Radiologic imaging and percutaneous treatment of pelvic lymphocele

Sclerotherapy of the Post renal Transplant Lymphoceles: A Meta-Analysis

PURPOSE

This study evaluated the effectiveness of sclerotherapy in treating lymphoceles after kidney transplantation, focusing on factors such as recurrence rates and procedural success.

MATERIALS AND METHODS

Retrospective studies using sclerotherapy as the only form of treatment for postrenal transplant lymphoceles were included. All studies used percutaneous transcatheter sclerotherapy as treatment, and the success rate of the intervention was recorded. Sixty-one references were obtained by manually searching the MEDLINE (n = 20), Embase (n = 41), and Cochrane Library databases (n = 0) for retrospective research studies that included the keywords "sclerotherapy post renal transplant lymphoceles." After removing 3 duplicates, 50 of the remaining articles were excluded after the screening, and the remaining studies were extracted for demographic data and our primary outcome of the success rate of sclerotherapy.

RESULTS

A descriptive analysis of the outcomes and complication rates associated with sclerotherapy interventions for lymphoceles is provided. A high degree of variation across the different studies was observed. According to the Kruskal-Wallis test, there was no correlation between the sclerosant used and the sclerotherapy complication rate (P = .472) or the success rate (P = .591). There was also no correlation between the gender of the patient and the success rate; however, there was a significant difference in the complication rate by gender (P < .005).

CONCLUSIONS

In conclusion, different sclerosant products have been used for therapy with no consensus on the most efficacious product because the success rate has been variable. In addition, the gender of the patient may influence the complication rates associated with sclerotherapy for lymphoceles in patients post-kidney transplant.

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

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

ABSTRACT

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

Intranodal Lymphangiography and Embolization for the Treatment of Early Postoperative Lymphatic Leaks after Pelvic Surgery

PURPOSE

To assess outcome and predictors of outcome after lymphatic embolization (LE) for early postoperative lymphatic leak after pelvic surgery.

MATERIAL AND METHODS

Lymphangiography (LG) procedures performed between May 2015 and February 2020 for postoperative intraperitoneal lymphatic leaks after pelvic surgery were reviewed. Treatment indication was lymphatic drainage of >500 mL/d persisting for >1 week. LE was performed by injecting glue into the iliac lymph node. Fisher exact and Wilcoxon rank-sum tests were used for comparative analysis, and logistic regression was used to assess predictors of outcome.

RESULTS

LG was performed in 71 patients. A leak was demonstrated in 69 patients who underwent LE. The mean drainage was 1,329 mL/d ± 773. Catheters were removed in 49 (69.0%) patients after 1 procedure and in 69 (97.2%) patients after a mean of 1.3 procedures. The mean drainage at the time of catheter removal was 157 mL/d ± 100. Failure occurred in 12 (16.9%) cases, including 2 (2.8%) cases of unsuccessful catheter removal and 10 (14.1%) cases of catheter reinsertion owing to recurrent ascites (n = 3) and lymphoceles (n = 7). Older age and drainage of >1,500 mL/d were associated with failure (P = .004). Drainage of >1,500 mL/d was associated with a post-LE catheter dwell time of longer than 1 week (P = .024). Minor adverse events were noted in 4 (5.6%) patients who presented with transient leg swelling.

CONCLUSIONS

LE was effective for treating pelvic surgery-related lymphatic leaks. Reintervention may be required. Drainage of >1,500 mL/d was associated with clinical failure and a post-LE catheter dwell time of longer than 1 week.

