Laparoscopic lymphocelectomy: a multi-institutional analysis

A Novel Technique Using Fluorescent Ureteral Catheter and Flexible Ureteroscope for Safe Laparoscopic Fenestration of Lymphocele after Kidney Transplantation

Laparoscopic fenestration of a postrenal transplant lymphocele is associated with a risk of renal hilar vessel and ureteral injury. Consequently, determination of the incision line is difficult. We describe a case of a 73-year-old man with postrenal transplant lymphocele who underwent a laparoscopic fenestration. We report a surgical video containing a new technique of laparoscopic fenestration using a fluorescent ureteral catheter in combination with a flexible ureteroscope. The combination of a fluorescent ureteral catheter and flexible ureteroscope during surgery enabled us to determine the incision line safely and accurately. Intraoperative real-time visualization of the lymphocele and ureter using a fluorescent ureteral catheter and a flexible ureteroscope is safer than conventional methods for laparoscopic fenestration. To the best of our knowledge, this is the first report of this novel technique.

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.

Intraperitoneal Ultrasound-Guided Safe Laparoscopic Fenestration of Lymphocele After Kidney Transplantation

Background: Lymphocele is a common complication after kidney transplantation, which does not require treatment unless it is symptomatic. In this study, we aimed to evaluate the incidence, clinical symptoms, treatment choices, and success of different treatment methods of symptomatic lymphocele. Materials and Methods: We evaluated 168 patients who had kidney transplantation between January 2012 and January 2020. Patients with decreased kidney functions due to lymphocele formation during the clinical follow-up were included in the study. External drainage catheter was placed in all patients, except one. In case of treatment failure with external drainage, laparoscopic fenestration guided by intraperitoneal ultrasonography was performed. Clinical symptoms and success rates of treatments were evaluated. Results: Symptomatic lymphocele requiring interventional treatment was detected in 15 (8.9%) of 168 renal transplant patients. All of the symptomatic lymphocele cases had increased serum creatinine levels, whereas 10 had decreased urine volume, 4 had abdominal discomfort, and 2 had ipsilateral lower extremity edema. External drainage catheter was placed as the first-line treatment in 13 patients. In 6 cases, due to treatment failure with external drainage and in 2 patients as a first-choice treatment, laparoscopic fenestration was performed. No lymphocele recurrence was observed during follow-up. Conclusion: Among various methods defined in the treatment of lymphocele, use of laparoscopic fenestration is increasing because of its high success rate and advantages over other methods. Intraperitoneal ultrasound-guided laparoscopic fenestration is a useful and safe method that can be performed as a first-choice treatment since it eliminates the risk of organ injury or bleeding.

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

Objectives:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

A Novel Technique in the Treatment of Lymphoceles After Renal Transplantation: C-Arm Cone Beam CT-Guided Percutaneous Embolization of Lymphatic Leakage After Lymphangiography

BACKGROUND

We aimed to evaluate the efficacy of percutaneous embolization after lymphangiography using C-arm cone-beam computed tomography (CBCT) performed at the site of lymphatic leakage in patients with postrenal transplant lymphocele.

METHODS

Between July 2014 and August 2017, 13 patients not responding to percutaneous ethanol sclerotherapy and conservative treatment for recurrent lymphocele after renal transplant were included. The mean age of the patients was 56.38 ± 9.91 (range, 36-70) years, and it comprised 9 men and 4 women. All patients underwent intranodal lymphangiography. C-arm CBCT-guided percutaneous embolization was performed in patients with confirmed lymphatic leakage. Patients who had no lymphatic leakage underwent drainage with fibrin glue injection.

RESULTS

Lymphatic leakage was observed in 9 patients after lymphangiography, and they underwent CBCT-guided percutaneous N-butyl-2-cyanoacrylate embolization. The volume of lymphatic drainage reduced to less than 10 mL in 8 patients. One patient who was not responding to embolization was treated surgically, after percutaneous drainage and fibrin glue injection. Lymphatic leakage was not observed in 4 patients after lymphangiography. Of these, 3 patients showed a reduction in the amount of lymphatic drainage after lymphangiography. All 4 patients underwent percutaneous drainage and fibrin glue injection. One patient did not respond to the treatment and was treated surgically. Prelymphangiography and postlymphangiography and embolization, the volume of lymphatic drainage was 113.07 ± 21.75 mL, and 53.84 ± 30.96 mL, respectively, and statistically significant decrease was detected (P < 0.005).

