Percutaneous management of postoperative lymphocele

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.

Laparoscopic Peritoneal Drainage of Symptomatic Lymphoceles after Pelvic Lymph Node Dissection Using Methylene Blue Instillation

BACKGROUND

Lymphoceles are frequent complications of pelvic lymph node dissection. While small lymphoceles often remain undetected, larger ones can cause complications and require further treatment, e.g. percutaneous tube drainage alone or in combination with sclerotherapy. However, recurrence rates are considerable, and long-lasting drainage may lead to infection, prolonged hospitalization, and as a consequence, increased overall costs. We report the results of a simplified laparoscopic approach to drain lymphoceles after radical prostatectomy plus pelvic lymphadenectomy using methylene blue instillation.

METHODS

13 patients with large symptomatic pelvic/retroperitoneal lymphoceles refractory to percutaneous tube drainage and doxycycline sclerotherapy received a laparoscopic transperitoneal marsupialization following instillation of a sterile diluted methylene blue solution into the drained cavity to refill and mark the lymphocele.

RESULTS

All lymphoceles were sterile and ranged in size from 7 x 6 x 4 to 15 x 12 x 6 cm. Clinical symptoms included lower abdominal swelling, tenderness in the iliac fossa, ipsilateral lymphedema, deep venous thrombosis, wound fistula, and hydronephrosis due to ureteral obstruction. After methylene blue instillation, the lymphoceles were easily identified and opened. Median total operative time was 50 (range 25-70) min; blood loss was negligible. There was one complication in the form of a metachronous infection in the operating field and no relapses. Patients were discharged 1-5 (median 3) days after the surgical procedure.

CONCLUSIONS

Laparoscopic peritoneal drainage requires greater operative skill than percutaneous approaches. However, the instillation of a methylene blue solution simplifies this procedure as the extent and location of the lymphoceles can be precisely identified during laparoscopy. We recommend early application of laparoscopic peritoneal drainage following methylene blue instillation for patients with sterile lymphoceles after pelvic lymph node dissection in whom temporary percutaneous drainage and sclerotherapy failed to resolve the lymph fluid collection.

Delayed infection of a pelvic lymphocele following pelvic lymphadenectomy

Pelvic lymphocele is an infrequent complication of pelvic surgery, usually presenting shortly after surgery. We report a case of an infected pelvic lymphocele presenting more than 1 year after a staging pelvic lymphadenectomy for adenocarcinoma of the prostate. This case illustrates that late infection of pelvic lymphoceles can occur following a pelvic lymphadenectomy and radical prostatectomy.

Management of persistent lymphocele by sclerotherapy with doxycycline

Three cases of lymphocele after lymphadenectomy for gynecologic malignancy are presented. These patients had large, symptomatic lymphoceles resistant to percutaneous catheter drainage. Sclerotherapy with a single dose of doxycycline was administered percutaneously to each patient. Single treatment achieved resolution in two patients. The third had a persistent lymphocele requiring excision. To our knowledge, doxycycline has not been used for sclerotherapy for lymphocele following radical gynecologic surgery. It may represent a viable addition to the conservative management of lymphoceles.

Retroperitoneal lymphocele formation after selective laparoscopic retroperitoneal lymph node sampling

Laparoscopic retroperitoneal lymph node sampling is being evaluated at several institutions as a minimally invasive alternative to evaluate pathologically retroperitoneal lymph nodes in cases of clinical stage A testis tumor. We report on the development of a symptomatic lymphocele after selective laparoscopic retroperitoneal lymph node sampling.

Laparoscopic internal drainage of lymphocele in renal transplant

Lymphoceles frequently develop following renal transplant surgery. The conventional methods used to drain lymphoceles are invasive and can be associated with complications. Laparoscopic drainage of posttransplant lymphoceles provides a safer alternative.