Percutaneous sclerotherapy with OK-432 for lymphocele after pelvic or para-aortic lymphadenectomy: preliminary results

BACKGROUND

Lymphoceles can result from disruption of lymphatic vessels after surgical procedures in areas with extensive lymphatic networks. Percutaneous catheter drainage with sclerotherapy can be performed for the treatment of lymphoceles. OK-432 has been used to treat benign cysts, such as lymphangioma and ranula. Therefore, we aimed to report the efficacy and safety of sclerotherapy using OK-432 for postoperative lymphoceles. This study retrospectively analyzed 16 patients who underwent sclerotherapy using OK-432 for postoperative pelvic and para-aortic lymphoceles between April 1, 2012, and March 31, 2020. All the patients underwent percutaneous drainage before sclerotherapy. The indications for sclerotherapy were persistent drainage tube output of greater than 50 mL per day and recurrent lymphoceles after percutaneous drainage. If less than 20 mL per day was drained after sclerotherapy, the tube was removed. When the drainage tube output did not decrease to less than 20 mL per day after the first sclerotherapy, the second sclerotherapy was performed 1 week later. Technical success was defined as the completion of drainage and sclerotherapy procedures. Clinical success was defined as the resolution of the patient's symptoms resulting from lymphoceles without surgical intervention. This study also evaluated the complications of sclerotherapy and their progress after sclerotherapy.

RESULTS

The mean initial lymphocele size and drainage duration after sclerotherapy were 616 mL and 7.1 days, respectively. The technical success rate and clinical success rate were 100% and 93%, respectively. Thirteen patients were treated by one-session sclerotherapy and three patients were treated by two-session sclerotherapy. Minor complications (fever) were observed in eight patients (50%). A major complication (small bowel fistula) was observed in one patient (7%). No recurrence of lymphoceles was observed during the mean follow-up period of 17 months.

CONCLUSION

Sclerotherapy with OK-432 is an effective therapeutic method for postoperative lymphoceles. Although most complications are minor, a small bowel fistula was observed in one patient.

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

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

Lymphatic Interventions in the Cancer Patient

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Supermicrosurgical lymphatic venous anastomosis for intractable lymphocele after great saphenous vein harvesting graft

Lymphoceles result from either trauma to the lymphatic vessels or after vein graft harvest, which occurs in 10% to 16% of patients. When a lymphocele persists despite conservative treatment, patients can experience undue distress. We have reported the case of successful treatment using lymphatic venous anastomosis (LVA) of an intractable lymphocele that had been refractory to conservative treatment, including stretch bandaging, drainage, and local injection for 2 years after great saphenous vein harvest. The lymphocele resolved shortly after the LVA without any adverse effects. LVA can be a useful and minimally invasive alternative treatment of lymphocele after harvesting the great saphenous vein.

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

MATERIALS AND METHOD

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

CITATION FORMAT

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

Lymphadenectomy in endometrial cancer - achieving more with less?

The lymph node status of patients with endometrial cancer is known to be a crucial determinant for the prognosis of the disease. It also provides the indication for further adjuvant treatment. The staging of endometrial cancer by surgery has been a controversial issue for more than 30 years. The significant complication rate after lymphadenectomy and the development of minimally invasive surgery have led to the use of sentinel lymph node (SLN) mapping. In the present review, we present the development of surgical staging procedures in patients with endometrial cancer and summarize the recently expanding body of published literature on the subject. SLN mapping is a safe and accurate technique, especially when indocyanine green is used as a tracer. SLN mapping appears to reduce complication rates as well as costs without affecting the oncologic outcome. Large prospective studies are needed to establish the effects of SLN mapping on the outcome of disease, especially in high-risk patients with endometrial cancer. Furthermore, the need for additional systematic lymphadenectomy prior to adjuvant radio-chemotherapy in patients diagnosed with isolated lymph node metastasis during SLN biopsy must be investigated further. This might pave the way for a new surgical approach in patients with endometrial cancer.

Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chylous Ascites and Lymphoceles: Evaluation and Interventions

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

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.

