Lymphoceles: diagnosis and management in urologic patients

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.

Lymphocele after anterior lumbar interbody fusion: a review of 1322 patients

OBJECTIVE

Anterior lumbar interbody fusion (ALIF) is an effective surgical modality for many lumbar degenerative pathologies, but a rare and infrequently reported complication is postoperative lymphocele. The goals of the present study were to review a large consecutive series of patients who underwent ALIF at a high-volume institution, estimate the rate of lymphocele occurrence after ALIF, and investigate the outcomes of patients who developed lymphocele after ALIF.

METHODS

A retrospective review of the electronic medical record was completed, identifying all patients (≥ 18 years old) who underwent at a minimum a single-level ALIF from 2012 through 2019. Postoperative spinal and abdominal images, as well as radiologist reports, were reviewed for mention of lymphocele. Clinical data were collected and reported.

RESULTS

A total of 1322 patients underwent a minimum 1-level ALIF. Of these patients, 937 (70.9%) had either postoperative abdominal or lumbar spine images, and the resulting lymphocele incidence was 2.1% (20/937 patients). The mean ± SD age was 67 ± 10.9 years, and the male/female ratio was 1:1. Patients with lymphocele were significantly older than those without lymphocele (66.9 vs 58.9 years, p = 0.006). In addition, patients with lymphocele had a greater number of mean levels fused (2.5 vs 1.8, p < 0.001) and were more likely to have undergone ALIF at L2-4 (95.0% vs 66.4%, p = 0.007) than patients without lymphocele. On subsequent multivariate analysis, age (OR 1.07, 95% CI 1.01-1.12, p = 0.013), BMI (OR 1.10, 95% CI 1.01-1.18, p = 0.021), and number of levels fused (OR 1.82, 95% CI 1.05-3.14, p = 0.032) were independent prognosticators of postoperative lymphocele development. Patients with symptomatic lymphocele were successfully treated with either interventional radiology (IR) drainage and/or sclerosis therapy and achieved radiographic resolution. The mean ± SD length of hospital stay was 9.1 ± 5.2 days. Ten patients (50%) were postoperatively discharged to a rehabilitation center: 8 patients (40%) were discharged to home, 1 (5%) to a skilled nursing facility, and 1 (5%) to a long-term acute care facility.

CONCLUSIONS

After ALIF, 2.1% of patients were diagnosed with radiographically identified postoperative lymphocele and had risk factors such as increased age, BMI, and number of levels fused. Most patients presented within 1 month postoperatively, and their clinical presentations included abdominal pain, abdominal distension, and/or wound complications. Of note, 25% of identified lymphoceles were discovered incidentally. Patients with symptomatic lymphocele were successfully treated with either IR drainage and/or sclerosis therapy and achieved radiographic resolution.

Fistula formation between infected pelvic lymphocele and sigmoid colon: A rare complication of pelvic lymphadenectomy

Lymphocele formation following pelvic lymphadenectomy is a well-known complication. In this article, we report a 56 years old female patient with a pelvic infected lymphocele fistulised in the sigmoid discovered in imaging 2 months after pelvic surgery. Lymphocele complications are rare and their diagnosis is based on imaging. However, lymphocele as a potential cause for fistula in the bowel as a particular new case has not been found in literature search.

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.

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.

Role of early povidone iodine instillation in post-renal transplant lymphorrhea: A prospective randomized study

OBJECTIVE

The aim of the present study was to prospectively evaluate the role of early povidone iodine instillation in the management of post-renal transplant lymphorrhea.

MATERIAL AND METHODS

Live-related renal transplant recipients operated between January 2002 and December 2015 were included in the study. Significant lymphorrhea was defined as >50 mL lymph from drain beyond postoperative day 5. Such patients were randomized into two groups by simple randomization using a computer-generated random list: group A (received 0.5% povidone iodine instillation) and group B (no instillation). Absolute risk reduction and numbers needed to treat were calculated to estimate the effect of povidone iodine instillation for the treatment of lymphorrhea and decrease in the incidence of lymphocoele.