CONCLUSIONS

Lymphangiography and CBCT-guided percutaneous embolization procedures might be an effective treatment method for patients with lymphocele refractory to treatment.

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.

Fibrin Glue Injections: A Minimally Invasive and Cost-Effective Treatment for Post-Renal Transplant Lymphoceles and Lymph Fistulas

Pelvic lymphoceles/lymph fistulas are commonly observed after kidney allotransplantation, especially when the kidney is placed in a retroperitoneal position. While the majority are <5 cm in diameter and resolve without intervention, some may continue to enlarge, and cause local or systemic symptoms or graft dysfunction. Among 1662 recipients of both living and deceased donor kidney transplants between January 2003 and July 2014, we found 46 (2.7%) patients with symptomatic lymphoceles requiring intervention. We studied the clinical outcomes and charges for three treatment modalities including open surgical drainage (22), laparoscopic surgical drainage (11), and percutaneous fibrin glue injections into the drained lymphocele cavity (13). The patient demographics and clinical characteristics were comparable for each treatment group, although maintenance immunosuppressive drugs differed by era. We found fibrin glue injections resulted in significantly lower (p = 0.04) rates of recurrence (1; 7.7%) than either laparoscopic (6; 54%) or open surgical drainage (6; 27.3%). In addition, fibrin glue injections generated significantly (p < 0.001) lower median ($4559) charges compared to either laparoscopic ($26,330) or open surgical drainage ($23,758). Fibrin glue treatment has the advantage of being an outpatient procedure, performed with the patient under local anesthesia, and does not incur the expense of an operative procedure or hospital admission associated with laparoscopic or open surgery.

Ultra-high-risk pregnancies in women after renal transplantation

OBJECTIVES

This study evaluates pregnancy outcomes in renal transplant recipients who have additional obstetrical, surgical, or urological risk factors.

STUDY DESIGN

Data from our transplantation and obstetrical databases were retrospectively analyzed to identify all women of reproductive age who had undergone renal transplantation between 1999 and 2013 at our tertiary referral center and had subsequently become pregnant. Characteristics of pregnancy and perinatal outcome parameters; obstetrical, urological, and surgical risk factors; and graft function were assessed. Descriptive data analysis, Fisher's exact test, unpaired Student's t-test and one-way analysis of the variance were performed.

RESULTS

The overall pregnancy rate after renal transplantation was 5% (n=13). 77% of the patients (n=10) had ultra-high-risk pregnancies due to additional risk factors. These included twin pregnancy, placenta previa/percreta, hypertension; previous heart transplantation, previous myocardial infarction; postoperative lymphocele, urinary leakage, hydronephrosis, or vesico-ureteral reflux. Two patients had two consecutive pregnancies. A total of 12 deliveries with 13 newborns were achieved. Cesarean section and preterm delivery rates were 67% and 50%, respectively. Mean gestational week at delivery was 36 ± 3. Mean creatinine levels were higher in women with preterm deliveries and in those of advanced age. Mean time between transplantation and delivery was 79 ± 36 months. All patients had adequate graft function after a mean follow-up of 128 ± 50 months after renal transplantation.

CONCLUSIONS

Pregnant women after renal transplantation commonly present with additional risk factors. In these ultra-high-risk pregnancies successful outcomes can be achieved in a multidisciplinary setting. Adequate graft function and urinary tract evaluation is necessary.

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.

Laparoscopic treatment of lymphoceles after renal transplantation

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of primary symptomatic lymphocele after kidney transplantation: a systematic review

BACKGROUND

Management of lymphoceles after kidney transplantation is highly variable. The aim of this study was to evaluate and compare the different approaches of lymphocele management among kidney transplant recipients.

METHODS

MEDLINE and EMBASE were systematically searched for case studies published between 1954 and 2010. Inclusion criteria were symptomatic lymphoceles developing in recipients of deceased or living donor kidneys with specified intervention and outcome. Primary outcome was the rate of recurrence. Secondary outcomes were the rate of conversion from laparoscopic to open surgery, hospital stay, and complication rates.