Contemporary lymphatic interventions for post-operative lymphatic leaks

Post-operative lymphatic injuries are uncommon but increase morbidity and mortality in vulnerable patient populations. Post-surgical lymphatic leaks are most commonly a consequence of radical neck dissection, esophagectomy, and lung cancer resections or retroperitoneal surgeries such as radical nephrectomy and lymphadenectomy. Injury may occur anywhere along the lymphatic chains with most serious leaks occurring along the axial skeleton between the inguinal region and the left venous angle. The resultant clinical manifestations of a lymphatic leak are dependent on the location and severity of the lymphatic injury as well as patient factors. Treatment strategies are tailored toward the causative etiology, symptom severity, and daily leak volume with higher volume leaks warranting a more aggressive approach. Lymphangiography and lymphatic interventions, such as embolization, are increasingly applied for both the diagnosis and as a minimally invasive therapy for lymphatic injuries. Herein, a review of lymphatic anatomy, lymphangiography, and lymphatic interventions for the treatment of post-operative chylothorax, chylous ascites, and lymphocele is presented.

Polidocanol echosclerotherapy treatment for lymphocele: case report and review

Formation of lymphocele secondary to transection of lymphatic channels during surgical procedures or traumas is relatively common and is reported in the postoperative period of approximately 30% of lymph node resection procedures. The condition may be asymptomatic or can present with complications such as pain, secondary infection, and compression of blood vessels, which can cause stasis, thrombosis, and edema. There is no consensus on treatment. This article describes three cases in which treatment was provided using polidocanol echosclerotherapy. Its relevance lies in the scarcity of reports in the literature.

The Efficacy of Lymph Node Embolization Using N-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery

PURPOSE

To compare the efficacy of lymph node (LN) embolization using N-butyl cyanoacrylate versus ethanol sclerotherapy in the management of symptomatic postoperative pelvic lymphorrhea.

MATERIALS AND METHODS

Thirty-three patients with 40 instances of symptomatic postoperative lymphorrhea were treated with either LN embolization or sclerotherapy at Seoul National University Hospital from January 2009 to July 2017 and were retrospectively included (LN embolization group: 24 lymphoceles of 19 patients, mean age of 59.29 years; sclerotherapy group: 16 lymphoceles of 14 patients, mean age of 60.95 years). The types of operations were hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9), radical prostatectomy (n = 3), and renal transplantation (n = 2) for the sclerotherapy group and radical prostatectomy (n = 10) and hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9) for the LN embolization group. The 3 most common indications of treatment were lower extremity edema (n = 11), pain (n = 11), and fever (n = 8). The amount of leak before treatment (initial daily drainage) and clinical outcomes, including the clinical success rate in 3 weeks, treatment period, and complication rate were compared between both groups.

RESULTS

LN embolization showed a higher 3-week clinical success rate than sclerotherapy in a univariate analysis (83.3% and 43.8%, P = .026). There was no statistically significant difference in the treatment period and the complication rate (7.1 days and 12.3 days, P = .098; 8.3% and 25.0%, P = .184).

CONCLUSIONS

LN embolization is more effective for treating postoperative pelvic lymphorrhea than sclerotherapy with similar safety.

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

PURPOSE

To retrospectively evaluate the short-term outcomes of lymphangiography and lymphatic embolization in the treatment of pelvic lymphocele after radical prostatectomy in patients with prostate cancer.

MATERIALS AND METHODS

The data of nine, consecutive patients who underwent lymphangiography and lymphatic embolization for pelvic lymphocele after radical prostatectomy with pelvic lymph node dissection (PLND) between January 2016 and May 2018, were retrospectively reviewed. Lymphangiography was performed through inguinal lymph nodes in order to identify the lymphatic leakage. When a leakage was found, lymphatic embolization was performed using a directly punctured fine needle at the closest upstream lymph node or lymphopseudoaneurysm and with N-butyl cyanoacrylate glue.

RESULTS

Lymphangiography demonstrated extravasation and/or lymphopseudoaneurysm in all of these patients. A total of 13 sessions of lymphangiography and lymphatic embolization were performed. The median number of lymphangiography and lymphatic embolizations required to achieve clinical success was one (range, 1-3). Three patients underwent repeated embolization with successful results. The technical and clinical success rates were 100%, respectively. The median time to resolution was 7 days (range, 2-19 days). There was no recurrence and no procedure-related complications during the follow-up period (mean, 26 weeks; range, 8-77 weeks) in all patients.

