Pelvic lymphocyst--a 10-year experience

Use of clinical variables for preoperative prediction of lymph node metastasis in endometrial cancer

OBJECTIVE

Endometrial cancer is the most common gynaecological cancer, and most patients are identified during early disease stages. Noninvasive evaluation of lymph node metastasis likely will improve the quality of clinical treatment, for example, by omitting unnecessary lymphadenectomy.

METHODS

The study population comprised 611 patients with endometrial cancer who underwent lymphadenectomy at four types of institutions, comprising seven hospitals in total. We systematically assessed the association of 18 preoperative clinical variables with postoperative lymph node metastasis. We then constructed statistical models for preoperative lymph node metastasis prediction and assessed their performance with a previously proposed system, in which the score was determined by counting the number of high-risk variables among the four predefined ones.

RESULTS

Of the preoperative 18 variables evaluated, 10 were significantly associated with postoperative lymph node metastasis. A logistic regression model achieved an area under the curve of 0.85 in predicting lymph node metastasis; this value is significantly higher than that from the previous system (area under the curve, 0.74). When we set the false-negative rate to ~1%, the new predictive model increased the rate of true negatives to 21%, compared with 6.8% from the previous one. We also provide a spreadsheet-based tool for further evaluation of its ability to predict lymph node metastasis in endometrial cancer.

CONCLUSIONS

Our new lymph node metastasis prediction method, which was based solely on preoperative clinical variables, performed significantly better than the previous method. Although additional evaluation is necessary for its clinical use, our noninvasive system may help improve the clinical treatment of endometrial cancer, complementing minimally invasive sentinel lymph node biopsy.

Robot-Assisted versus Laparoscopic Surgery for Pelvic Lymph Node Dissection in Patients with Gynecologic Malignancies

Objectives

The objective of this study was to compare the surgical outcomes for pelvic lymph node dissection (PLND) performed through conventional laparoscopic surgery (CLS) versus robot-assisted surgery (RAS) in patients with gynecologic malignancies.

Materials and Methods

Perioperative data, including operative time, estimated blood loss, and complications, were retrospectively analyzed in 731 patients with gynecologic malignancies who underwent transperitoneal PLND, including 460 and 271 in the CLS and RAS groups, respectively. Data were statistically analyzed using the Chi-square test or Student's t-test as appropriate. P < 0.05 was considered statistically significant.

Results

The mean age was 50 ± 14 years and 53 ± 13 years in the RAS and CLS groups (P < 0.01), respectively. The mean body mass index was 23.4 ± 4.8 kg/m2 and 22.4 ± 3.6 kg/m2 in the RAS group and CLS groups (P < 0.01), respectively. The operative time, blood loss, and number of resected lymph nodes were 52 ± 15 min, 110 ± 88 mL, and 45 ± 17, respectively, in the RAS group and 46 ± 15 min, 89 ± 78 mL, and 38 ± 16, respectively, in the CLS group (all P < 0.01). The rate of Clavien-Dindo Grade ≥ III complications was 6.3% and 8.7% in the RAS and CLS groups, respectively (P = 0.17).

Conclusion

Shorter operative time and lower blood loss are achieved when PLND for gynecologic malignancies is performed through CLS rather than RAS. However, RAS results in the resection of a greater number of pelvic lymph nodes.

Is advanced bipolar v anced bipolar vessel sealing de essel sealing device really eff eally effective in decreasing the pelvic lymphocele ratio in open surgery for endometrial cancer?

BACKGROUND

We aim to show pelvic lymphocele (PL) rates in patients who were operated for endometrial cancer (EC) and underwent systematic paraaortic bilateral pelvic lymph node dissection (PABPLND) with advanced bipolar vessel sealing device (ABVSD).

METHODS

The medical files of all patients who underwent open surgery for EC between January 2017 and December 2021 were retrospectively analyzed. One hundred three patients who operated with the diagnosis of high-intermediate and high-risk endometrial cancer were included. Systematic PABPLND was performed with total abdominal hysterectomy with or without bilateral salpingo-oophorectomy during surgery to all patients. All operations were performed by same three surgeons who were expert in their field. While the lymph packages were removed during surgical dissection, the distal afferent and proximal efferent lymphatic channels were sealed with LigaSure™ blunt tip sealer/divider (Medtronic, Covidien, USA). The patients were scanned with computed tomography (CT) between 8 and 12 weeks postoperatively. Lymphocele diagnosis was confirmed by radiologists and largest diameter was recorded. Clinical-pathological findings of all patients were recorded.

RESULTS

Mean age and body mass index (BMI) of all participants were 58.6 ±10.2 years and 28.1± 5.6 kg/m2 . The most histopathological findings were endometrioid type (84.5%) and grade 2 (44.2%) ECs. The pelvic lymphocele (PL) was detected with CT in 24 of 103 patients at 8 to 12 weeks postoperatively. Only two PL patients were symptomatic. The first patient had symptoms of pelvic fullness and compression while the second patient had infected image. PL was located to right pelvic area in first case while the second was located on the vaginal cuff.

DISCUSSION

The dissection and sealing of major lymph vessels were achieved during the removal of all lymph packages with LigaSure™ blunt tip laparoscopic sealer/divider. The use of advanced bipolar systems can reduce the formation of PL in lymph node dissection in endometrial cancer.

Sentinel Lymph Node Biopsy in Uterine Cancer: Time for a Modern Approach

Since the validation of the sentinel node technique (SLN) for vulvar cancer 20 years ago, this technique has been introduced in the management of operable cervical cancer and endometrial cancer. For cervical cancer a "one fits all" attitude has mainly been presented. However, this approach, consisting of a frozen section during the operation, can be discussed in some stages. We present and discuss the main option for each stage, as well as some secondary possibilities. For endometrial cancer, SLN is now the technique of choice for the nodal staging of low- and intermediate-risk groups. Some discussion exists for the high-risk group. We also discuss the impacts of using preoperatively the molecular classification of endometrial cancer. Patients with POLE or TP53 mutations could have different nodal staging. The story of SLN in uterine cancers is not finished. We propose a comprehensive algorithm of SLN in early cervical and endometrial cancers. However, several ongoing trials will give us important data in the coming years. They could substantially change these propositions.

Evaluating the importance of routine drainage following laparoscopic pelvic lymph node dissection for gynecological malignancies

OBJECTIVE

To determine the efficacy of drainage following pelvic lymph node (PLN) dissection, especially for cases involving laparoscopic surgery.

METHODS

In this retrospective study, 368 patients with malignant gynecological tumors who underwent systemic PLN dissection at Keio University Hospital between January 2012 and October 2018 were enrolled. Drainage tubes were placed in the retroperitoneal fossa in all patients. Medical records were used for data collection.

