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Prophylactic Peritoneal Fenestration during Kidney Transplantation Can Reduce the Type C Lymphocele Formation. J Clin Med 2021; 10:jcm10235651. [PMID: 34884352 PMCID: PMC8658067 DOI: 10.3390/jcm10235651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Lymphocele is a common complication following kidney transplantation (KTx). We aimed to evaluate the preventive effect of peritoneal fenestration during KTx in reducing lymphocele. From January 2001, the data of all KTx were prospectively gathered in our digital data bank. From 2008, preventive peritoneal fenestration was performed as a routine procedure for all patients with KTx. Between 2001 and 2008, 579 KTx were performed without preventive peritoneal fenestration. To compare the results between with and without peritoneal fenestration, the same number of patients after 2008 (579 patients) was included in this study. The pre-, intra-, and postoperative data of the patients in these two groups were analyzed and compared, especially regarding the postoperative different types of lymphocele formation. The mean recipient age was 52.6 ± 13.8, and 33.7% of the patients were female. Type C lymphocele was significantly lower in the group with preventive fenestration (5.3% vs. 8.8%, p = 0.014 for 31/579 vs. 51/579). Peritoneal dialysis and implantation of the kidney in the left fossa were independently associated with a higher rate of type C lymphocele (OR 2.842, 95% CI 1.354–5.967, p = 0.006 and OR 3.614, 95% CI 1.215–10.747, p = 0.021, respectively). The results of this study showed that intraoperative preventive peritoneal fenestration could significantly reduce type C lymphocele.
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Pose RM, Knipper S, Würnschimmel C, Tennstedt P, Michl U, Maurer T, Graefen M, Steuber T. Significant reduction of lymphoceles after radical prostatectomy and pelvic lymph node dissection. BJU Int 2021; 128:728-733. [PMID: 34036733 DOI: 10.1111/bju.15497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/23/2021] [Accepted: 05/23/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To reduce the risk of symptomatic lymphocele (SLC), we present a technique using peritoneal fenestration that allows lymphatic fluid to drain into the abdomen, as SLC formation after open retropubic radical prostatectomy (ORP) with pelvic lymph node dissection (PLND) is a common adverse event. PATIENTS AND METHODS We identified 1513 patients who underwent ORP with PLND between July 2018 and November 2019. Of those, 307 patients (20.3%) received peritoneal fenestration and 1206 (79.7%) no fenestration. The rate of LCs and the necessity for intervention were analysed by uni- and multivariable logistic regression (MLR) models. A propensity score matching was performed, as well. RESULTS The median (interquartile range [IQR]) age was 65 (60-70) years. A median (IQR) of 16 (10-22) lymph nodes were dissected, 22 vs 14 lymph nodes in the fenestration vs non-fenestration group (P < 0.001). Overall, 189 patients (12.5%) were diagnosed with a LC after ORP, while 21 patients (6.8%) in the fenestration and 168 (13.9%) in the non-fenestration group had LCs (P = 0.001). In 70 patients (4.7%), LCs required further intervention, categorised as Clavien-Dindo Grade IIIa/b, with a smaller proportion in the fenestration group (2.9% vs 5.0% in the non-fenestration group, P < 0.001). There were no Clavien-Dindo Grade IV or V complications, in particular no abdominal complications in association with peritoneal fenestration observed. In MLR, peritoneal fenestration was associated with a reduced risk of LCs (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.2-0.5; P < 0.001). The risk reduction was also shown after propensity score matching (OR 0.38, 95% CI 0.21-0.68; P = 0.001). The number needed to treat was 14. CONCLUSIONS Peritoneal fenestration may decrease the rate of SLC after ORP with (extended) PLND. Therefore, it should be part of the operative strategy.