RESULTS

A total of 1766 patients underwent renal transplant during this period. One hundred seventeen patients with lymphorrhea through the drain underwent randomization into group A (n=61) and group B (n=56). In group A, 58 patients had successful resolution within 2 weeks, whereas in group B, 34 patients had successful resolution within 2 weeks. Overall, 9 (14.75%) patients in group A and 29 (51.78%) patients in group B had lymphatic collections (both symptomatic and asymptomatic). Symptomatic lymphocoele was present in 1 patient in group A and 7 patients in group B on follow-up. Absolute risk reduction was 10.8%, and for every symptomatic lymphocoele prevented, 10 patients needed povidone iodine instillation.

CONCLUSION

Povidone iodine instillation after 5 days of transplantation aids in the early resolution of post-renal transplantation lymphorrhea, as well as reduces the incidence of future lymphocoele.

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.

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.

What Are the Risk Factors for Lymphocyst Formation Apart From Lymphnode Dissection and Lymphnode Count in Gynecologic Malignancy?

Aim: Lymphocyst is one of the most common complications of lymphadenectomy and generally encountered during uro-gynecological oncology surgeries. We aimed to define the risk factors for formation of a lymphocyst in patients with various gynecological cancer types in whom a lymphadenectomy was performed. Methods: This retrospective study was performed on 206 patients. Of the 206 patients, 100 were diagnosed with a lymphocyst, and 106 were assigned to a control group. Laboratory findings and surgical characteristics of the patients were compared. Results: No differences were observed in age, pre-operative hemoglobin; platelet, white blood cell, and lymphocyte counts; or pre-operative albumin level (p = 0.315, 0.500, 0.525, 0.683, 0.740, and 0.97, respectively). A significant effect of the heparin dose × heparin days interaction and lymphocyst formation was observed (p = 0.002). Lymphocysts were most frequently detected in the ovarian cancer subgroup (49 %). Significant differences were detected between the groups in the percentages of patients who underwent CT only and RT only treatments (p = 0.001 and 0.002, respectively). The logistic regression analysis revealed a relationship between the LMWH dose × days interaction and formation of a lymphocyst (OR, 1.10; 95 % CI, 1.0-1.13; p = 0.01). Conclusion: The association between total LMWH dose administered and the formation of lymphocysts in patients with gynecological pelvic cancer was investigated for the first time. Significant relationship between heparin dose × days and lymphocyst formation was found. Although anticoagulation with LMWH is essential for preventing thromboembolism, it should be used appropriately to prevent other complications, such as bleeding and lymphocysts.

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 marsupialisation of pelvic lymphoceles in different anatomic locations following radical prostatectomy

BACKGROUND

Pelvic lymphoceles (LCs) following radical prostatectomy (LC-RPs) are a well-described complication. Symptomatic LC-RPs are the most frequent, nonfunctional, postradical prostatectomy complications.

OBJECTIVES

Description of the clinical presentations of LC-RPs and the detailed technique of laparoscopic pelvic LC marsupialisation (LM), including perioperative results and follow-up.

DESIGN, SETTING, AND PARTICIPANTS

Data from 105 patients (age range: 57-76 yr) with symptomatic LC-RPs who underwent surgery in our institute were evaluated retrospectively. Pelvic ultrasound (US) and computed tomography scans, performed on all patients, revealed LC volumes ranging from 100 to 1200 ml. Fifty-five patients were refractory to prior percutaneous tube drainage and/or sclerotherapy. LM was performed using a three-trocar (n=60 patients) or two-trocar technique (n=45 patients).

SURGICAL PROCEDURE

With the patient in Trendelenburg position, LCs were accurately identified by inspection, compressibility, and/or laparoscopic needle aspiration. A Foley catheter was inserted. Through one or two working trocars in the left lower abdomen, an adequate peritoneal window (wide ellipse) was excised. The LC cavity was inspected and septae, membranes, and haematomas were removed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Perioperative surgical outcomes, analgesic medication, and inflammation parameters were recorded. Follow-up and success rates were estimated with US for LC recurrence.