RESULTS

Laparoscopy was performed on 81 patients, and laparotomy was performed on 287 patients. In the laparoscopy group, tubes were removed 1 day post surgery. In the laparotomy group, tubes were removed 1 day post surgery in 167 patients and 4 days post surgery in 120 patients. Compared with the laparotomy group, we determined the laparoscopy group to have a significantly lower prevalence of lymphocyst (6.2% vs 20.2%, p = 0.002) but a similar prevalence of lymphedema (4.9% vs 5.2%), and symptomatic lymphocyst (2.5% vs 4.5%). The two laparotomy groups did not differ significantly with respect to the prevalence of lymphedema (4.8% vs 5.8%), lymphocyst (20.4% vs 20.0%), or symptomatic lymphocyst (4.2% vs 5.0%).

CONCLUSION

Our results suggest that routine drainage should be omitted, especially in cases involving laparoscopic surgery.

Associated risk factors of lower limb lymphedema after treatment of cervical and endometrial cancer

The scope of the study was to identify the associated risk factors of lower limb lymphedema development in cervical and endometrial cancer patients. We retrospectively analysed 326 patients: 186 cases (57.06%) with cervical cancer and 140 cases (42.94%) with endometrial cancer were treated in Surgery, Radiotherapy, Oncology and Gynaecology Clinics of ‘St. Apostle Andrew’ Emergency Clinical Hospital Galati over 9 years. Adjuvant radiotherapy was performed in 83.57% of endometrial cancer cases. Adjuvant chemotherapy was performed in 45.16% of cervical cancer cases. Over 10 lymph nodes were removed in 74.73% of cervical cancer patients. Incidence of lymphedema was 15.05% in cervical cancer patients and 10% in endometrial cancer patients, P=0.06. Analysed risk factors for lower limb lymphedema occurrence were: Age, disease stage, radiotherapy, number of invaded lymph nodes (for cervical cancer patients), number of removed lymph nodes (for cervical cancer patients) and obesity. Multivariate analysis for associated risk factors of lower limb lymphedema development in cervical cancer showed that number of removed lymph nodes, OR=2.109 (0.907-4.903), P<0.0001, number of lymph nodes with metastasis, OR=1.903 (0.253-4.332), P=0.004 and obesity, OR=1.713 (0.226-2.967), P=0.006 were found as statistically significant risk factors for lower limb lymphedema onset. For endometrial cancer patients, obesity, OR=1.518 (0.721-2.75), P=0.0003, was the only associated risk factor with statistical significance for the lower limb lymphedema development. Lower limb lymphedema represents one of the adverse reactions of multimodal treatment in gynaecological cancers which affects patient's quality of life. Lower limb lymphedema occurrence is related with number of risk factors, the most important being removed lymph nodes, obesity and radiotherapy.

Comparison of lymphatic complications between sentinel node navigation surgery and pelvic lymphadenectomy in patients with cervical cancer

BACKGROUND

Sentinel node navigation surgery (SNNS) has been frequently used in early cervical cancer. However, the incidence and potential reduction of lymphatic complications following the removal of the sentinel lymph node remain unknown. Thus, this study aimed to evaluate the occurrence of lymphatic complications post sentinel node navigation surgery in patients with early cervical cancer.

METHODS

A total of 167 patients, including 70 and 97 patients who had undergone SNNS and pelvic lymphadenectomy (PLA), respectively, were enrolled in this study. We compared the lymphatic complications (lower extremity lymphedema and pelvic lymphocele) between the SNNS and PLA groups.

RESULTS

The median number of sentinel lymph nodes removed was 2 (range: 1-14). Among the 70 patients in the SNNS group, there were 0 (0%) and 3 (4.3%) occurrences of lower extremity lymphedema and pelvic lymphocele, respectively. The occurrences of lower extremity lymphedema and pelvic lymphocele were significantly lower in the SNNS group than in the PLA group, despite circumflex iliac node removal.

CONCLUSIONS

The occurrence of lymphatic complications (lower extremity lymphedema and pelvic lymphocele) was significantly lower in the SNNS group than in the PLA group. We found that SNNS, and not PLA, was the best treatment option for preventing the development of lower extremity lymphedema and pelvic lymphocele, despite circumflex iliac node preservation.

Development of prediction models for lymph node metastasis in endometrioid endometrial carcinoma

BACKGROUND

In endometrioid endometrial cancer (EEC), current clinical algorithms do not accurately predict patients with lymph node metastasis (LNM), leading to both under- and over-treatment. We aimed to develop models that integrate protein data with clinical information to identify patients requiring more aggressive surgery, including lymphadenectomy.

METHODS

Protein expression profiles were generated for 399 patients using reverse-phase protein array. Three generalised linear models were built on proteins and clinical information (model 1), also with magnetic resonance imaging included (model 2), and on proteins only (model 3), using a training set, and tested in independent sets. Gene expression data from the tumours were used for confirmatory testing.

RESULTS

LNM was predicted with area under the curve 0.72-0.89 and cyclin D1; fibronectin and grade were identified as important markers. High levels of fibronectin and cyclin D1 were associated with poor survival (p = 0.018), and with markers of tumour aggressiveness. Upregulation of both FN1 and CCND1 messenger RNA was related to cancer invasion and mesenchymal phenotype.

CONCLUSIONS

We demonstrate that data-driven prediction models, adding protein markers to clinical information, have potential to significantly improve preoperative identification of patients with LNM in EEC.

Treatment of lymphocele with negative pressure wound therapy post inguinal mass excision: A case-report

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Safe and effective approach for treating inguinal lymphocele.

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Excision with ligation of lymphatic vessels.

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Negative pressure wound therapy.

Introduction

A lymphocele is defined as an atypical collection of lymphatic fluid not bordered by distinct epithelial lining, which develops in anatomic compartments. Inguinal lymphocele is a common complication of surgery in the inguinal region, with an incidence ranging from 1 to 87 %. This report summarizes the management of an inguinal lymphocele post excision of an inguinal mass.

Presentation of case

Herein, we present a case in which an inguinal lymphocele developed four months post excision of an inguinal mass, which was later diagnosed as lymphoma and treated with iliac chain radiation therapy. The conservative treatment with lymphocele drainage, compression dressing and prophylactic antibiotic was initially implemented. As the patient did not respond to conservative treatment, the surgical strategy consisted of excision of lymphocele associated with lymphatic ducts ligation. Negative pressure wound therapy completed the treatment.

Discussion

Non-surgical treatment of lymphocele developing from lymphatic injure during groin dissection is not rarely unsuccessful. Surgical options include lymphocele excision with either ligation of the lymphatic ducts or lymphatic-venous shunts between afferent lymphatics and the collateral branch of great saphenous vein. Vacuum-assisted closure therapy assists the wound healing process by increasing blood flow, removing inhibiting factors of wound healing and decreasing the bacterial count.