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Affiliation(s)
- Randi M Pose
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sophie Knipper
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Würnschimmel
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre Tennstedt
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Michl
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Steuber
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Golriz M, Sabagh M, Mohammadi S, Ghamarnejad O, Khajeh E, Mieth M, Al-Saeedi M, Diener MK, Mihaljevic AL, Morath C, Zeier M, Kulu Y, Mehrabi A. PREventive effect of FENestration with and without clipping on post-kidney transplantation lymphatic complications (PREFEN): study protocol for a randomised controlled trial. BMJ Open 2020; 10:e032286. [PMID: 33051226 PMCID: PMC7554503 DOI: 10.1136/bmjopen-2019-032286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Peritoneal fenestration is an effective preventive method for reducing the rate of lymphatic complications in kidney transplantation (KTx). The size of the fenestration plays an important role in its effectiveness. A large peritoneal window is no longer indicated, due to herniation and difficulties in performing biopsies. Small preventive fenestration is effective but will be closed too early. The aim of this study is to evaluate whether metal clips around the edges of a small fenestration result in optimal effects with minimum fenestration size. METHODS AND ANALYSIS This trial has been initiated in July 2019 and is expected to last for 2 and a half years. All patients older than 18 years, who receive kidneys from deceased donors, will be included. The kidney recipients will be randomly allocated to either a control arm (small fenestration alone) or an intervention arm (small fenestration with clipping). All fenestrations will be round, maximum 2 cm, and close to the kidney hilum. Clipping will be performed with eight metal clips around the peritoneal window (360°) in every 45° in an oblique position. The primary endpoint is the incidence of symptomatic post-KTx lymphatic complications, which require interventional treatment within 6 months after KTx. Secondary endpoints are intraoperative and postoperative outcomes, including blood loss, operation time, severity grade of lymphocele/lymphorrhea and relative symptoms. ETHICS AND DISSEMINATION This protocol study received approval from the Ethics Committee of the University of Heidelberg (Registration Number S-318/2017). A Standard Protocol Items: Recommendations for Interventional Trials checklist is available for this protocol. The results will be disseminated through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03682627).
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Mohammadsadegh Sabagh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Sara Mohammadi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
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Mihaljevic AL, Heger P, Abbasi Dezfouli S, Golriz M, Mehrabi A. Prophylaxis of lymphocele formation after kidney transplantation via peritoneal fenestration: a systematic review. Transpl Int 2017; 30:543-555. [DOI: 10.1111/tri.12952] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 12/19/2016] [Accepted: 03/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- André L. Mihaljevic
- Department of General, Visceral and Transplantation Surgery; University Hospital Heidelberg; Heidelberg Germany
| | - Patrick Heger
- Department of General, Visceral and Transplantation Surgery; University Hospital Heidelberg; Heidelberg Germany
| | - Sepehr Abbasi Dezfouli
- Department of General, Visceral and Transplantation Surgery; University Hospital Heidelberg; Heidelberg Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery; University Hospital Heidelberg; Heidelberg Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery; University Hospital Heidelberg; Heidelberg Germany
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Prevention and management of lymphocele formation following kidney transplantation. Transplant Rev (Orlando) 2017; 31:100-105. [DOI: 10.1016/j.trre.2016.11.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 11/09/2016] [Indexed: 11/19/2022]
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Zingg T, Teixeira Farinha H, Demartines N, Pascual M, Matter M. A Renal Paratransplant Hernia Causing Complete Small Bowel Obstruction: A Case Report and Review of the Literature. Transplant Proc 2017; 49:210-212. [PMID: 28104139 DOI: 10.1016/j.transproceed.2016.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/22/2016] [Indexed: 11/16/2022]
Abstract
A rare type of acquired internal hernia, the renal paratransplant hernia (RPTH), of which only 11 cases have been reported in the literature so far, can follow renal transplantation. We report a patient who presented with acute abdominal pain and vomiting 6 weeks after renal transplantation in the right iliac fossa. A noncontrast abdominal computed tomography scan showed signs of small bowel obstruction. The patient was taken to the operating room for a midline laparotomy, and RPTH with incarcerated small bowel was diagnosed. The bowel loop was released and found to be viable. The postoperative course was unremarkable. It is unclear whether perioperative peritoneal defects or spontaneous ruptures of lymphoceles into the peritoneal cavity form the basis of this rare type of internal hernia. Surgeons should be aware of this entity and avoid both peritoneal defects and postoperative lymphoceles by paying careful attention to meticulous surgical technique.
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Affiliation(s)
- T Zingg
- Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.