CONCLUSIONS

Lymphangiography and lymphatic embolization are safe and effective for the management of pelvic lymphoceles after radical prostatectomy with PLND.

Ultrasound characteristics of a symptomatic and asymptomatic lymphocele after pelvic and/or paraaortic lymphadenectomy

OBJECTIVE

To describe the sonographic characteristics of a lymphocele after pelvic and/or paraaortic lymphadenectomy for gynecological malignancy, analyze and identify ultrasound characteristics related to the symptomatic and asymptomatic lymphoceles.

MATERIALS AND METHODS

This is a retrospective analysis of ultrasound examination data collected consecutively in patients after pelvic and/or paraaortic lymphadenectomy in one institution. We recorded the number of lymphoceles, localization, size; ultrasound morphology following International Ovarian Tumor Analysis group classification and symptoms.

RESULTS

We described and analyzed 227 lymphoceles (150 asymptomatic and 77 symptomatic) in 161 patients. The asymptomatic lymphocele is typically a thick-walled cystic lesion without vascularization, round and unilocular with anechoic or ground-glass content. The symptomatic lymphocele is typically an oval, or ovoid, unilocular lesion with low-level or anechoic content (ground glass content is unlikely to be present, p < 0.001) and the presence of debris and septations. The lymphocele size (p = 0.001), number of lymphoceles (>1) (p = 0.005), septa (p = 0.002), and debris (p < 0.001) were independent ultrasound features correlating to symptoms development. More than one lymphocele (p = 0.047), septations (p = 0.007) and presence of debris (p < 0.001) were independent ultrasound features correlated to infection.

CONCLUSION

Ultrasound features of symptomatic and asymptomatic lymphocele differ. The clues for lymphocele differential diagnosis are the history of lymphadenectomy and the finding cystic lesion with typically ultrasound features of lymphocele, adjacent to great pelvic vessels. Unique ultrasound features of lymphocele may help to distinguish from tumor relapse, hematoma, abscess, seroma or urinoma.

CT-guided procedures: an initial experience

Background and aims

Despite their usefulness, CT-guided procedures have a low profile in Romania. The current study has the purpose of describing a first experience in performing these procedures.

Methods

Tumors and fluid collections that were inaccessible for biopsy or drainage by ultrasound or endoscopic guidance were included. The procedures were performed using a 64-slice GE Optima CT660 CT scanner. The biopsies were carried out using the coaxial technique with an 18 G semiautomatic needle. The drainages were performed using 10 F pig-tail drains that were inserted using the Seldinger technique. Data regarding the size and location of the target lesion, puncture technique, success and complication rates were recorded.

Results

Between May 2017 and April 2018, 30 procedures were performed, of which 26 biopsies and 4 drainage insertions. Of the biopsies 3 were mediastinal, 8 pulmonary, 6 retroperitoneal, 4 pelvic, and 5 of the bone. The drainages were performed for pelvic lymphoceles. The average lesion size was 3.2 cm (0.7–9 cm), with a depth from the skin of 9.1 cm (0.6–15.2 cm). The average procedure duration was 58 minutes (31–93 minutes). A conclusive histopathological diagnosis was set after 92.3% of biopsies. Three procedures resulted in complications, two being minor (hemothorax, soft tissue hematoma) and one severe (tension pneumothorax requiring drainage).

Conclusions

CT guidance offers safe access to lesions that cannot be biopsied or drained under ultrasound or endoscopic guidance.

Management of Chyloretroperitoneum After Lumbar Surgery by Anterior Approach

BACKGROUND

Anterior lumbar approach, routinely used in spinal surgery, provides many advantages, specifically avoidance of manipulation and potential injury to nervous system structures; it also provides indirect central and foraminal decompression, with a complication rate of 1%-3%. Chyloretroperitoneum is a rare complication of spinal procedures using anterior lumbar approach. The aim of this study was to discuss diagnosis, treatment, and management of chyloretroperitoneum based on review of the international literature through 2017.

METHODS

The literature review was conducted using the terms "chyloretroperitoneum," "spinal surgery," and "lymphocele." Additionally, an illustrative case of chyloretroperitoneum following anterior retroperitoneal lumbar approach was presented.