RESULTS

Fifty-two retrospective case series with 1113 cases of primary lymphocele were selected for review. No randomized controlled trials or prospective cohort studies were located. Primary treatment modalities included were as follows: aspiration (n=218), sclerotherapy (n=155), drainage (n=219), laparoscopic surgery (n=333), and open surgery (n=188). Of the 218 cases of lymphocele managed with aspiration alone, 141 recurred with a recurrence rate of 59% (95% confidence interval [CI]: 52-67). Among those who received laparoscopic and open surgery, the recurrence rates were 8% (95% CI: 6-12) and 16% (95% CI: 10-24), respectively. The conversion rate from laparoscopic to open surgery was 12% (95% CI: 8-16).

CONCLUSIONS

Laparoscopic fenestration of a symptomatic lymphocele is associated with the lowest risk of lymphocele recurrence. However, the evidence base to support a recommendation for laparoscopic surgery as first line treatment is weak and highlights the need for a multicenter prospective cohort study to examine the benefits of incorporating initial simple aspiration into the management of lymphocele after kidney transplantation.

[Lymphoceles after radical retropubic prostatectomy. A treatment algorithm]

Lymphoceles represent a common complication following pelvic lymphadenectomy and radical retropubic prostatectomy. Relevant articles published in the last 25 years and our own results based on a prospective study were taken as the basis for a treatment algorithm for lymphoceles after radical prostatectomy.The type of intervention depends on the clinical situation of the patient. Symptomatic lymphoceles can be managed initially by percutaneous aspiration with or without instillation of sclerosing agents. However, lymphocele recurrence rates are high. Symptomatic, sterile lymphoceles appear to be ideally suited for drainage by laparoscopic techniques. This method is effective, usually immediately definitive, results in minimal patient morbidity, and allows for a more rapid recovery. Infected lymphoceles require percutaneous or open surgical drainage. Laparoscopic marsupialization of symptomatic lymphoceles after pelvic lymphadenectomy for prostate cancer appears to be safe and effective. Because of the minimal postoperative morbidity, rapid convalescence, and low recurrence rate, laparoscopic lymphadenectomy should be considered as a first-line treatment for symptomatic, uninfected sterile lymphoceles.

Sclerotherapy in the management of postoperative lymphocele

PURPOSE

To describe a single-center experience with sclerotherapy of postoperative lymphocele and to determine the risk factors for failure of treatment.

MATERIALS AND METHODS

From 1999 to 2007, 43 patients with postsurgical lymphocele were treated with sclerotherapy with a combination of povidone iodine, alcohol, and doxycycline. The treatments were repeated at weekly intervals. The initial drainage volume of the lymphocele, the location of the lymphocele, the number of treatments, and the outcomes were retrospectively collected.

RESULTS

In 38 patients, the lymphocele was drained percutaneously, and in five patients, the treatment was initiated through an existing surgically placed drainage tube. Sclerotherapy was successful in 33 patients (77%). Complications that resulted in termination of the treatment were seen in five patients (12%): testicular pain, cellulitis, posttreatment increase in creatinine, acute renal tubular necrosis, and abdominal infection. In one of these patients the lymphocele resolved after resolution of the infection. The average number of treatments was four (range, 1-14). There was no difference in success rate between superficial intraabdominal and soft-tissue lymphoceles. There was a significant difference (P < .05) in the fluid volume at initial drainage between the failure group (1,708 mL +/- 1,521) and the success group (206 mL +/- 213). This assumes an attempt was made to drain the collection completely at the initial procedure.

CONCLUSIONS

Sclerotherapy of postoperative lymphoceles is an effective treatment. Success of sclerotherapy is directly related to the size of the lymphocele cavity.

Did volume of lymphocele after kidney transplantation determine the choice of treatment modality?

INTRODUCTION

Lymphocele is a lymph collection that forms after surgery following injury to lymph nodes and vessels. The aim of the study was to perform a retrospective analysis of different treatment modalities of lymphocele in patients after kidney transplantation.

