphocele

Background. Pelvic lymphoceles are frequently described as a complication of pelvic lymphadenectomy performed for surgical staging of gynaecologic malignancies. Case Report. A 72-year-old woman presented with severe symptomatic and refractory lymphocele associated with persistent lower limb lymphedema and recurrent erysipelas. After four CT fluoroscopy scan guided percutaneous catheter drainages, the lymphocele complicated with infection finally resolved with two sessions of bleomycin sclerotherapy. Conclusion. Symptomatic persistent lymphoceles require treatment and nowadays the first option is interventional radiologic procedures. Bleomycin is a safe and effective sclerosing agent and therefore should be regarded as a first-line treatment choice.

Oedema, solid organ transplantation and mammalian target of rapamycin inhibitor/proliferation signal inhibitors (mTOR-I/PSIs)

Mammalian target of rapamycin inhibitor (mTOR-I)/proliferation signal inhibitors (PSI) including sirolimus and everolimus represent a new class of drugs increasingly used in solid-organ transplantation as alternatives to calcineurin inhibitors for patients with renal dysfunction, transplant coronary arterial vasculopathy or malignancy. The most frequently occurring mTOR-I/PSI-related adverse events are similar to those associated with other immunosuppressive therapies, but some side effects are more characteristic of proliferation signal inhibitors (e.g. lymphocele, arthralgia, oedema and hyperlipidaemia). The present paper review incidence, clinical presentation and mechanism of oedema within the clinical experience of mTOR-I/PSI in solid organ transplantation.

Laparoscopic treatment of lymphoceles after renal transplantation

OBJECTIVE

Lymphocele formation following renal transplantation is a frequent complication and may affect as many as 49% of patients. Operative treatment of symptomatic post transplant lymphocele (PTL) consists of wide drainage of the fluid collection into the abdominal cavity by excising its wall, connecting the lymphocele cavity to the intraperitoneal space. Laparoscopic fenestration seems to be the best treatment as it combines satisfying success rates with a minimally invasive approach. The aim of the study was to review a single center experience on the laparoscopic treatment of symptomatic PTL and detail relevant aspects of the surgical technique.

MATERIALS AND METHODS

The data of 25 patients who underwent laparoscopic surgical treatment for a symptomatic lymphocele following kidney transplantation were retrospectively reviewed. Demographic data and surgical results were assessed. Detailed surgical technique is provided.

RESULTS

Between 1996 and 2008, 991 patients received a kidney transplant at our institution. Twenty-five patients (2.52%) developed a symptomatic lymphocele and laparoscopic drainage was performed. The indications for surgical drainage were graft dysfunction (84%), local symptoms (16%) or both (32%). The mean time until surgical therapy was 14.2 ± 6 weeks. Mean hospital stay was 1.5 ± 0.2 days. Postoperative complications occurred in only 2 patients (8%) (one ureteral injury and one incisional hernia) and required reoperation. After a mean followup of 36.2 ± 4 months, only 1 patient had a symptomatic recurrence.

CONCLUSIONS

Laparoscopic fenestration is an effective surgical technique to treat symptomatic lymphocele following kidney transplantation with low recurrence rate and long standing results.

Pseudorejection and true rejection after kidney transplantation: classification and clinical significance

OBJECTIVES

Multiple factors may result in an elevation in serum creatinine level after kidney transplantation, mimicking rejection. It is crucial to differentiate between a true rejection and other conditions inducing a 'pseudorejection', in order to avoid overtreatment, or worse, mistreatment. Our goal was to review and classify true rejections and pseudorejections and their clinical significance.

MATERIAL AND METHODS

This was a retrospective review of articles published in the USA and Europe, from 1976 to the present. The sites from which information was retrieved included PubMed, Clinical Imaging, Histopathology, Archives of Surgery, JACS, the American Urological Association, Medline and Springer Link. The importance of the resistive index will also be emphasized.

RESULTS

We reviewed 61 articles regarding the causes of renal graft dysfunction, which may be classified into true rejections and pseudorejections, the latter including the following 6 factors: hyperglycemia, ureteral obstruction, lymphocele, arterial stenosis, infection and recurrence of primary pathology.