RESULTS

In 33 cases, including the present case, clinical symptoms appeared after discharge in 75.8% (n = 25) and reflected direct mass effect. Abdominopelvic computed tomography permitted assessment of the fluid collection observed as a hypodense collection around the psoas muscle. In 24 cases, drainage of the chyloretroperitoneum was maintained for a mean duration of 2.9 days. Surgery was performed in 14 patients (42.4%) owing to lymphatic collection. In 5 cases, surgery was performed for direct lymphatic vessel treatment. Laparoscopic marsupialization of the collection and peritoneal fenestration were performed, especially after percutaneous drainage failure.

CONCLUSIONS

Computed tomography was the most useful imaging modality for diagnosis and assessment of associated complications. If puncture alone is not sufficient and should be avoided, percutaneous computed tomography-guided drainage with sclerosing agent administration appears to be a safe and efficient first-line treatment. Laparoscopic fenestration should be used in cases of complicated or recurrent lymphoceles.

Laparoscopic management of retroperitoneal lymphocoele: A late complication of laparoscopic presacral neurectomy

This is the first case report of a symptomatic retroperitoneal lymphocoele formation occurring a decade after laparoscopic presacral neurectomy successfully managed by laparoscopic surgery.

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.

Intranodal Glue Embolization for the Management of Postsurgical Groin Lymphocele and Lymphorrhea

This report describes intranodal lymphatic embolization for treatment of groin lymphatic leaks following surgery or percutaneous vascular interventions. In 10 consecutive patients with groin lymphatic leak between 2015 and 2017, lymphangiography with embolization was performed by intranodal injection with dilute N-butyl cyanoacrylate (NBCA). Mean volume of dilute NBCA (1:3 with ethiodized oil) injected was 1 mL. Clinical success rate was 80%. Median time to resolution was 7 days. Intranodal lymphatic embolization for treatment of groin lymphatic leaks is a safe and effective treatment alternative to surgery resulting in a rapid time to resolution.

An unusual localization of seven months delayed pelvic lymphocele following radical retropubic prostatectomy: Case report and literature review

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Lymphocele after radical prostatectomy leading major complications is rare.

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Lymphocele is the most common cause of hospital readmission after radical prostatectomy.

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Lymphocele can be seen in atypical regions after radical prostatectomy.

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Percutaneous interventions can be used for pelvic lymphocele treatment.

Introduction

A pelvic lymphocele is a collection of lymphatic fluid that develops after extensive lymphadenectomies in surgeries such as urological malignancies or renal transplantation. Pelvic lymphoceles may cause complications such as fever, abdominal pain, leg swelling, genital swelling and flank pain. This report summarizes the management of a pelvic lymphocele after open radical retropubic prostatectomy with bilateral lymphadenectomy.

Presentation of case

Herein, we present a case in which a pelvic lymphocele developed seven months post-radical open retropubic prostatectomy and through this patient we discussed the lymphocele following radical prostatectomy. The pelvic lymphocele occurred along the sciatic nerve from the sciatica foramen to the intergluteal muscles. The patient was treated with three drainage catheters. This localization is an atypical and unusual for lymphocele after radical retropubic prostatectomy.

Discussion

Lymphocele formation that leads to major complications after radical prostatectomy is rare. Lymphocele formation is most commonly seen in the early postoperative period, but it should be considered in patients with fever, abdominal pain or leg swelling during the late postoperative period. Lymphocele formation was the most common cause of hospital readmission after radical prostatectomy.

Conclusion

Lymphocele formation can be seen in atypical regions and can lead to unexpected complications after radical prostatectomy. Therefore, it should be brought to mind when complaints such as fever and lower extremity swelling occurred in patients underwent extensive lymph node dissection. Surgical treatment options are available, but percutaneous interventions can also be used.