RESULTS AND LIMITATIONS

Five pelvic LC locations could be identified: paravesical, lateral pelvic (encapsulated and uncapsulated), prevesical, and with retroperitoneal extension. These were relevant for clinical diagnosis and management options. Pelvic LCs were right-sided in 37 patients, left-sided in 15, and on both sides in 53. All LM were uneventful and operating time (mean) ranged from 15 to 265 (31.7) min, which became shorter with increasing experience. One conversion with postoperative blood transfusion was necessary. Patients were discharged between 2 and 4 (mean: 2.3) d postoperatively. Postoperative US revealed primary success in all cases. Three patients developed recurrence from 1 to 3 wk posthospitalisation; otherwise, none had treatment for LC during a mean follow-up of 20 mo. Limitations include the retrospective study design and the small number of patients.

CONCLUSIONS

LC-RPs are common and can be classified into five different patterns of clinical/anatomic presentation. LM is simple, feasible, and safe as the first-line treatment for large, noninfected, symptomatic or refractory LC-RPs with fewer complications and an overall 97% success rate.

Management of postoperative lymphoceles after lymphadenectomy: percutaneous catheter drainage with and without povidone-iodine sclerotherapy

PURPOSE

To report our single-center experience in managing symptomatic lymphoceles after lymphadenectomy for genitourinary and gynecologic malignancy and to compare clinical outcomes of percutaneous catheter drainage (PCD) alone versus PCD with transcatheter povidone-iodine sclerotherapy (TPIS).

METHODS

The medical records of patients who presented for percutaneous drainage of pelvic lymphoceles from February 1999 to September 2007 were retrospectively reviewed. Catheters with prolonged outputs >50 cc/day were treated with TPIS. Technical success was defined as the ability to achieve complete resolution of the lymphocele. Clinical success was defined as resolution of the patient's symptoms that prompted the intervention.

RESULTS

Sixty-four patients with 70 pelvic lymphoceles were treated. Forty-six patients (71.9 %) had PCD, and 18 patients (28.1 %) had multisession TPIS. The mean initial cavity size was 294.9 cc for those treated with TPIS and 228.2 cc for those treated with PCD alone (range 15-1,600) (p = 0.59). Mean duration of catheter drainage was 19 days (29 days with TPIS, 16 days with PCD, p = 0.001). Mean clinical follow-up was 22.6 months. Technical success was 74.3 % with PCD and 100 % with TPIS. Clinical success was 97 % with PCD and 100 % with TPIS. Postprocedural complications included pericatheter fluid leakage (n = 4), catheter dislodgement (n = 3), catheter occlusion (n = 9), and secondary infection of the collection (n = 4).

CONCLUSION

PCD of symptomatic lymphoceles is an effective postoperative management technique. Initial cavity size is not an accurate predictor of the need for TPIS. When indicated, TPIS is safe and effective with catheter outputs >50 cc/day.

Modified laparoscopic lymphocele marsupialization for the treatment of lymphoceles after radical prostatectomy: first results

OBJECTIVES

The objective of this study was to describe a simple modification of the laparoscopic pelvic lymphocele marsupialization (LL) following radical prostatectomy lymphoceles (RP-LC).

PATIENTS AND METHODS

Forty-eight patients (57-76 years) with symptomatic RP-LC underwent surgery in our institute. This was through an open approach in 6 (open drainage [OL]) and LL in rest of the patients (12 with 3 [LL3] and 30 with 2 [LL2] trocars). All except 2 patients were refractory to percutaneous tube drainage and/or sclerotherapy. Pelvic ultrasound and/or computed tomography scans revealed LC size (4 × 5-11 × 12 cm) and volumes (100-1100 mL).

RESULTS

All surgeries were uneventful with an operative time of 15-60 minutes for LL and 35-90 minutes for OL and it became shorter with increasing experience with LL2 (15-25 minutes). Mean hospitalization time was 2.3 and 8 days after LL (LL2 and LL3) and OL, respectively. LC were at the right side in 10 patients, at the left side in 6, and at both sides in 14. Postoperative ultrasound revealed primary success in all cases. No patient developed recurrence of or had treatment for lymphocele during a mean follow-up time of 19 months.

CONCLUSION

LL2 is a simple, feasible, and safe procedure that could be used as a first-line treatment for large, noninfected symptomatic or refractive RP-LC.