CONCLUSIONS

'Pseudorejection' has been described only once, for the first time in 1976 in the USA, and there have been no other reports since then. Multiple factors, mainly hyperglycemia, may induce a pseudorejection, presenting with an elevation of serum creatinine level and leading the clinician to an erroneous diagnosis of true rejection initially, resulting in inappropriate management.

Post-kidney transplantation lymphocele due to a lymphatic filariasis

Lymphocele is a well-known complication of renal transplantation. Presenting symptoms are nonspecific; most patients are entirely asymptomatic. Herein, we have reported a case of lymphocele due to an asymptomatic lymphatic Wuchereria bancrofti filariasis with deterioration of graft function. A 53-year-old man with end-stage renal disease secondary to vascular disease was admitted 40 days after transplantation with vague, isolated abdominal pain. An abdomen and pelvis ultrasound examination demonstrated a cystic structure in the renal hilus. Graft function deteriorated, so the patient underwent puncture of the lymphocele followed by povidone iodine sclerotherapy. In the percutaneous drainage, we noted a fine whitish strand 4-mm thick similar to the shape of the stent, a part of which seemed to go into the transplantation fossa. Parasitological examination showed an adult female worm of W bancrofti measuring 6 cm. The test for microfilaremia was negative. The patient was treated for 10 days with a combination of Ivermectin and Albendazole associated with Doxycycline. The collection rapidly decreased after worm treatment. This case describes a post-renal transplantation lymphocele due to asymptomatic lymphatic filariasis.

Retroperitoneal lymphocele after lumbar total disc replacement: a case report and review of literature

BACKGROUND

Retroperitoneal lymphoceles (RPLs) caused by injury to the lymphatics are commonly seen after pelvic lymphadenectomy, renal transplantation, and gynecologic tumor resection surgeries. Degenerative disc disease still remains the major cause of low-back pain. Anterior lumbar spinal procedures, such as anterior lumbar interbody fusion and anterior lumbar arthroplasty, have been increasingly performed for treatment of axial back pain. RPLs, as an approach-related complication, though infrequent, have been reported after anterior lumbar spinal surgery. We report a case of RPL after total disc replacement of the lumbar spine. To our knowledge, there has been no prior report of RPL after total disc replacement managed by percutaneous aspiration only.

METHODS

A 49-year-old woman who underwent total disc replacement at the L4-5 level presented with a postoperative complication of RPL. The imaging findings, clinical course, and treatment are discussed, and a review of literature is presented.

RESULTS

The patient presented with significant abdominal swelling and discomfort at 4 weeks after surgery without any signs or symptoms of infection. Investigations showed an RPL. She was treated by multiple aspirations under ultrasound guidance. At 12 months' follow-up, the patient had no further abdominal symptoms and had gone back to her routine activities and work with significant improvement in back pain.

CONCLUSIONS

RPL is an uncommon complication after anterior lumbar surgery and can be managed effectively if detected and diagnosed early. Although repeated aspiration is associated with high recurrence and infection, it is a safe and minimally invasive procedure to manage RPL.

The diagnostic value of protein clearances in rejection of human renal allografts

The relative clearances of transferrin, haptoglobin, IgG, and IgA were used as a diagnostic test for detection of acute rejection episodes after renal transplantation, using an automated immunoprecipitin reaction. Thirty-six out of 40 rejections were predicted by 0--5 days. The sensitivity and specificity were 90% and 98%, respectively. The predictive value of a positive diagnostic test was 86% and of a negative 99%. False positives caused by fever and urinary obstruction could probably be excluded by the finding of an increased urinary excretion of beta2-microglobulin prior to the increased relative clearance of transferrin, haptoglobin, IgG and IgA. This would improve the predictive value of a positive test to 95%. Daily or more frequent protein clearance determinations should be performed in renal transplant patients, since the method used was easy, rapid and suited for sequential analysis, and the procedure was without risk for the patient.