Conclusion

Inguinal lymphocele that is not reabsorbed or does not resolve with conservative treatment should be surgically treated. Lymphocele excision with ligation of lymphatic vessels, followed by negative pressure wound therapy appears to be a safe and effective approach.

Risk factors for lymphatic complications following lymphadenectomy in patients with cervical cancer

Background

The purpose of this study was to evaluate the occurrence of lymphatic complications following pelvic lymphadenectomy (PLA) in patients with cervical cancer.

Methods

A retrospective study of 169 cervical cancer patients was conducted. Lower extremity lymphedema (LEL) was diagnosed using the International Society of Lymphology guidelines, and pelvic lymphocele (PL) was evaluated using trans-vaginal ultrasonography and computed tomography.

Results

The median patient age was 46 years (range: 22-74) and median body mass index was 21.7 kg/m2 (range: 15.7-37.1). The median number of lymph nodes (LNs) removed was 27 (range: 22-74); 94 (55.6%) patients underwent circumflex iliac node (CIN) dissection; 39 (23.1%) patients received adjuvant chemotherapy; and 81 (47.9%) patients received adjuvant postoperative radiotherapy. There were 28 (16.6%) and 32 (18.9%) occurrences of LEL and PL, respectively. In multivariate logistic regression analysis, the number of LNs removed (odds ratio [OR]: 3.37; 95% CI: 1.43-8.54; P = 0.0053) and CIN removal (OR: 3.92; 95% CI: 1.55-11.4; P = 0.0033) were independent risk factors for LEL; however, no risk factors were significantly associated with PL.

Conclusions

Our results demonstrated that CIN removal and the number of LNs removed were significant risk factors for LEL in patients with cervical cancer. However, we did not identify any significant risk factors for PL in this study. We instead speculate that LN dissection itself causes PL. We suggest that establishment of comprehensive PLA without CIN dissection, or use of the sentinel lymph node concept, will prevent the occurrence of lymphatic complications in cervical cancer patients.

Efficacy of a Fibrin Sealant (Tissucol Duo) for the Preventionof Lymphocele after Laparoscopic Pelvic Lymphadenectomy:A Randomized Controlled Trial

STUDY OBJECTIVE

To assess the efficacy of Tissucol Duo (Baxter AG, Vienna, Austria) fibrin sealant in decreasing the incidence of lymphocele (LC) after pelvic laparoscopic lymph node dissection using harmonic shears.

DESIGN

Randomized controlled trial (Canadian Task Force classification level I).

SETTING

Tertiary referral and educational center.

PATIENTS

Seventy-four patients randomized to the use of sealant per hemipelvis.

INTERVENTION

Fibrin sealant.

MEASUREMENTS AND MAIN RESULTS

After bilateral pelvic lymphadenectomy a fibrin sealant was used in 1 hemipelvis but not the other, applied in 41 patients (55.4%) to the left and 33 patients (44.6%) to the right hemipelvis. The primary outcome was the incidence of LC after surgery in symptomatic and asymptomatic patients. Imaging (ultrasound, computed tomography, and magnetic resonance) was performed to detect LC at 3, 6, and 12 months after surgery. Overall, 26 patients (35.1%) developed LC, and 4 were symptomatic (5.4%). Allowing patients to serve as their own treatment group and control, the hemipelvis treated with Tissucol Duo corresponding to the treatment group and that not treated to the control group, LCs were found in 17 (23%) and 14 (19%) cases, respectively, but the difference was not significant. The mean initial LC maximum diameter was 27.1 mm (standard deviaiotn, 35.2), and LCs tended to decrease in size during the first year to a mean of 8.7 mm.

CONCLUSION

Application of Tissucol Duo fibrin sealant after laparoscopic pelvic lymphadenectomy using ultrasonic shears does not decrease the occurrence of symptomatic or asymptomatic LC.

Risk factors, microbiology and management of infected lymphocyst after lymphadenectomy for gynecologic malignancies

Objective

To evaluate risk factors, microbiology and management of infected lymphocysts in patients undergoing systemic lymphadenectomy for gynecological cancer.

Methods

Patients with gynecological cancer who developed postoperative lymphocysts after lymphadenectomy were enrolled between January 2009 and June 2017. The clinical data of infected lymphocysts were analyzed and compared with non-infected lymphocysts. Multivariate analysis of risk factors, the microbiology and therapeutic strategies for infected lymphocysts were also evaluated.

Results

A total of 115 patients out of 619 developed postoperative lymphocysts, the incidence of infected lymphocysts was 4.36%. Infected lymphocysts were more frequently found in patients with combined pelvic and para aortic lymphadenectomy, higher number of resected pelvic lymph nodes, lower level of postoperative serum hemoglobin and higher proportion of neutropenia. The median diameter of infected lymphocysts was significantly larger than non-infected (71.89 vs 38.47 mm, P < 0.001) and a large size (diameter over 60 mm) was identified as an independent risk factor for infected lymphocysts (OR = 3.933, P = 0.017). The microbiology of infected lymphocysts includes gram-positive cocci, gram-negative bacillus and anaerobic bacteria. Percutaneous catheter drainage was successfully performed in 20 patients with infected lymphocysts. 16 of 19 patients with large lymphoceles received combined antibiobics and PCD therapy and showed clinical remission in all cases. Patients with large size infected lymphocysts who received combined therapy experienced a significantly shorter treatment period and lower recurrent rate than those with only antibiotics (P = 0.046, P = 0.018).

Conclusions

The current study demonstrated that a diameter over 60 mm was an independent risk factor for infected lymphocysts. The predominant bacteria originated from the urogenital or skin flora. The combination of PCD with appropriate antibiotics was a convenient and effective therapeutic strategy resulting in a high success rate.

Retroperitoneal drainage versus no drainage after pelvic lymphadenectomy for the prevention of lymphocyst formation in women with gynaecological malignancies

BACKGROUND

This is an updated version of an original Cochrane review published in Issue 6, 2014. Pelvic lymphadenectomy is associated with significant complications including lymphocyst formation and related morbidities. Retroperitoneal drainage using suction drains has been recommended as a method to prevent such complications. However, findings from recent studies have challenged this policy.

OBJECTIVES

To assess the effects of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy on lymphocyst formation and related morbidities in women with gynaecological cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2017) in the Cochrane Library, electronic databases MEDLINE (1946 to March Week 2, 2017), Embase (1980 to 2017 week 12), and the citation lists of relevant publications. We also searched the trial registries for ongoing trials on 20 May 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the effect of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy in women with gynaecological cancer. Retroperitoneal drainage was defined as placement of passive or active suction drains in pelvic retroperitoneal spaces. No drainage was defined as no placement of passive or active suction drains in pelvic retroperitoneal spaces.