MATERIAL AND METHODS

A lymphocele located in renal graft area was observed in 25 of 386 transplanted patients (6.5%). Mean patient age was 45 (95% confidence interval [CI], 40 to 50) years. Mean observation time was 35 (95% CI, 27 to 43) months.

RESULTS

Mean time from transplantation to diagnosis of lymphocele was 29 days (range, 4 to 127). In 13 patients (54.2%), the lymphocele was symptomatic, requiring initial treatment by repeated needle aspirations or percutaneous drainage. Among 7 patients with persistence of the lesion treatment by sclerotherapy with doxycycline, povidone-iodine, and/or ethanol was successful in 4 cases who showed maximal lymphocele volume of 500 mL. Three other patients, namely, volumes of 120, 874, and 2298 mL were referred for surgery; in two cases, internal marsupialization was performed and in one case external drainage was necessary due to abscess formation. Mean time from the diagnosis to recovery in patients requiring surgical treatment was 15 (range, 8 to 24) weeks. Eleven patients with asymptomatic lymphoceles (mean volume 45 mL; range, 8 to 140) were monitored to resolution after a mean of 4 (range, 1 to 11) weeks.

CONCLUSION

All lymphoceles with the maximal volume exceeding 140 mL were clinically symptomatic. Initial percutaneous drainage with or without sclerotherapy was an effective method of treatment. Punctures, drainage, and sclerotherapy were not effective in patients with lymphoceles (>500 mL).

Percutaneous transcatheter ethanol sclerotherapy and catheter drainage of postoperative pelvic lymphoceles

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

Treatment of a recurrent inguinal lymphocele in a penis cancer patient by lymphography and selective ligation of lymphatic vessels

We report a case of recurrent inguinal lymphocele formation after inguinal lymphadenectomy treated by lymphographic mapping and selective ligation of the lymphatic vessels. Lymphographic mapping was performed by puncturing a lymphatic vessel at the dorsum of the foot. After isolating the vessels that drained into the lymphocele, they were clipped and divided through a small skin incision. The described technique showed an instant and complete suspension of the lymph secretion with subsequent complete healing. Lymphatic mapping and selective ligation of afferent lymphatic vessels proved to be an effective treatment of a recurrent inguinal lymphocele.

Urologic complications in renal transplant recipients by donor type

BACKGROUND AND PURPOSE

Reduced donor morbidity has been established after laparoscopic donor nephrectomy compared with open harvest, but differences in recipient outcomes remain less obvious. We compared the urologic complications in patients receiving kidneys procured by cadaveric, open, and laparoscopic harvest.

PATIENTS AND METHODS

A retrospective study of all the kidney transplantations performed between January 1998 and December 2003 was undertaken to extract 100 consecutive patients in each group. All urologic complications were obtained and grouped by the type of donor procurement.

RESULTS

Overall, 48 of the 276 transplant patients (17%) had urologic complications: 14% of the cadaveric-donor recipients, 20% of the open-donor recipients, and 18% of the laparoscopic-donor recipients. There were no ureteral complications in the laparoscopic group.

CONCLUSIONS

Laparoscopically procured donor kidneys were associated with significantly fewer recipient ureteral complications than open cadaver or live-donor procurement.

Laparoscopic Marsupialization of Postrenal Transplantation Lymphoceles

BACKGROUND AND PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Novel Technique to Prevent Lymphocele Recurrence after Laparoscopic Lymphocele Fenestration in Renal Transplant Patients

PURPOSE

To describe the use of nonabsorbable polymer ligating (NPL) clips to prevent recurrence after laparoscopic lymphocele fenestration and to determine the efficacy and safety of this treatment in renal-transplant patients at our center.

PATIENTS AND METHODS

From December 2000 to October 2005, nine patients with a mean age of 38.5 years (range 26-54 years) and symptomatic lymphoceles were treated laparoscopically among 144 renal-transplant patients. The overall incidence of symptomatic lymphocele was 6.2% (9/144). The mean time from transplantation to diagnosis was 55.5 days (range 20-98 days). Patient and lymphocele characteristics, complications, recurrence rate, and outcomes of this procedure were analyzed retrospectively.