A successful case of a para-aortic lymphocele treated with autologous peripheral blood injection

A lymphocele is one of the complications of systematic pelvic or para-aortic lymphadenectomy. Although most patients are entirely asymptomatic, our patient exhibited an obstructive ileus at the jejunum compressed by a lymphocele. We report here a case of a subsequent para-aortic lymphocele treated with autologous peripheral blood injection. A 68-year-old woman with sigmoid colon cancer (T3N2bM1a) underwent laparoscopic sigmoidectomy. After 4 courses of chemotherapy (CapeOX + Bmab), para-aortic lymphadenectomy was additionally performed. One month later, an obstructive ileus occurred suddenly due to a lymphocele. A drainage catheter was placed into the lymphocele and a total of 35 mL of autologous peripheral blood was injected in 4 divided doses through the catheter. The volume of the lymphocele gradually reduced and the ileus improved after blood injection. This is the first report of a successful case of a subsequent para-aortic lymphocele treated with autologous peripheral blood injection without any complications.

Lymphocele Following Liposuction in the Thigh

Lymphocele has not been reported as a complication after liposuction. In this study, we present the case of a patient who developed a cystic lesion after liposuction in her right thigh. The cyst could contract and evolve. The diagnosis of pseudobursa seroma (late seroma) was first considered. However, lymphoscintigraphy showed that lymphatic fluid accumulated in the cyst, and lymphatic vessel connected with it. The final diagnose was a lymphocele. After interventional therapy and conservative treatment failed, the lymphocele was resected. The subcutaneous soft tissue around the cyst was divided into bundles and then ligated with the purpose of blocking lymph leakage from the lymphatic duct.

LEVEL OF EVIDENCE V

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Extraperitoneal laparoscopic resection for retroperitoneal lymphatic cysts: initial experience

BACKGROUND

To assess the safety and efficacy of laparoscopic retroperitoneal resection for retroperitoneal lymphatic cysts.

METHODS

A retrospective analysis was conducted based on clinical data from eight patients with hydronephrosis caused by retroperitoneal lymphatic cysts. All patients underwent laparoscopic retroperitoneal lymphatic cyst resection and received postoperative follow-up. A follow-up ultrasound was performed postoperatively every 6-12 months to evaluate the recovery of the hydronephrosis.

RESULTS

All operations were successful, and their postoperative pathological results revealed lymphatic cyst walls. The operation time ranged from 43 to 88 min (mean: 62 min), with a blood loss of 20 to 130 mL (mean: 76 mL), and the length of hospital stay was 3 to 6 days (mean: 4.5 days). Within the follow-up of 12 to 36 months (mean: 28.5 months), great relief was detected in all eight cases, and no recurrence was found. Moreover, complications such as renal pedicle or renal pelvis injury were not observed.

CONCLUSIONS

Laparoscopic retroperitoneal lymphatic cyst resection is an effective treatment for retroperitoneal lymphatic cysts and has the advantages of being minimally invasive, producing less intraoperative blood loss and leading to a quick recovery. This treatment thus deserves further studies.

Detection and management of retroperitoneal cystic lesions: A case report and review of the literature

The identification of cystic lesions within the retroperitoneal space is a rare event that poses clinicians the challenge of a difficult diagnosis and disease management. Retroperitoneal cystic lesions account for a group of lesions that range from common benign lesions (e.g., lymphoceles developing as a surgical complication) to rare aggressive malignant neoplasms. Currently, in the majority of cases, image-guided procedures allow for a pathological diagnosis to be achieved in these challenging lesions, thus offering the chance of an appropriate treatment; however, the overall clinical assessment of retroperitoneal cysts is highly demanding. The present study reports the management of a representative clinical case, presenting with a voluminous cystic mass able to dislocate cave vein, whose diagnosis was preceded by a deep vein thrombosis. Computed tomography-scan and ultrasound guided percutaneous drainage were performed to achieve the diagnosis. Following the discussion of the current case report, a review of the pathological and radiological characteristics of retroperitoneal cystic lesions is presented.