| | - H Teixeira Farinha
- Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - N Demartines
- Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - M Pascual
- Centre de Transplantation d'Organes, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - M Matter
- Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Nelson EW, Gross ME, Mone MC, Hansen HJ, Sheng X, Cannon KM, Alder S. Does ultrasonic energy for surgical dissection reduce the incidence of renal transplant lymphocele? Transplant Proc 2012; 43:3755-9. [PMID: 22172841 DOI: 10.1016/j.transproceed.2011.08.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 08/30/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the difference in post-renal transplant lymphocele rate based on the surgical dissection technique for control of lymphatics by examining the historical case group under the direction of a single, university-based surgeon in a retrospective, cohort study. PATIENTS Five hundred thirty-two consecutive renal transplant patients from January 1994 to December 2009. FINDINGS Of the 532 cases studied, 259 (48.7%) had suture ligation and 273 (51.3%) employed ultrasonic dissection (UD) for control of lymphatics during renal transplantation. There was no difference found in the rate of lymphocele formation, requiring either percutaneous or surgical drainage, when surgical ties (8.9%) were compared to UD (9.2%; P=.999). Logistic regression analysis showed that the odds ratio for developing a lymphocele was independent of surgical dissection technique. Within the logistic analysis, the prediction for lymphocele was increased 3.29 times for pediatric patients (P=.002) and increased 2.97 times for those who received a living donor graft (P=.001), and there was a trend for those with a history of more than one renal transplant of 2.01 times (P=.079). SUMMARY Surgical dissection technique was not a factor in the development of post-renal transplant lymphocele. Younger age, living donor transplant, and repeat transplant status were found to be predictive variables for symptomatic lymphoceles requiring drainage, which may be considered when patients present for posttransplant evaluations for laboratory alterations.
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Affiliation(s)
- E W Nelson
- Department of Surgery, University of Utah, Salt Lake City, Utah 84132, USA.
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Prophylactic Peritoneal Fenestration to Prevent Morbidity After Kidney Transplantation: A Randomized Study. Transplantation 2011; 92:196-202. [DOI: 10.1097/tp.0b013e318220f57b] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Post-kidney transplantation lymphocele due to a lymphatic filariasis. Transplant Proc 2011; 42:2808-12. [PMID: 20832594 DOI: 10.1016/j.transproceed.2010.04.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Revised: 12/20/2009] [Accepted: 04/08/2010] [Indexed: 11/22/2022]
Abstract
Lymphocele is a well-known complication of renal transplantation. Presenting symptoms are nonspecific; most patients are entirely asymptomatic. Herein, we have reported a case of lymphocele due to an asymptomatic lymphatic Wuchereria bancrofti filariasis with deterioration of graft function. A 53-year-old man with end-stage renal disease secondary to vascular disease was admitted 40 days after transplantation with vague, isolated abdominal pain. An abdomen and pelvis ultrasound examination demonstrated a cystic structure in the renal hilus. Graft function deteriorated, so the patient underwent puncture of the lymphocele followed by povidone iodine sclerotherapy. In the percutaneous drainage, we noted a fine whitish strand 4-mm thick similar to the shape of the stent, a part of which seemed to go into the transplantation fossa. Parasitological examination showed an adult female worm of W bancrofti measuring 6 cm. The test for microfilaremia was negative. The patient was treated for 10 days with a combination of Ivermectin and Albendazole associated with Doxycycline. The collection rapidly decreased after worm treatment. This case describes a post-renal transplantation lymphocele due to asymptomatic lymphatic filariasis.
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Ulrich F, Niedzwiecki S, Fikatas P, Nebrig M, Schmidt SC, Kohler S, Weiss S, Schumacher G, Pascher A, Reinke P, Tullius SG, Pratschke J. Symptomatic lymphoceles after kidney transplantation - multivariate analysis of risk factors and outcome after laparoscopic fenestration. Clin Transplant 2009; 24:273-80. [DOI: 10.1111/j.1399-0012.2009.01073.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kalb B, Martin DR, Salman K, Sharma P, Votaw J, Larsen C. Kidney transplantation: structural and functional evaluation using MR Nephro-Urography. J Magn Reson Imaging 2009; 28:805-22. [PMID: 18821623 DOI: 10.1002/jmri.21562] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
End-stage-renal disease (ESRD) is a major health issue in the United States, and the Medicare costs of ESRD totaled nearly USD 21 billion in 2005. Renal transplantation has emerged as the treatment of choice in this patient population, providing improved quality of life and lower healthcare costs compared with other treatment options. Imaging evaluation of a graft kidney plays a critical role in the postoperative care of the renal transplant patient. In the past, diagnostic evaluation of the transplant kidney has depended upon a combination of ultrasonography, computed tomography, MRI, and biopsy, used in conjunction with the patient's clinical presentation. However, new and developing advances in MR technology has lead to the development of MR Nephro-Urography (MRNU), which provides both anatomic and functional evaluation of the kidney in a single examination. It is expected that the increasing use of MRNU will have a significant impact on the management of renal transplant patients. This review describes MRNU methodology, examines known posttransplant complications, and highlights the utility of MRNU as a comprehensive imaging examination to diagnose both surgical and medical complications of the transplant kidney.
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Affiliation(s)
- Bobby Kalb
- Emory University School of Medicine, 1365 Clifton Road NE, Building A - AT622, Atlanta, Georgia 30322, USA
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