DATA COLLECTION AND ANALYSIS

We assessed studies using methodological quality criteria. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We examined continuous data using mean difference (MD) and 95% CI.

MAIN RESULTS

Since the last version of this review, we have identified no new studies for inclusion. The review included four studies with 571 women. Regarding short-term outcomes (within four weeks after surgery), retroperitoneal drainage was associated with a comparable rate of overall lymphocyst formation when all methods of pelvic peritoneum management were considered together (2 studies; 204 women; RR 0.76, 95% CI 0.04 to 13.35; moderate-quality evidence). When the pelvic peritoneum was left open, the rates of overall lymphocyst formation (1 study; 110 women; RR 2.29, 95% CI 1.38 to 3.79) and symptomatic lymphocyst formation (2 studies; 237 women; RR 3.25, 95% CI 1.26 to 8.37) were higher in the drained group. At 12 months after surgery, the rates of overall lymphocyst formation were comparable between the groups (1 study; 232 women; RR 1.48, 95% CI 0.89 to 2.45; high-quality evidence). However, there was a trend toward increased risk of symptomatic lymphocyst formation in the group with drains (1 study; 232 women; RR 7.12, 95% CI 0.89 to 56.97; low-quality evidence).

AUTHORS' CONCLUSIONS

Placement of retroperitoneal tube drains has no benefit in the prevention of lymphocyst formation after pelvic lymphadenectomy in women with gynaecological malignancies. When the pelvic peritoneum is left open, the tube drain placement is associated with a higher risk of short- and long-term symptomatic lymphocyst formation. We found the quality of evidence using the GRADE approach to be moderate to high for most outcomes, except for symptomatic lymphocyst formation at 12 months after surgery, and unclear or low risk of bias.

Optimal timing for drainage of infected lymphocysts after lymphadenectomy for gynecologic cancer

BACKGROUND

A lymphocyst (lymphocele) is a common complication of lymphadenectomy, which is a widely used surgical method for gynecologic cancers. In cases of infected lymphocysts, therapeutic strategies, including the timing and duration of antibiotics administration and cyst drainage, may vary depending on the physician. The aim of this study was to determine the optimal timing for drainage of lymphocysts infected with bacteria resistant to antibiotic treatment.

MATERIALS AND METHODS

Clinical data for 1175 patients who underwent a lymphadenectomy as part of surgery for a gynecologic malignancy between April 2000 and August 2012 at Osaka University Hospital, Osaka, Japan, were analyzed.

RESULTS

Of the 282 patients who developed a lymphocyst (24%), 35 with infected lymphocysts (12%) were analyzed. Lymphocyst infection was not associated with tumor origin, type of hysterectomy, or region of lymphadenectomy (P = 0.81, P = 0.59, and P = 0.86, respectively). The total treatment period of cases treated only with antibiotics tended to be shorter than that of cases treated with combined antibiotics and drainage, but the difference was not significant (P = 0.061). However, for severe cases which needed drainage, initiating the drainage by day 5 significantly shortened the total treatment period compared with cases started on or after day 6 (P = 0.042).

CONCLUSIONS

The appropriate time point for initiating lymphocyst drainage has been difficult to determine. The present study implies that for severe lymphocyst infections, where drainage is required in addition to antibiotics, the earlier the drainage is performed, the shorter the treatment period is. Further studies may be required to decide other optimal treatment strategies for infected lymphocysts.

Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device

OBJECTIVE

A number of new techniques have been developed to prevent lymphocele formation after pelvic lymphadenectomy in gynecologic cancers. We assessed whether the electrothermal bipolar vessel sealing device (EBVSD) could decrease the incidence of postoperative lymphocele secondary to pelvic lymphadenectomy.

METHODS

A total of 321 patients with gynecologic cancer underwent pelvic lymphadenectomy from 2005 to 2011. Pelvic lymphadenectomy without EBVSD was performed in 134 patients, and pelvic lymphadenectomy with EBVSD was performed in 187 patients. We retrospectively compared the incidence of lymphocele and symptoms between both groups.

RESULTS

Four to 8 weeks after operation, 108 cases of lymphocele (34%) were detected by computed tomography scan examination. The incidence of lymphocele after pelvic lymphadenectomy was 56% (75/134) in the tie ligation group, and 18% (33/187) in the EBVSD group. We found a statistically significant difference in the incidence of lymphocele between both groups (p<0.01). To detect the independent risk factor for lymphocele development, we performed multivariate analysis with logistic regression for three variables (device, number of dissected lymph nodes, and operation time). Among these variables, we found a significant difference (p<0.001) for only one device.

CONCLUSION

Use of the EBVSD during gynecological cancer operation is useful for preventing the development of lymphocele secondary to pelvic lymphadenectomy.

Retroperitoneal drainage versus no drainage after pelvic lymphadenectomy for the prevention of lymphocyst formation in patients with gynaecological malignancies

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 1, 2010. Pelvic lymphadenectomy is associated with significant complications including lymphocyst formation and related morbidities. Retroperitoneal drainage using suction drains has been recommended as a method to prevent such complications. However, this policy has been challenged by the findings from recent studies.

OBJECTIVES

To assess the effects of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy on lymphocyst formation and related morbidities in gynaecological cancer patients.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 12) in The Cochrane Library, electronic databases MEDLINE (Nov Week 3, 2013), EMBASE (2014, week 1), and the citation lists of relevant publications. The latest searches were performed on 10 January 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the effect of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy in gynaecological cancer patients. Retroperitoneal drainage was defined as placement of passive or active suction drains in pelvic retroperitoneal spaces. No drainage was defined as no placement of passive or active suction drains in pelvic retroperitoneal spaces.

DATA COLLECTION AND ANALYSIS

We assessed studies using methodological quality criteria. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We examined continuous data using mean difference (MD) and 95% CI.

MAIN RESULTS

Since the last version of this review, no new studies have been identified for inclusion. The review included four studies with 571 participants. Considering the short-term outcomes (within four weeks after surgery), retroperitoneal drainage was associated with a comparable rate of overall lymphocyst formation when all methods of pelvic peritoneum management were considered together (two studies, 204 patients; RR 0.76, 95% CI 0.04 to 13.35). When the pelvic peritoneum was left open, the rates of overall lymphocyst formation (one study, 110 patients; RR 2.29, 95% CI 1.38 to 3.79) and symptomatic lymphocyst formation (one study, 137 patients; RR 3.25, 95% CI 1.26 to 8.37) were higher in the drained group. At 12 months after surgery, the rates of overall lymphocyst formation were comparable between the groups (one study, 232 patients; RR 1.48, 95% CI 0.89 to 2.45). However, there was a trend toward increased risk of symptomatic lymphocyst formation in the group with drains (one study, 232 patients; RR 7.12, 95% CI 0.89 to 56.97). The included trials were of low to moderate risk of bias.