Retroperitoneal lymphocele after lumbar total disc replacement: a case report and review of literature

BACKGROUND

Retroperitoneal lymphoceles (RPLs) caused by injury to the lymphatics are commonly seen after pelvic lymphadenectomy, renal transplantation, and gynecologic tumor resection surgeries. Degenerative disc disease still remains the major cause of low-back pain. Anterior lumbar spinal procedures, such as anterior lumbar interbody fusion and anterior lumbar arthroplasty, have been increasingly performed for treatment of axial back pain. RPLs, as an approach-related complication, though infrequent, have been reported after anterior lumbar spinal surgery. We report a case of RPL after total disc replacement of the lumbar spine. To our knowledge, there has been no prior report of RPL after total disc replacement managed by percutaneous aspiration only.

METHODS

A 49-year-old woman who underwent total disc replacement at the L4-5 level presented with a postoperative complication of RPL. The imaging findings, clinical course, and treatment are discussed, and a review of literature is presented.

RESULTS

The patient presented with significant abdominal swelling and discomfort at 4 weeks after surgery without any signs or symptoms of infection. Investigations showed an RPL. She was treated by multiple aspirations under ultrasound guidance. At 12 months' follow-up, the patient had no further abdominal symptoms and had gone back to her routine activities and work with significant improvement in back pain.

CONCLUSIONS

RPL is an uncommon complication after anterior lumbar surgery and can be managed effectively if detected and diagnosed early. Although repeated aspiration is associated with high recurrence and infection, it is a safe and minimally invasive procedure to manage RPL.

Comparative study of in vivo lymphatic sealing capability of the porcine thoracic duct using laparoscopic dissection devices

PURPOSE

Sealing the lymphatic vessels during abdominal and pelvic surgery is important to prevent the leakage of lymphatic fluid and its resultant sequelae. To our knowledge we compared for the first time the quality of lymphatic sealing by each of 4 commonly used laparoscopic dissection devices.

MATERIALS AND METHODS

A total of 12 domestic pigs were used to test dissecting devices, including monopolar scissors (Ethicon Endo-Surgery, Cincinnati, Ohio), Harmonic ACE Scalpel, LigaSure V, EnSeal and Trissector. A midline incision was made from mid sternum to umbilicus, the diaphragm was divided and the porcine thoracic duct was isolated. In all animals each device was used to seal an area of the duct and each seal was placed at least 2 cm from the prior seal. In group 1 the thoracic duct of 6 pigs was cannulated with a 5Fr catheter and the seal was subjected to burst pressure testing using a burst pressure measuring device (Cole-Parmer, Vernon Hills, Illinois). In the 6 pigs in group 2 each seal was immediately sent for histopathological evaluation. Specimens were given a score for the extent of cautery damage, including 0-none, 1-minimal, 2-moderate, 3-severe and 4-extreme.

RESULTS

A total of 64 seals were created, of which 35 were subjected to burst pressure testing. Mean size of the thoracic duct was 2.6 mm. No acute seal failures were observed with any bipolar device or the harmonic shears. However, 2 immediate failures (33%) were seen with monopolar scissors. Mean burst pressure for monopolar scissors, Harmonic ACE Scalpel, LigaSure V, EnSeal and Trissector was 46 (range 0 to 165), 540 (range 175 to 795), 258 (range 75 to 435), 453 (range 255 to 825) and 379 mm Hg (range 175 to 605), respectively (p <0.05). Trissector, Harmonic ACE Scalpel and EnSeal generated seals with significantly higher burst pressure than that of monopolar scissors (p <0.05). Histopathological evaluation revealed that LigaSure caused less thermal damage than Trissector and EnSeal (p <0.05).

CONCLUSIONS

Each device tested except monopolar scissors consistently produced a supraphysiological seal and should be suitable for sealing lymphatic vessels during laparoscopic surgery.