RESULTS

Laparoscopic treatment was successful in eight patients; the other was converted to open surgery. One patient sustained an allograft-ureteral injury. The mean operative time was 90.7 minutes (range 75-120 minutes), and the mean postoperative stay was 4.1 days (range 1-7 days). Lymphocele recurrence was found in the first two patients after laparoscopic surgery without NPL clips. With a mean follow-up of 42.3 months (range 31-51 months), no recurrence was observed in patients in whom NPL clips were used to maintain the patency of the peritoneal window. No late laparoscopy-related complications occurred.

CONCLUSION

Laparoscopic lymphocele fenestration with NPL clips is a safe, technically easy, and efficacious procedure for the treatment of symptomatic lymphoceles after renal transplantion.

Long-Term Outcome of Cadaveric Renal Transplant After Treatment of Symptomatic Lymphocele

PURPOSE

Between January 1993 and December 2002 a total of 1,289 renal transplants were performed at our institution. Symptomatic post-transplant lymphocele presenting as increased creatinine and hydronephrosis of the allograft was recorded at 0.02%. Records of the 27 patients in whom symptomatic lymphocele developed and of those who underwent contralateral kidney transplant (control group) were compared to determine the long-term effects of lymphocele formation on allograft function.

MATERIALS AND METHODS

A total of 37 procedures for the treatment of lymphocele were performed in 24 patients. Open marsupialization (12) and laparoscopic marsupialization (3) procedures were performed as primary treatments. Two patients underwent repeat open marsupialization. Aspiration and percutaneous catheter drainage were performed as a primary procedure in 7 and 1 cases, respectively. Percutaneous nephrostomy was required in 4 cases before definitive treatment.

RESULTS

The mean time to development of a lymphocele was 121 days (range 35 to 631). Symptomatic lymphocele did not require treatment in 3 patients. Of 19 patients undergoing primary marsupialization, recurrence in 2 necessitated repeat surgery. However, aspiration and percutaneous drainage proved to be definitive in only 2 cases. In total 8 patients required more than 1 procedure. At a mean followup of 63 months (SD 30.3) 21 allografts continued to function with a mean serum creatinine of 152 mumol/l (SD 67.9). In the control group 3 patients experienced graft failure and mean serum creatinine was 154 mumol/l (SD 51.9). Five patients died in the lymphocele group, 2 with functioning grafts compared to 4 deaths in the control group.

CONCLUSIONS

Surgical marsupialization is the preferred primary treatment for symptomatic lymphocele and is associated with excellent long-term allograft outcome.

[Complications of laparoscopic urological procedures]

Laparoscopic urology has evolved considerably during last decade as well as number and spectrum of surgical related complications. Experiences reported by laparoscopic trained groups allow preventing, promptly recognizing, and safe and efficient management of the laparoscopic related complications. We present our complications in all patients undergoing urological laparoscopic procedures from November 1992 to June 2005. A literature search was conduced to evaluate complications of every laparoscopic procedure.

Diagnostics and Therapy of Lymphoceles After Kidney Transplantation

Lymphocele incidence after kidney transplantation is as high as 18%. We retrospectively studied the therapy of 42 lymphoceles that occurred in our clinic between 1990 and 2005, focusing on possible predisposing factors for their formation and the results of several therapy variants: conservative, operative, percutaneous puncture, and laparoscopic or open marsupialization. There was no connection between lymphocele formation and the following parameters: the extent to which the iliac vessels had been prepared, the materials used for the preparation, or whether clips or ligatures were applied. Lymphoceles may originate either from the lymphatic system of the recipient or the transplanted kidney. The most sensible measures to prevent their occurrence therefore seems to be to restrict the transplant bed to the smallest permissible level with careful ligature of the lymphatic vessels in the area of the kidney hilus. Treatment for lymphoceles should start with minimally invasive measures. We use the following algorithm in our clinic: puncture to differentiate between urinoma/lymphocele and to test for bacterial infection, sclerotization (200 mg doxycyclin), and finally marsupialization if persistent. The choice of operative technique depends on the location. This algorithm resulted in a relapse rate of 9.5% during the postoperative observation period of up to 15 years.