Percutaneous transcatheter ethanol sclerotherapy and catheter drainage of postoperative pelvic lymphoceles

The aim of this study is to investigate the efficacy and long-term results of percutaneous transcatheter ethanol sclerotherapy (PTES) for postoperative pelvic lymphocele treatment. Fifty-two patients who were referred for lymphocele treatment were included in this study. Sixty lymphoceles of 52 patients were treated by percutaneous treatment with or without ethanol sclerotherapy. Lymphoceles developed in 47 and 5 patients, who underwent gynecologic malignancy operation (31 ovarian cancer, 6 cervix cancer, 10 endometrial cancer) and renal transplantation, respectively. Lymphoceles were catheterized by ultrasonography and fluoroscopy guidance using the Seldinger technique. Lymphoceles smaller than 150 mL underwent single-session ethanol sclerotherapy and the others were treated by multiple-session ethanol sclerotherapy. In 10 patients, percutaneous ethanol sclerotherapy could not be performed and they were treated only by percutaneous catheter drainage. The mean lymphocele volume was 329 mL (15-2900 mL). The mean catheterization duration was 11.8 days (1-60 days). The mean follow up time was 25.8 months (2-64 months). The initial treatment was successful in 46 out of 50 (91%) lymphoceles treated with PTES and 7 out of 10 (70%) lymphoceles treated with percutaneous catheter drainage. Minor complications (secondary infection and catheter dislodgement) were noted in seven (11.6%) patients. Recurrence developed in four and three patients who were treated by PTES and percutaneous catheter drainage, respectively. Five of these patients were treated with PTES without further recurrence. Percutaneous transcatheter ethanol sclerotherapy is an effective and reliable method for the treatment of postoperative lymphoceles.

Laparoscopic Marsupialization of Postrenal Transplantation Lymphoceles

BACKGROUND AND PURPOSE

Clinically significant post-transplantation lymphoceles are not uncommon. Surgical marsupialization with internal peritoneal drainage is the treatment of choice. We describe the successful laparoscopic formation of a peritoneal window for post-transplantation lymphocele drainage as an effective and minimally invasive procedure.

PATIENTS AND METHODS

Between August 1995 and September 2001, 135 consecutive renal transplantations were performed, and 9 patients developed clinically significant lymphoceles. Four of the nine patients were treated by laparoscopic drainage via a peritoneal window. Analysis of predisposing risk factors commonly associated with lymphoceles was performed. The surgical outcome was assessed.

RESULTS

Laparoscopic drainage was successful in all patients. The average operative time was 40 minutes. The mean hospital stay was 1.5 days for patients undergoing laparoscopic drainage versus 5 days for those having open surgical drainage. Accidental division of the right native ureter occurred in one patient, which was identified intraoperatively. None of the patients had developed recurrence of lymphocele after a mean follow-up of 10.7 months (range 6-22) months.

CONCLUSION

In patients with a clinically significant post-transplantation lymphocele of appropriate size and location, laparoscopic drainage is easy, safe, and effective. It decreases hospital stay and hastens convalescence.

Octreotide in the Treatment of Lymphorrhea After Renal Transplantation: A Preliminary Experience

BACKGROUND

Lymphorrhea is a minor complication after kidney transplantation but may develop into a lymphocele and prolong hospital stay. Treatment is conservative based on percutaneous drainage until lymphatic leakage cessation. It has been reported that octreotide has beneficial effects to treat lymphorrhea after axillary node dissection and excision of lymphatic malformations. The aim of this study was to report preliminary experience about octreotide treatment in lymphorrea after kidney transplantation.

MATERIALS AND METHODS

This retrospective study included 20 recipients of cadaveric kidney allografts with posttransplant lymphorrhea including 10 treated with instillation of povidone iodate solution, and the other 10 with octreotide (0.1 mg three times a day subcutaneously). We reviewed the daily amount of fluid collection, duration of lymphorrhea, complications, lymphocele formation, rejection episodes, graft outcomes, and hospital stay.

RESULTS

The average duration of lymphorrhea was 8.5 (+/-4.5) and 16.3 (+/-7.3) days for the octreotide versus the povidone groups, respectively (P = .001). No complications occurred among the octreotide group, while three lymphoceles grew among patients treated with povidone solution. No differences were observed for acute rejection episodes or renal function between the groups. No octreotide-related adverse events were noted.

CONCLUSION

The mean length of lymphorrhea was lower with octreotide versus iodate povidone solution treatment. There was a shorter hospital stay and minor patient discomfort. In conclusion, lymphatic leakage after kidney transplantation may be successfully managed by octreotide administration.