Late spontaneous kidney graft decapsulation after administration of sirolimus in a recipient with chronic hepatitis B and C infection: a case report

Late spontaneous kidney graft decapsulation with fluid collection is a rare condition with only a few cases reported in the literature. Common causes of renal allograft rupture include acute rejection, acute tubular necrosis, renal vein thrombosis, and trauma. Sirolimus related late spontaneous decapsulation has not been reported in the past. Interestingly, sirolimus may promote lymphocele formation in renal transplant recipients, including those presenting with chronic hepatitis B or C. Herein, we report a case of late spontaneous decapsulation with subcapsular hematoma formation developing 12 years after receipt of a cadaveric allograft. The patient was infected with both hepatitis B and C viruses. Cyclosporine was replaced by sirolimus for maintenance therapy because of chronic rejection and acute deterioration of renal function. He presented to the hospital at 9 months after sirolimus inception because of a sudden onset of pain and swelling over the kidney graft. Magnetic resonance imaging found the capsule to be stripped from the kidney by a collection of liquefied hematomas. A laparoscopic fenestration was performed by creation of a peritoneal window adjacent to the renal allograft. When patients have chronic hepatitis, tacrolimus might be a better choice than sirolimus.

Lymphocele formation after anterior lumbar interbody fusion at L4-5. Case report

In this report, the authors present the case of patient with a lymphocele in the retroperitoneal area following anterior lumbar interbody fusion at L4-5. A lymphocele is a rare complication of spinal operations, especially lower lumbar spinal surgeries. The authors discuss this complicating factor and describe its features and treatments.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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 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.

Pelvic lymphocele following motor vehicle collision

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

Indications for pelvic lymphadenectomy in prostate cancer

Clearly, pelvic lymphadenectomy can provide important staging information in the management of prostate cancer, but this benefit is counterbalanced by a modest increase in morbidity and the significant cost of the procedure. It is difficult to provide universal recommendations concerning the indications for pelvic lymphadenectomy. Part of the problem lies in the fact that urologists perform pelvic lymphadenectomy for several different reasons. Some surgeons perform pelvic lymphadenectomy to better counsel patients after radical prostatectomy about their risk for disease progression and for planning adjuvant radiotherapy or hormonal therapy. For these surgeons, preoperative clinical staging parameters do not exclude patients from pelvic lymphadenectomy, and frozen section analysis intraoperatively provides no useful information. Alternatively, the staging information from pelvic lymphadenectomy can be used to justify cancellation of the subsequent prostatectomy should regional spread of prostate cancer be identified, sparing the patient the morbidity of an unnecessary radical prostatectomy. With this approach, despite the false-negative rate of up to 30%, the expense of frozen section analysis seems justified. For this second group of surgeons, the problem becomes balancing the modest morbidity and cost of pelvic lymphadenectomy against the probability that nodal spread of prostate cancer will be missed if the procedure is omitted. The authors consider a greater than 4% risk for missing regional disease to be unacceptable in this setting. Following this assumption, Table 3 outlines parameters for clinical stage, Gleason score, and preoperative PSA within which pelvic lymphadenectomy is indicated. These recommendations are based on [table: see text] predictions from the Partin nomogram, which has been validated using a series of over 4000 patients. For the large number of patients with clinical T1c disease and a preoperative PSA less than 10 ng/mL, bilateral pelvic lymphadenectomy is indicated only if prostate biopsy identifies tumor of Gleason grade 4 or higher. For lower-grade tumors in this patient population, the risk for nodal metastasis was less than 5% in the Johns Hopkins and Mayo Clinic series of over 5800 patients with prostate cancer. For a large pool of patients, the several thousand dollar cost of pelvic lymphadenectomy and the risk for injury to the obturator nerves and vessels, the formation of lymphoceles, and chronic genital edema can be eliminated with low risk. A nomogram-based approach provides only a starting point for a decision analysis framework to determine whether the surgeon should perform lymphadenectomy at the time of radical prostatectomy because current nomograms predict only lymph node positivity. In a decision analysis framework, some patient and physician value is derived from a negative lymphadenectomy. Moreover, the morbidity associated with pelvic lymphadenectomy and the potential inconvenience associated with treating such morbidity also would be factored into the decision. Consequently, a decision analysis framework that takes into account prognostic value, costs, morbidity, and health state uses ultimately will provide the most informative method for determining when pelvic lymphadenectomy is indicated in patients with prostate cancer.