Radiologic imaging and percutaneous treatment of pelvic lymphocele

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

Laparoscopic fenestration of lymphoceles after kidney transplantation with diaphanoscopic guidance

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

Laparoscopic fenestration of posttransplant lymphoceles in children

BACKGROUND/PURPOSE

Lymphoceles are frequently observed as a surgical complication after renal transplantation. Whereas the frequency, pathogenesis, diagnosis, and treatment of lymphoceles has been well described in adult patients, no data are available for the pediatric age group.

METHODS

Since December 2000; 5 children (2 boys and 3 girls; median age, 6 years; range, 6 to 15 years) of a total of 21 (10 boys and 11 girls; median age, 13 years; range, 2 to 19 years) children undergoing kidney transplantation had a posttransplant lymphocele. The clinical course, renal function, and ultrasonographic appearance of the transplanted kidney of all children were observed in a prospective manner.

RESULTS

The lymphoceles became obvious between day 13 and 48 (median, 20 days) posttransplantation. Lymphocele size ranged from 2.0 x 3.0 cm to 11.0 x 15.0 cm. They were localized at any site (superior, inferior, lateral, medial, and dorsal) around the transplanted kidney. Four patients had a significant decrease of renal function, in 2 children mild urinary tract obstruction occurred, and 1 patient suffered from considerable abdominal pain. Diagnosis was established by ultrasound scan in all cases. All patients were treated by laparoscopic fenestration of the lymphocele immediately after diagnosis, except 1 patient, in whom fenestration was not done until 10 months later. Operating time ranged from 45 to 90 minutes (median, 62 minutes). No intraoperative or postoperative complication occurred. Renal function, urinary tract obstruction, and pain recovered soon after operation in all patients. After 3 to 10 months (median, 8 months) postoperatively, no relapse has been observed.

CONCLUSIONS

Our data emphasize laparoscopic fenestration as the treatment of choice for children with posttransplant lymphoceles, because it is safe, effective, and technically easy to perform. If done early after diagnosis, renal function will recover immediately.

Applications of laparoscopic surgery in urology: impact on patient care

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

Laparoscopic treatment of post renal transplant lymphoceles

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of lymphoceles after renal transplantation: laparoscopic versus open drainage

PURPOSE

Laparoscopic surgery has become widely accepted for the treatment of lymphoceles following kidney transplantation. In this single center study we retrospectively reviewed our results of the surgical management of post-transplant lymphoceles, assessing indication and outcome of laparoscopic versus open drainage.

MATERIALS AND METHODS

The records of 60 patients who underwent surgical treatment for a symptomatic lymphocele following kidney transplantation or combined kidney/pancreas transplantation were retrospectively reviewed.

RESULTS

Between 1995 and 2002, 1,836 patients received a kidney transplant at the University of California San Francisco. In 60 patients (3.3%) a symptomatic lymphocele developed and either laparoscopic (20) or open drainage (40) was completed. The conversion rate from laparoscopic to open drainage was 16.5%. The most common indications for open lymphocele drainage were noninfectious wound complications (13 patients) and a high risk of vessel or ureter injury (8) due to proximity of the lymphocele to hilar structures. Additional surgery on the graft was required in 5 patients. Intraoperative blood loss was significantly lower in the laparoscopy group. Median hospital stay was 1 day in the laparoscopy group versus 4 days in the open drainage group. No perioperative complications were observed in either group. After a median followup of 38 months, 2 patients in each treatment group had a symptomatic recurrence.

CONCLUSIONS

Although both surgical approaches are safe and effective, laparoscopic drainage should remain the method of choice for the treatment of post-transplant lymphocele. However, open drainage should be performed in patients with wound complications and in those with a small lymphocele adjacent to vital renal structures.