Radiologic imaging and percutaneous treatment of pelvic lymphocele

Pelvic lymphocele, also known as lymphocyst, is a cystic structure caused by lymphatic injury usually secondary to pelvic lymphadenectomy and renal transplantation. Lymphoceles can cause morbidity and rarely mortality by compression of adjacent structures and infectious complications. This review discusses etiology and treatment options for pelvic lymphoceles including surgical and percutaneous methods with emphasis on percutaneous techniques particularly in conjunction with sclerotherapy. Percutaneous catheter drainage with sclerotherapy procedure with various sclerosing agents is described in detail. Ethanol, povidone-iodine, tetracycline, doxycycline, bleomycin, talc and fibrin glue can be used as sclerosing agents. Combination of sclerosing agents to percutaneous catheter drainage significantly improves success rate in the treatment of pelvic lymphoceles. Infected lymphoceles are usually treated solely with percutaneous catheter drainage. Percutaneous treatment can be tailored according to volume of lymphoceles. We generally prefer single session sclerotherapy and 1 day catheter drainage in lymphoceles less than 150 mL, and larger ones are treated by multi-session sclerotherapy until daily drainage decreases below 10 mL. Percutaneous treatment preferably with sclerotherapy should be considered as the first-line treatment modality for pelvic lymphoceles due to its effectiveness, widespread applicability on an outpatient basis, ease of procedure and low complication rate.

Laparoscopic fenestration of lymphoceles after kidney transplantation with diaphanoscopic guidance

In laparoscopic fenestration of lymphoceles after kidney transplantation, identification of the correct site of incision is sometimes difficult. We developed a new technique, using diaphanoscopy in 3 patients. After ultrasound-guided puncture and dilation, the correct incision site is identified by white light with a cystoscope inserted into the lymphocele cavity.

Post transplant lymphocele: a single centre experience

The occurrence of post renal transplant lymphocele is variable and the best approach to treatment is not well defined. The purpose of this study was to find out the incidence of post transplant lymphocele at our centre, identify demographic or surgical factors that may have influenced lymphocele formation, and distinguish the best approach to treatment. The charts of 138 consecutive renal transplant recipients from 1996 to 2001 were retrospectively reviewed. The demographic characteristics, comorbid illnesses, occurrence of lymphocele and its treatment modality were recorded. A total of 36 (26%) patients developed lymphoceles. There was a significant relationship between an increased body mass index (BMI) and lymphocele occurrence (P > 0.01). The recurrence rate with drainage alone was 33%, which decreased to 25% with sclerotherapy. In comparison, both laparoscopic and open surgical marsupialization had a much lower but similar recurrence rate of 12%. The laparoscopic method had less morbidity, a shortened hospital stay, and less infection than open surgery.

Applications of laparoscopic surgery in urology: impact on patient care

From its first use as a diagnostic tool, urologic laparoscopy has developed into a complex therapy for both benign and malignant disease. Most procedures are still performed at large centers with experienced laparoscopists but nonacademic urologists are starting to gain the necessary training and skills. With the clear advantage that laparoscopy shows over open procedures in terms of decreased perioperative morbidity and quicker recovery times, patients are increasingly asking for this approach. The urologic community must meet this challenge and train future urologists to meet the expected demand.

Laparoscopic treatment of post renal transplant lymphoceles

BACKGROUND

Traditionally, a post transplant lymphocele (PTL) is drained by widely opening the wall connecting the lymphocele cavity to the intraperitoneal space via laparotomy. We hypothesize that laparoscopic techniques can be effectively used for the treatment of PTL.

METHODS

Patients requiring intervention for PTL between 1993 and 2002 were identified via a retrospective review. Results of drainage via laparotomy and laparoscopy were compared.

RESULTS

During the study period 685 renal transplants (391 cadaveric, 294 living) were performed. The incidence of lymphocele was 5% [34/685 (36 cases)]. The indications for surgical drainage were local symptoms (69%), graft dysfunction (14%), or both (17%). The mean time to surgical therapy was 4.9 months. Laparoscopic drainage was performed in 25 patients (74%) and open drainage in 9 patients (26%). Open procedures were performed in cases for: previous abdominal surgery (5), undesirable lymphocele characteristics or location (2), or with concomitant open procedures (3). There were no conversions or operative complications in either group. There was no difference in operative time for the laparoscopic group vs the open group (108 +/- 6 vs 123 +/- 18 min, p = 0.8). Hospital stay was significantly shorter for the laparoscopic group (1.7 +/- 0.8 vs 3.8 +/- 1.0, p = 0.0007), with 88% of laparoscopic patients being either overnight admissions or same day surgery. Two patients (5%) developed symptomatic recurrences requiring reoperation [1 laparoscopic (4%), 1 open (10%)].