AUTHORS' CONCLUSIONS

Placement of retroperitoneal tube drains has no benefit in prevention of lymphocyst formation after pelvic lymphadenectomy in patients with gynaecological malignancies. When the pelvic peritoneum is left open, the tube drain placement is associated with a higher risk of short and long-term symptomatic lymphocyst formation.

Lymphocele Prevention After Pelvic Laparoscopic Lymphadenectomy by a Collagen Patch Coated With Human Coagulation Factors: A Matched Case-Control Study

Objective

Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy.

Materials and Methods

The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration.

Results

The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request.

Conclusions

In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

Lower-limb drainage mapping for lymphedema risk reduction after pelvic lymphadenectomy for endometrial cancer

OBJECTIVES

Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique.

METHODS

This prospective study included patients with endometrial cancer requiring pelvic lymphadenectomy, without neoadjuvant radiotherapy or chemotherapy and without history of lower-limb surgery. A radiopharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection, then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis.

RESULTS

Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral, and pelvic LLDNs (detection rate: 100%). The intraoperative detection rate was 83% (10/12). Median number of hot nodes per patient was 5 nodes (range: 3-7) on the right and 3 nodes (range: 2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial groups. None of the patients had node metastases at any site. No early complications related to the technique occurred.

CONCLUSION

Our mapping technique appears feasible, safe, and associated with a high LLDN identification rate. LLDN mapping may allow the preservation of LLDNs, thereby decreasing the risk of lower-limb lymphedema and improving quality of life.

Complications of lymphadenectomy for gynecologic cancer

INTRODUCTION

Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies.

METHODS

Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL.

RESULTS

We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25-45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5-18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02-0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2-16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL.

CONCLUSION

Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.

Lymphoceles, lymphorrhea, and lymphedema after laparoscopic and open endometrial cancer staging

PURPOSE

To evaluate the incidence of lymphoceles, lymphorrhea, and lymphedema after systematic pelvic lymphadenectomy in patients who underwent laparoscopic or open abdominal staging for endometrial cancer.

METHODS

A total of 138 consecutive women who underwent systematic laparoscopic pelvic lymphadenectomy for endometrial cancer staging were compared to 123 historical control subjects staged via an open approach. Postoperative screening for lymphadenectomy-related complications by ultrasound was consistently performed.

RESULTS

The incidence of perioperative complications was lower in cases than in control subjects. Overall, lymphoceles were diagnosed in 19 (15.4%) and 2 (1.4%) patients who had open and laparoscopic staging, respectively (odds ratio 12.42; 95% confidence interval 2.82-54.55; P < 0.0001). Symptomatic lymphoceles were more frequent after open staging than after laparoscopy (P = 0.028). Lymphorrhea occurred in 1 and 4 patients after laparoscopic and open surgery (P = 0.19). No difference in the incidence of lymphedema was observed.

CONCLUSIONS

Our findings suggest that laparoscopic endometrial cancer staging is associated with a lower occurrence of both asymptomatic and symptomatic lymphoceles compared to open surgery.

Robot-assisted removal of a lymphocyst causing severe neuralgic pain and adductor atrophy

Following a robot-assisted radical hysterectomy and pelvic lymphadenectomy for early-stage cervical cancer, a 53-year-old woman was diagnosed with a 50-mm right-sided pelvic lymphocyst by the use of vaginal ultrasonography. She gradually developed intermittent increasingly severe neuralgic pain mimicking a meralgia paresthetica. A neurolysis was proposed by the neurosurgeons. Awaiting this intervention, a pelvic MRI revealed a partial atrophy of the ipsilateral adductor muscles and a probable entrapment of the obturator nerve by the lymphocyst as an alternative cause of the pain. Using a four-arm da Vinci-S-HD robot the lymphocyst, located deep in the right obturator fossa and surrounding the obturator nerve, was completely removed, sparing the partially atrophic obturator nerve. No bleeding occurred. The surgery time was 95 min. At 10 months' follow-up the patient was relieved of her pain with no signs of a new lymphocyst.

A randomized study comparing the use of the Ligaclip with bipolar energy to prevent lymphocele during laparoscopic pelvic lymphadenectomy for gynecologic cancer

OBJECTIVE

This prospective randomized pilot study compared the use of the Ligaclip (Ethicon Endo-Surgery, Cincinnati, OH) with bipolar coagulation in preventing lymphoceles after laparoscopic pelvic lymphadenectomy for gynecologic cancer.

STUDY DESIGN

Thirty patients with gynecologic malignancy, who had laparoscopic pelvic lymphadenectomy were randomly assigned for lymphadenectomy in 1 side of the pelvis using the Ligaclip, whereas, in the other side, the bipolar coagulation to seal lymphatic vessels was used.

RESULTS

At ultrasound examination, we detected lymphocele in 10 patients (33%). Lymphocele developed in 9 (30%) patients on the side where laparoscopic pelvic lymphadenectomy was perfomed using bipolar coagulation, and in 1 (3.3%) patient on the side where laparoscopic pelvic lymphadenectomy was performed using the Ligaclip. Univariate analysis revealed that the Ligaclip's use compared with electrocoagulation in the laparoscopic pelvic lymphadenectomy is an independent predictive factor for development of lymphocele (P = .006).

CONCLUSION

This study demonstrates that the use of the Ligaclip to close lymphatic vessels may reduce the incidence of lymphoceles in patients undergoing laparoscopic pelvic lymphadenectomy.

Retroperitoneal drainage versus no drainage after pelvic lymphadenectomy for the prevention of lymphocyst formation in patients with gynaecological malignancies

BACKGROUND

Pelvic lymphadenectomy is associated with significant complications including lymphocyst formation and related morbidities. Retroperitoneal drainage using suction drains has been recommended as a method to prevent such complications. However, this policy has been challenged by the findings from recent studies.

OBJECTIVES

To assess the effects of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy on lymphocyst formation and related morbidities in gynaecological cancer patients.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2009) in The Cochrane Library, electronic databases (MEDLINE, EMBASE), and the citation lists of relevant publications. The latest searches were performed on 14 May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the effect of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy in gynaecological cancer patients. Retroperitoneal drainage was defined as placement of passive or active suction drains in pelvic retroperitoneal spaces. No drainage was defined as no placement of passive or active suction drains in pelvic retroperitoneal spaces.

DATA COLLECTION AND ANALYSIS

We assessed studies using methodological quality criteria. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We examined continuous data using weighted mean difference (WMD) and 95% CI.