[Ultrasonography in urology]

After its introduction more than twenty years ago, ultrasound has continually increased in importance in urology diagnostics and is currently one of the most frequent exploratory techniques used. It corresponds to one out of every four imaging techniques carried out in medicine. The possibility of intervention under echographic control, for either diagnostic or therapeutic purposes, has been studied ever since ultrasound first appeared. Nowadays, interventionist echography is a commonly used technique in urology and is applied in a wide range of procedures carried out on the prostate gland, bladder and kidney that require echography-guided puncture techniques. Timely modifications of ultrasound for control and monitoring of treatments such as shock wave extracorporeal lithotripsy or transperineal brachitherapy has increased even more its day-to-day use by urologists. New technologies currently under development such as high-energy ultrasound in the management of kidney and prostate cancer, 3-dimensional ultrasound, Doppler-energy and contrast ultrasound have also increased the importance of this procedure in urology.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic fenestration of posttransplant lymphoceles

BACKGROUND

A lymphocele is a common finding after renal transplantation and occurs in up to 20% of patients. The majority of patients are asymptomatic. However, once a lymphocele has become symptomatic (e.g., through transplant dysfunction) this condition has to be treated. We report our 9-year experience with laparoscopic lymphocele fenestration and discuss the current management options for posttransplant lymphoceles.

METHODS

Since 1993, 19 patients (11 males and 8 females; median age 56 years, range 22-68 years) of a total of 31 patients with a symptomatic posttransplant lymphocele have undergone laparoscopic fenestration of their lymphocele at a median of 66 days (range, 19-111 days) following successful renal transplantation in our department. As a first-line treatment, a percutaneous pigtail drainage catheter was inserted in all patients. In case of failure in resolving the fluid collection, the next step included sclerotherapy by instillation of tetracycline or ethanol into the lymphocele cavity in some cases. In patients with a persistent lymphocele, a laparoscopic lymphocele fenestration via a transabdominal approach was undertaken to achieve adequate drainage.

RESULTS

Primary laparoscopic lymphocele fenestration was successful in all except two patients, who required a conversion. The median operating time was 36 min (range, 20-70 min). Following the procedure, renal transplant function remained stable or returned to individually normal levels in all patients. Median duration of hospital stay was 4 days (range, 1-13 days). At median follow-up of 27 months, all patients were alive with a functioning transplant.

CONCLUSIONS

Laparoscopic lymphocele fenestration is reserved for patients in whom temporary drainage with or without sclerotherapy failed to resolve the fluid collection. In these cases the laparoscopic approach offers obvious technical and clinical advantages compared to open operative techniques.

Laparoscopic surgery in renal transplant recipients

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

Laparoscopic ultrasonography

The use of laparoscopic ultrasonography (LUS) allows visualization of tissues beyond the two-dimensional laparoscopic picture, enhancing the amount and quality of information available to the surgeon. Linear-array transducers with frequencies of 7.5 to 10 MHz are typically used for LUS, employing B-mode scanning and color Doppler capability on probes with articulating tips. In general surgery, LUS has become a common adjunct to the intraoperative staging of upper gastrointestinal malignancy to determine resectability, avoiding unnecessary laparotomy. In urology, LUS appears to be a promising adjunct for four current procedures: difficult pelvic lymphocele marsupialization, renal cyst decortication, nephrolithotomy and other renal stone surgery, and cryotherapy of renal masses. The role of LUS during varicocelectomy is limited, and enthusiasm for this procedure is waning. Laparoscopic ultrasonography is a critical adjunct to renal cryoablation, a developmental procedure that currently lacks long-term data but is promising as therapy for small, incidentally detected renal masses. It appears that as laparoscopic urologic procedures continue to expand, so will the application of this promising operative imaging modality.

Needlescopic urology: current status

Technological miniaturization is an emerging trend that encompasses virtually all surgical subspecialties. Minimization of surgical trauma while maximizing surgical cure through gradual progression from maximally invasive to minimally invasive to ultimately noninvasive technologies must be the goal. Needlescopic techniques represent a natural evolution and sophistication of conventional laparoscopy. At the author's center, needlescopic techniques have been used to particular advantage in four specific clinical applications: adrenalectomy, pediatric orchiopexy, detaching the bladder cuff during laparoscopic nephroureterectomy, and as an adjunctive needlescopic port for retraction purposes during conventional laparoscopic surgery. Given the urologist's natural facility with small-diameter endoscopes, the specialty is uniquely positioned to take a leadership position in this emerging field. Increased experience and careful comparisons with conventional laparoscopy will determine the true role of needlescopic technology in the armamentarium of the urologic surgeon.