CONCLUSIONS

Laparoscopic fenestration of a peritransplant lymphocele is a safe and effective treatment. The large majority of patients treated with laparoscopic fenestration were discharged within one day of surgery. Unless contraindications exist, laparoscopy should be considered first-line therapy for the surgical treatment of posttransplant lymphocele.

Scintigraphic patterns of lymphocele in post-renal transplant

Lymphocele is a common cause of fluid collection in post-renal transplant patients. Most of these patients are routinely followed up with 99mTc diethylenetriaminepentaacetate renal dynamic scintigraphy. The present study retrospectively reviews the range of findings with renal dynamic scintigraphy in documented lymphoceles. A lymphocele was diagnosed when there was a pelvic collection on ultrasonography with a similar biochemical composition to plasma. Four types of scintigraphy patterns were noted in lymphocele in a total of 13 patients. In nine patients there was an initial photopenic area, which progressively filled up with tracer activity equal to that of the background level in delayed images. In two other patients, the activity in the initial photopenic area exceeded the background activity in delayed images. A persistently photopenic area was seen in early and delayed images in the two remaining patients. In addition, a rim of increased tracer activity was noted surrounding the photopenic area in four patients in the early images. In conclusion, an initial photopenic area (with or without a surrounding rim of increased tracer activity), which fills up with tracer in delayed images seems to be the most common pattern seen in lymphoceles in scintigraphic studies of renal transplants. The presence of a rim sign may add confidence to the reporting of a collection as a lymphocele.

Incidence, therapy, and consequences of lymphocele after sirolimus-cyclosporine-prednisone immunosuppression in renal transplant recipients

BACKGROUND

In a retrospective study we sought to dissect the factors associated with an increased occurrence of clinically significant perinephric fluid collections and lymphoceles among sirolimus-treated renal transplant recipients.

METHODS

We compared the incidence, predisposing factors, and consequences of these fluid collections among patients treated with sirolimus-cyclosporine (CsA)-prednisone (Pred) (n=354, group I) versus CsA-Pred with or without azathioprine (n=136, group II).

RESULTS

More group I patients (135/354; 38.1%) displayed perinephric fluid collections (denoted as group III) then group II patients (24/136; 17.6%) (denoted as group IV) (P <0.001). In both subgroups the serum creatinine levels were elevated at the time of diagnosis from a nadir of 2.04+/-1.61 to 4.09+/-2.95 mg/dL (group III) and from 2.53+/-2.34 to 4.36+/-2.90 mg/dL (group IV). A significantly greater number of patients required treatment for lymphoceles among group I (56/354; 15.8%) versus group II recipients (6/136; 4.4%; P<0.001). Single or repeated percutaneous drainage procedures successfully treated 35 group I patients versus all 6 group IV patients (P =0.033). No patients in group II versus 21 patients in group I underwent surgical procedures (P <0.001). A significantly higher rate and higher histologic grade of acute rejection episodes, particularly proximate to the onset of the lymphocele, occurred among group IV patients, namely 54.2% (13/24) versus 21.4% (29/135) group III patients (P <0.001).

CONCLUSIONS

Addition of sirolimus to a CsA-Pred regimen resulted in both a higher incidence and a requirement for more aggressive treatment of perinephric fluid collections and lymphoceles.

Laparoscopic treatment of lymphoceles in patients after renal transplantation

Postoperative lymphoceles after renal transplantation appear in up to 18% of patients, followed by individual indisposition, pain or impaired graft function. Therapeutic options are percutaneous drainage, needle aspiration with sclerosing therapy, or internal surgical drainage by conventional or laparoscopic approach. The laparoscopic procedure offers short hospitalisation time and quick postoperative recovery. From 1993 to 1997, 16 patients underwent laparoscopic fenestration of a post-renal transplant lymphocele, and were presented in a retrospective analysis. Three patients have had previous abdominal surgery. Following preoperative ultrasound and CT scan, 16 patients underwent laparoscopic drainage after drainage and staining of the lymphocele with methylene blue. No conversion was necessary. Mean operation time was 42 min, no intraoperative complications were seen. Oral nutrition and immunosuppression were continued on the day of surgery, and patients were discharged between the 2nd and 5th (median hospital stay 3.3 d) day after surgery. No recurrence was evident in a follow-up time of 15-54 months (median 31.4 months). Renal function remained unchanged in all patients postoperatively.