MAIN RESULTS

Considering the short-term outcomes (within four weeks after surgery), retroperitoneal drainage was associated with a comparable rate of overall lymphocyst formation when all methods of pelvic peritoneum management were considered together (two studies, 204 patients; RR 0.76, 95% CI 0.04 to 13.35). When the pelvic peritoneum was left open, the rates of overall lymphocyst formation (one study, 110 patients; RR 2.29, 95% CI 1.38 to 3.79), and symptomatic lymphocyst formation (one study, 137 patients; RR 3.25, 95% CI 1.26 to 8.37) were higher in the drained group. At 12 months after surgery, the rates of overall lymphocyst formation were comparable between the groups (one study, 232 patients; RR 1.48, 95% CI 0.89 to 2.45). However, there was a trend toward increased risk of symptomatic lymphocyst formation in the group with drains (one study, 232 patients; RR 7.12, 95% CI 0.89 to 56.97).

AUTHORS' CONCLUSIONS

Placement of retroperitoneal tube drains has no benefit in prevention of lymphocyst formation after pelvic lymphadenectomy in patients with gynaecological malignancies. When the pelvic peritoneum is left open, the tube drain placement is associated with a higher risk of short and long-term symptomatic lymphocyst formation.

Evaluation of morbidity of suction drains after retroperitoneal lymphadenectomy in gynecological tumors: a systematic literature review

INTRODUCTION

The prophylactic use of closed suction drains after retroperitoneal lymphadenectomy in the management of gynecologic tumors has been widely used to prevent collections of clots or lymph and to avoid infections and postoperative fistulas. The improvement of newer surgical techniques, the use of antibiotic prophylaxis, and the nonclosure of the peritoneum led to the need to reevaluate the use of drains. Retrospective, prospective, and randomized studies did not find differences in the postoperative morbidity between the use and nonuse of drains. Some studies even suggested worse morbidity with the use of drains.

OBJECTIVES

To assess the morbidity of the use of drains compared with no drains in a systematic literature review with aggregate effect measure (meta-analysis).

MATERIALS AND METHODS

Between 1966 and August 2007, 3 independent reviewers analyzed all studies that assessed the use of drains or no drains through a comprehensive literature search of the MEDLINE, EMBASE, and Cochrane Central Databases. Statistical analysis was carried out through the RevMan software.

RESULTS

Of the 285 studies initially reviewed, 11 were selected. Only 4 were considered adequate for group analysis, totaling 571 patients. When assessing outcomes altogether, namely, fever morbidity, symptomatic lymphocysts, deep vein thrombosis, pelvic infection, and fistulas, the relative risk was 1.76 (95% confidence interval, 1.04-3.01) and number necessary to harm was 12.2 referring to the use of drains.

CONCLUSIONS

The prophylactic use of continuous suction drains after retroperitoneal lymphadenectomy in the management of gynecologic tumors should be avoided.

Risk factors for lower limb lymphedema after lymph node dissection in patients with ovarian and uterine carcinoma

Background

Lymph node dissection has proven prognostic benefits for patients with ovarian or uterine carcinoma; however, one of the complications associated with this procedure is lymphedema. We aimed to identify the factors that are associated with the occurrence of lymphedema after lymph node dissection for the treatment of ovarian or uterine carcinoma.

Methods

A total of 694 patients with histologically confirmed ovarian (135 patients) or uterine cancer (258 with cervical cancer, 301 with endometrial cancer) who underwent lymph node dissection were studied retrospectively. Logistic regression analyses were used to identify the risk factors associated with occurrence of lymphedema.

Results

Among ovarian and uterine cancer patients who underwent pelvic lymph node dissection, post-operative radiotherapy (odds ratio: 1.79; 95% confidence interval: 1.20–2.67; p = 0.006) was statistically significantly associated with occurrence of lymphedema.

Conclusion

There was no relationship between any surgical procedure and occurrence of lymphedema among patients undergoing pelvic lymphadenectomy. Our findings are supported by a sound biological rationale because they suggest that limb lymphedema is caused by pelvic lymph node dissection.

Natural history of pelvic lymphocysts as observed by ultrasonography after bilateral pelvic lymphadenectomy

OBJECTIVES

To determine, in patients who have undergone bilateral pelvic lymphadenectomy for gynecological cancer, the incidence of lymphocyst formation, their change in size with time, risk factors and correlation with symptoms.

METHODS

This was a prospective observational study of 108 patients undergoing bilateral pelvic lymphadenectomy for gynecological cancer in our unit. We performed serial three-dimensional (3D) ultrasound assessment at 2 and 6 weeks and 3, 6, 9 and 12 months after surgery. Before each ultrasound assessment, symptoms were recorded and a physical examination was performed.

RESULTS

Forty-eight (44.4%) patients had unilateral or bilateral lymphocysts detected during the follow-up period; 26 were on the left side, 16 were on the right side and six were bilateral. In 39 (81.2%) of the patients, the lymphocysts were first noted 2 weeks after the operation. In nine (18.8%) the lymphocysts persisted until 12 months after surgery. There was no association between lymphocyst formation and diagnosis, type of operation performed, surgeon, operative blood loss, adjuvant radiotherapy and number of lymph nodes removed. Four lymphocysts were detected by physical examination before the ultrasound diagnosis. There was no association between lymphocyst and symptoms, including pain over the abdomen, pelvis, thigh, legs or back, lymphedema, fever or symptoms of cystitis. Only one patient developed an infection of the lymphocyst, which required surgical intervention.

CONCLUSION

Lymphocyst formation is common following bilateral pelvic lymphadenectomy. Most patients with lymphocysts are asymptomatic and the development of major complications is rare.

Randomised trial of drains versus no drains following radical hysterectomy and pelvic lymph node dissection: a European Organisation for Research and Treatment of Cancer-Gynaecological Cancer Group (EORTC-GCG) study in 234 patients

Drainage, following radical hysterectomy and pelvic lymph node dissection to prevent postoperative lymphocyst formation and surgical morbidity, is controversial. To study the clinical significance of drainage, 253 patients were registered and 234 patients were randomised into two arms. In one arm (n=117) postoperative drainage was performed, in the other arm (n=117) no drains were inserted. In both arms closure of the peritoneum of the operating field was omitted. The main exclusion criteria were blood loss of more than 3000 ml during surgery or persistent oozing at the end of the operation. Clinical and ultrasound or CT-scan evaluation was done at one and 12 months postoperatively. The median follow-up amounted to 13.3 months. No difference in the incidence of postoperative lymphocyst formation or postoperative complications was found between the two study arms. The late (12 months) incidence of symptomatic lymphocysts was 3.4% (drains: 5.9%; no drains: 0.9%). The difference showed a p-value of 0.06 in Fisher's Exact test. The operating time was related to the occurrence of postoperative lymphocyst formation. It was concluded that drains can be safely omitted following radical hysterectomy and pelvic node dissection without pelvic reperitonisation in patients without excessive bleeding during or oozing at the end of surgery.