A review of the postoperative lymphatic leakage

Lymphatic complications are rare, but well-known phenomena, and have been described by many researchers. However, many diagnoses of lymphatic complications are found confusing due to different definition. A literature search in Pubmed was performed for studies postoperative lympatic complications. These complications divided into two parts: lymphatic leakage and lymphatic stasis. This review is about lymphatic leakage, especially, postoperative lymphatic leakage due to the injury of lymphatic channels in surgical procedures. According to polytrophic consequences, many types of postoperative lymphatic leakage have been presented, including lymph ascites, lymphocele, lymphorrhea, lymphatic fistula, chylous ascites, chylothorax, chyloretroperitoneum and chylorrhea. In this review, we focus on the definition, incidence and treatment about most of these forms of lymphatic complications to depict a comprehensive view of postoperative lymphatic leakage. We hold the idea that the method of treatment should be individual and personal according to manifestation and tolerance of patient. Meanwhile, conservative treatment is suitable and should be considered first.

An unusual case of neurogenic thoracic outlet syndrome

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Lymphatic cyst is an unusual cause of neurogenic thoracic outlet syndrome.

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Only one previous case has been reported till date from the United States.

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Surgery is preferred to sclerotherapy, with higher success rates.

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Combined supraclavicular and transaxillary approach provides excellent exposure.

Introduction

Neurogenic thoracic outlet syndrome (nTOS) is the most common manifestation of thoracic outlet syndrome (TOS), accounting for more than 95% of cases. It is usually caused by cervical ribs, anomalies in the scalene muscle anatomy or post-traumatic inflammatory changes causing compression of the brachial plexus.

Case presentation

: We present an unusual case of nTOS caused by a cystic lymphangioma at the thoracic outlet, with only one case reported previously in the literature. We used a combined supraclavicular and transaxillary approach for complete removal, which resulted in excellent recovery of the patient.

Discussion

Though lymphatic cysts may be commonly encountered in surgical practice, compression causing nTOS is extremely rare. The location of the lymphatic cyst with compression of the brachial plexus may provide a challenge for treatment. Surgical excision is the preferred method of management, with higher success rates than sclerotherapy.

Conclusion

Surgical excision to ensure complete removal of the cyst is recommended. Sclerotherapy may be used in cases where complete excision of the cyst wall may not be possible.

Treatment of Post-transplant Lymphocele in Children

OBJECTIVE

To review our single-center experience in managing posttransplant lymphoceles in pediatric kidney recipients. Lymphoceles are well-known complications after pediatric kidney transplantation (KT). However, there is no standard treatment for lymphoceles, and the literature lacks consensus on which is the most appropriate approach.

MATERIALS AND METHODS

We reviewed our retrospective institutional database for recipients of pediatric KT performed between January 2000 and December 2015 who developed lymphoceles.

RESULTS

Out of the 176 patients who underwent KT, lymphoceles occurred in 9 (5.1%) patients. The mean age of recipients in this group was 12.8 years (standard deviation [SD] 4.8) (r: 1-17) and the mean body weight was 43.1 kg (SD 18.8) (r: 9.5-69). Mean lymphocele onset was 32.2 days (SD 23.4) (r: 11-85) post transplantation. Six patients presented with increased serum creatinine from the baseline, whereas 3 patients remained asymptomatic. Ultrasound was the primary diagnostic procedure in all patients. Lymphoceles resolved spontaneously in asymptomatic patients (n = 3), and thus these patients were not further treated. All symptomatic patients (n = 6) were treated: 2 underwent percutaneous catheter drainage and 4 underwent transcatheter sclerotherapy (TS). The main sclerosing agent used was povidone-iodine. In 3 patients, TS with povidone-iodine failed, and they underwent additional procedures: 2 underwent TS with polidocanol and 1 underwent open drainage. There was no graft loss in any of the patients, and no recurrence was documented during a follow-up period of mean 30.3 months (SD 15.6) (r: 7-57).

CONCLUSION

There is no gold-standard treatment for lymphoceles in children, and reports in the literature on the topic are scarce. Percutaneous catheter drainage with or without TS is safe and effective, although it can lengthen hospitalization and increase morbidity.

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.