Laparoscopic surgery in renal transplant recipients

An exponential increase has occurred in the use of laparoscopic surgery in patients who have undergone prior renal transplantation. The main indications are the treatment of symptomatic pelvic lymphoceles and native kidney nephrectomy for various reasons. Most reports have shown laparoscopy to be equally effective and less morbid than conventional open surgery. In addition to conferring the benefits of a minimally invasive approach, laparoscopy potentially offers three advantages specific to this immunosuppressed population of patients. First, it avoids the potential wound-related problems inherent in open surgery. Second, by reducing hospitalization, it reduces the risk for nosocomial infections. Third, by allowing an earlier resumption of oral intake, it enables the continuation of oral immunosuppression. Proper perioperative management of fluid and electrolyte balance is critical in this group of patients. Despite concerns, there is no evidence showing that laparoscopy adversely affects allograft function.

Laparoscopic lymphocelectomy: a multi-institutional analysis

PURPOSE

Because symptomatic lymphoceles are infrequent, single center studies generally report small numbers of patients. We report a multi-institutional experience with and long-term outcome following laparoscopic lymphocelectomy in 81 patients.

MATERIALS AND METHODS

Data were obtained from 9 institutions at which at least 5 cases of laparoscopic lymphocelectomy had been performed. Baseline patient demographics, operative time and blood loss, special operative adjunct techniques, postoperative course, convalescence, complications and lymphocele recurrence data were collected and analyzed.

RESULTS

A total of 56 men and 25 women with a mean age of 41 years were included in the study. Lymphocele formed after renal transplantation in 78 patients (96%) and after pelvic lymph node dissection in 3 (4%). Average operating time was 123 minutes with a mean blood loss of 43 ml. Omentopexy was performed in 11 cases (13.6%). No intraoperative stenting of the transplant ureter was performed. Intraoperative complications consisted of laryngospasm, bladder injury, inferior epigastric artery injury and mild renal capsule hematoma in 1 patient each. Conversion to open surgery was required for repair of bladder injury in 1, repair of preexisting hernia in 1, unusually thickened lymphocele wall in 1 and inaccessible lymphocele location in 4 cases. Mean time to ambulation and resumption of regular diet was 1 day, and mean hospital stay was 1.5 days. Postoperative complications included trocar site hernia in 1 and urinary retention in 2. Convalescence averaged 2.5 weeks. During a mean followup of 27 months 5 patients (6%) had lymphocele recurrence.

CONCLUSIONS

Laparoscopic lymphocelectomy is safe, minimally invasive and effective. It is an excellent alternative to the conventional open surgical approach.

Is lymphocele in renal transplantation an avoidable complication?

BACKGROUND

This study evaluated the impact of surgery in the incidence of lymphocele after kidney transplantation (KTx).

METHODS

A prospective randomized study was conducted during a 6-year period on a group of patients undergoing KTx and operated on by the same surgeon (CVS). A total of 280 patients undergoing KTx were randomly allocated into two groups: (1) group C (control group) was 140 patients who were submitted to KTx with standard technique: implantation of the kidney in the controlateral iliac fossa with vascular anastomoses on the external iliac vessels; and (2) group M (modified technique group) was 140 patients who underwent a modified technique with a cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels. Both groups were comparable for age, cold ischemia time, incidence of rejection episodes, presence of adult polycystic kidney disease, and source of donor graft.

RESULTS

Group M showed an incidence of lymphocele production (3 patients, 2.1%) significantly lower than group C (12 patients, 8.5%). Eight patients (1 in group M and 7 in group C) required surgical treatment by peritoneal fenestration. No allograft or recipient was lost as a result of fluid collection but the hospitalization was shorter in group M than in group C.

CONCLUSIONS

A cephalad implantation of the renal graft in the ipsilateral iliac fossa has been associated with a lower incidence of lymphocele, probably because vascular anastomoses on the common iliac vessels cause less lymphatic derangement than those performed on the external iliac vessels.