Radiotherapy negates the effect of retroperitoneal nonclosure for prevention of lymphedema of the legs following pelvic lymphadenectomy for gynecological malignancies: an analysis from a questionnaire survey

Using patient questionnaires, we studied the long-term effect of leaving the peritoneum open on the incidence of lymphedema of the legs in patients following pelvic lymphadenectomy for gynecological malignancies. The patients were retrospectively assigned to one of two groups, depending on whether the retroperitoneum was closed or left open at surgery. Three years after surgery, we obtained valid questionnaire responses from 101 patients (43 cervical, 46 endometrial, and 12 ovarian cancers) in the closure group and 83 patients (34 cervical, 40 endometrial, and 9 ovarian cancers) in the nonclosure group. In patients' self-analysis, the overall incidence of lymphedema of the legs was significantly lower in the nonclosure group than in the closure group (25.3% and 50.5%, respectively; P < 0.01). The incidence of lymphedema of the legs was significantly increased by postoperative radiotherapy. Especially in the nonclosure group, the incidence of lymphedema was only 15.8% in patients who did not have radiotherapy, but it increased significantly (44.4%) (P < 0.05) when patients underwent radiotherapy. In conclusion, this questionnaire survey suggested that leaving the retroperitoneum open after lymphadenectomy is significantly effective in reducing the incidence of leg lymphedema, which impairs patients' quality of life more than expected by physicians.

An analysis of the risk factors and management of lymphocele after pelvic lymphadenectomy in patients with gynecologic malignancies

OBJECTIVES

The incidence and risk factors of lymphocele development after pelvic lymphadenectomy were evaluated and its management investigated.

MATERIALS AND METHODS

This retrospective study was carried out on 264 patients who received a pelvic lymphadenectomy, between March 1999 and February 2003, due to gynecologic cancer. The patients were classified into two groups; the lymphocele (n=50) and non-lymphocele groups (n=214), as confirmed by ultrasonography, CT scan and MRI. Each group was compared by cancer type and stage, BMI, preoperative Hb, use of pre/postoperative chemotherapy or radiotherapy, number of resected pelvic lymph nodes and the volume of postoperative drainage from a Hemovac pelvic drain.

RESULTS

Of the 264 patients tested, 15 of 105 cervical cancer (14%), 22 of 115 ovarian cancer (19%) and 11 of 40 endometrial cancer patients (27%), a total of 50 patients (18%), developed lymphoceles. In the lymphocele group (n=50), 13 patients were diagnosed with complicated lymphocele. The BMI and number of resected pelvic lymph nodes were found to be higher in the lymphocele than in the non-lymphocele group (23.94+/-3.38 vs. 22.52+/-3.00, p=0.00 and 26.80+/-14.82 vs. 22.96+/-10.18, p=0.03, respectively), and showed statistical significance. The occurrence of lymphoceles was lower without postoperative radiotherapy (p=0.01).

CONCLUSION

Among the 264 patients, a total of 50 patients (18%) developed lymphoceles. The BMI and number of resected lymph nodes were higher in the lymphocele group, and the use of postoperative radiotherapy was associated with a higher risk of lymphoceles. Thirteen of the 50 patients that developed lymphoceles (n=50) required treatment for lymphocele-related complications.

Pelvic lymphocyst infection associated with maternally inherited diabetes mellitus

A 45-year-old woman with 20-year history of diabetes mellitus was admitted to our hospital because of high fever and abdominal pain. Radical hysterectomy and bilateral pelvic lymphadenectomy had been performed 4 months before admission for invasive cervical cancer. On admission, elastic hard tumors were palpable in the lower abdomen. Laboratory examination showed positive C-reactive protein (CRP), anemia and renal dysfunction. Computed tomography (CT) revealed several lymphocysts in the pelvis. She was diagnosed with infection of pelvic lymphocysts. Since her mother also had diabetes associated with deafness, we examined mitochondrial DNA in leukocytes and detected an A to G transition at the nucleotide position of 3243 (A3243G mutation). She was diagnosed as maternally inherited diabetes mellitus and deafness (MIDD). Puncture of the cysts followed by administration of antibiotics resulted in marked improvement of symptoms and laboratory findings. This is a rare case of pelvic lymphocyst infection in a patient with a mitochondrial disorder. Although the exact mechanism of infection is not clear, MIDD may represent an unusual risk factor for infection, and further investigation is necessary to assess the influence of mitochondrial dysfunction on the immune system. Pelvic lymphocyst infection should be considered in the differential diagnosis of abdominal pain and fever in patients with MIDD after abdominal surgery.

Postsurgical pelvis: treatment follow-up

Imaging for recurrence and complications of gynecologic malignancies following treatment with radical hysterectomy, chemotherapy, and radiation therapy has become an important determinant for treatment options available to patients. MR imaging and computed tomography can be used to provide evidence of limited local disease recurrence and thereby identify disease that is still potentially curable with adjuvant treatments. This article examines the imaging modalities currently used to detect recurrence and assist in making treatment changes for gynecologic malignancies and presents specific patient findings following definitive primary treatment of uterine cancer and ovarian cancer with radical hysterectomy, radiation therapy, or chemotherapy.

Pelvic lymphocele following motor vehicle collision

The development of lymphocele has been described in the mediastinum following thoracic duct injury from blunt trauma or surgery, in lower extremity surgery or trauma, and in the pelvis following renal transplant or staging lymphadenectomy. We describe a case of pelvic lymphocele following blunt trauma from a motor vehicle collision in which the patient did not sustain any fractures. The patient subsequently experienced right lower extremity pain and swelling thought to result from a deep venous thrombosis. Venogram demonstrated external compression of the right iliac vein, and computed tomography revealed a pelvic fluid collection. The patient underwent successful pigtail catheter placement under ultrasound guidance, and his symptoms resolved completely following 4 weeks of external drainage. A brief review of the diagnosis and management of lymphocele follows.

Vascular problems of the pelvis

Vascular tumors of the pelvis are a rare, diverse group of neoplasms. These benign or malignant tumors can arise from the endothelium, smooth muscle cells, or pericytes of the arterial venous or lymphatic walls. They are rarely diagnosed by physical examination but more commonly seen with imaging studies such as computed tomography, magnetic resonance imaging, or angiography. Benign and malignant tumors can be differentiated pathologically by the two major anatomic characteristics of vascular channel formation and the regularity of endothelial cell proliferation. This review will focus on the clinical presentation, diagnosis, treatment, outcomes, and surgical approaches to benign and malignant vascular tumors of the pelvis.

Lymphedema and lymphocysts following lymphadenectomy may be prevented by omentoplasty: A pilot study

OBJECTIVES

Pelvic lymph node dissection as part of the staging surgery for cervical carcinoma interrupts the afferent lymphatics, so the lymph drains retroperitoneally. New surgical techniques designed to leave the peritoneum open after the retroperitoneal dissection, in particular the application of a pedicled omentoplasty along the dissection route, have been advocated to prevent the formation of lymphocysts and lymphedema. We investigated the possible benefit of pedicled omentoplasty in preventing lymphocysts and lymphedema following pelvic lymph node dissection.

METHODS

In this pilot study with historical controls we compared the formation of lymphocysts and lymphedema following two different surgical techniques for pelvic node dissection: group I (historical controls), in which the dorsal peritoneum was left open, and group II, in which the dorsal peritoneum was left open with application of a pedicled omentoplasty. In these two groups of gynecologic patients, we compared the lymph flow patterns and the occurrence of lymphedema following systemic pelvic lymphadenectomy. The two groups were of comparable clinical status and consisted of 12 (group I) and 10 (group II) patients. Lymphocysts, if any, were detected by CT scan, the lymph flow patterns were visualized by dynamic lymphscintography, and lymphedema was visualized by physical examination and magnetic resonance imaging of the groin and the upper leg.

RESULTS

In both groups a distinct intraperitoneal absorption of the lymph fluid was observed. Pedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluid, resulting in less lymphedema in the upper leg.

CONCLUSION

It appeared that leaving the dorsal peritoneum open to give the lymph stream the opportunity to pour into the abdominal cavity is important in preventing lymphocysts and lymphedema. The dynamic lymphscintigraphy described in this paper showed that the intraabdominal lymph flow is absorbed by the peritoneum and even more quickly by the pedicled omentum.

Pelvic lymphocysts following retroperitoneal lymphadenectomy: retroperitoneal partial "no-closure" for ovarian and endometrial cancers

BACKGROUND AND OBJECTIVES

Pelvic lymphocysts have been reported mainly following pelvic lymphadenectomy for cervical cancer. We attempted to assess whether retroperitoneal partial "no-closure" reduces the incidence of lymphocyst formation following retroperitoneal lymphadenectomy.

METHODS

Sixty-one patients with ovarian cancer or endometrial cancer who underwent retroperitoneal lymph node resection were assigned at random to a retroperitoneal partial "no-closure" group or a "closure" group. The incidence of lymphocysts in the two groups as determined using ultrasonography was compared.

RESULTS

Lymphocysts appeared in 23/61 patients (38%) in total. In the "closure" group, the incidence was 52% (16/31), but in the "no-closure" group it was only 23% (7/30); the incidence in the "no-closure" group was significantly lower (P < 0.05). The incidence of postoperative fever was 17% (5/30) in the "no-closure" group, which was lower than that in the "closure" group (42%, 13/31), but not significantly so (P < 0.1). No patients in the "no-closure" group required surgical procedures such as needle aspiration or cyst drainage.

CONCLUSIONS

Retroperitoneal partial "no-closure" appears to be a useful procedure for reducing the incidence of pelvic lymphocysts associated with retroperitoneal lymphadenectomy.

A randomized study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynecologic malignancies

OBJECTIVE

To evaluate the clinical effectiveness of retroperitoneal drainage following lymphadenectomy in gynecologic surgery.

METHODS

One hundred thirty-seven consecutive patients undergoing systematic lymphadenectomy for gynecologic malignancies were randomized to receive (Group A, 68) or not (Group B, 69) retroperitoneal drainage. The pelvic peritoneum and the paracolic gutters were not sutured after node dissection. Perioperative data and complications were recorded.

RESULTS

Clinical and surgical parameters were comparable in the two groups. Postoperative hospital stay was significantly shorter in Group B (P < 0.001), whereas the complication rate was significantly higher in Group A (P = 0.01). This was mainly due to a significant increase in lymphocyst and lymphocyst-related morbidity. Sonographic monitoring for lymphocyst showed free abdominal fluid in 18% of drained and 36% of not-drained patients (P = 0.03). Symptomatic ascites developed in 2 drained (3%) and 3 not-drained (4%) patients (NS), respectively.

CONCLUSIONS

Prophylactic drainage of the retroperitoneum seems to increase lymphadenectomy-related morbidity and postoperative stay. Therefore, routine drainage following lymphadenectomy seems to be no longer indicated when the retroperitoneum is left open.

The role of laparoscopic surgery in gynaecological oncology

Minimal access surgery is here to stay in gynaecological oncology. Within the last three years, rapid strides have been made in applying minimal access surgical techniques to a wide range of gynaecological oncology procedures. The re-assessment of radical vaginal surgery has come largely because of the ease of accessing the pelvic lymph nodes using retroperitoneal and intraperitoneal techniques. An ability to assess the lymph nodes of the pelvis and the para-aortic region prior to definitive therapy is making management of many oncological conditions more logical. Question marks still arise over the place of minimal access surgery in ovarian cancer. A recent study by Professor Gunther Kinderman (Munich) in which, following a postal questionnaire, he identified an unacceptably high rate of laparoscopic interventions in invasive cancer with a parallel unacceptably high rate of metastatic disease, particularly in the port sites, has demonstrated a need for constant vigilance and careful assessment of the application of minimal access surgery in certain areas of oncology. Even while this chapter was in press, Professor Daniel Dargent has shown the possibility of carrying out assessment laparoscopically of the groin lymph nodes using a combination of minimal access surgery and plastic surgical techniques to remove fat. This technique when applied to sentinel node identification may revolutionize our assessment of the groin. Clearly this is an exciting time in gynaecological oncology and many and new inventive applications are being visualized by surgeons throughout the world. When this chapter is rewritten in two years time, inevitably, a considerable part of it will be altered. A glimpse of the future has been seen and we await the full vision with bated breath.

Pelvic and paraaortic lymphocysts after radical surgery because of cervical and ovarian cancer

To determine the incidence and clinical import of lymphocysts after radical gynecologic surgery including lymphadenectomy, we reviewed the records of 173 patients with cervical cancer and 135 patients with ovarian cancer who were followed up by computed tomography. Lymphocysts were found in 35 (20%) and 43 (32%) of the patients, respectively. Patients with cervical cancer and positive lymph nodes had a significantly higher rate of lymphocyst formation than did those with negative nodes (29% versus 14%, respectively, p less than 0.02). Age, type of lymphadenectomy, volume of fluid furthered by postoperative drains, disease stage, and tumor histology were not related to lymphocyst development. We saw no complications strictly attributable to lymphocysts. The clinical import and treatment possibilities are discussed.