Sclerosis of Postoperative Lymphoceles: Avoidance of Prolonged Catheter Drainage with Use of a Fibrin Sealant

Intranodal Glue Embolization for Postoperative Lymphatic Leaks in the Groin and Pelvis: Comparison with Sclerotherapy

PURPOSE

To compare the effectiveness of and adverse events related to intranodal glue embolization (IGE) with those of intracavitary sclerotherapy for the treatment of postoperative groin and pelvic lymphatic leaks.

MATERIALS AND METHODS

From November 2015 to July 2021, IGE for postoperative pelvic or groin lymphocele or lymphorrhea was performed in 33 patients. From January 2010 to July 2021, 28 patients with postoperative pelvic or groin lymphocele were treated with sclerosis alone. Clinical success was defined as resolution of drainage within 3 weeks of the last intervention performed without recurrence. Patients presenting >1 year after surgery or with <30 days of follow-up were excluded. Patients with lymphorrhea treated with IGE were not statistically compared with those in the sclerosis group because they were not eligible for sclerosis.

RESULTS

Clinical success was similar between the groups (lymphocele IGE, 15/18, 83.3%, vs sclerosis, 15/23, 65.2% [P = .29]; lymphorrhea IGE, 8/9, 88.9%). The mean number of interventions performed to successfully treat a lymphocele was significantly higher in the sclerosis group (2.5 for sclerosis vs 1.3 for IGE; P = .003; lymphorrhea IGE, 1.0). The mean time to resolution was significantly longer for sclerosis than for IGE (27 vs 7 days; P = .002; 4 days for lymphorrhea IGE). There were no sclerosis-related adverse events and 2 IGE-related adverse events: (a) 1 case of mild lymphedema and (b) 1 case of nontarget embolization resulting in deep vein thrombosis.

CONCLUSIONS

For treatment of postoperative pelvic and groin lymphoceles, IGE results in faster resolution with fewer interventions compared with sclerosis. IGE is also an effective treatment for postoperative groin lymphorrhea.

Retroperitoneal Viscum album extract instillation in patients with a large amount of drainage after kidney transplantation

Purpose

After kidney transplantation (KT), a large amount of drainage can delay postoperative recovery. Viscum album extract is an agent used in pleurodesis, and the purpose of this study was to evaluate the efficacy of this agent in reducing the amount of drainage after KT.

Methods

Medical records of patients with a large amount of drainage (≥ 100 mL/day) on postoperative day (POD) 7 after KT who had undergone V. album extract instillation through drainage tube (n = 115) or conservative management (n = 177) were retrospectively reviewed. The primary endpoint was a decrease in the amount of drainage on POD 14 from POD 7.

Results

A decrease in the amount of drainage on POD 14 from POD 7 was larger in the V. album extract instillation group than in the conservative management group (–228.3 ± 181.6 mL vs. –144.6 ± 202.0 mL, P < 0.001). Duration of hospitalization after operation was shorter in the V. album extract instillation group than in the conservative management group (15.9 ± 3.2 days vs. 18.1 ± 5.3 days, P < 0.001). In multivariate analysis, there was a statistically significant association of V. album extract instillation with lower risk of persistent large amount of drainage (≥ 100 mL/day on POD 14), with an odds ratio of 0.57 (95% confidence interval, 0.35–0.93; P = 0.026).

Conclusion

Retroperitoneal V. album extract instillation could be effective in reducing the amount of drainage and promoting postoperative recovery in patients with a large amount of drainage after KT.

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.

Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Povidone-iodine sclerotherapy of primary symptomatic lymphocele after kidney transplantation

OBJECTIVE

To report the efficacy and safety of povidone-iodine sclerotherapy of primary symptomatic lymphocele after kidney transplantation in a large contemporary cohort study.

PATIENTS AND METHODS

A single-institutional study was conducted including consecutive patients who underwent povidone-iodine sclerotherapy for primary symptomatic lymphocele after kidney transplantation between January 2013 and March 2020. Sclerotherapy was used as the first-line treatment of symptomatic lymphocele. Recurrent lymphoceles were managed with open or laparoscopic fenestration. The primary outcome was the efficacy of sclerotherapy which was defined as the absence of second sclerotherapy or salvage surgery.

RESULTS

A total of 965 renal transplantations were included. Sclerotherapy for primary symptomatic lymphocele was performed in 60 cases (6.2%). The median (IQR) number of instillation, the volume of povidone-iodine per instillation and drainage time were 3 (3-3), 60 (38-80) mL and 6 days (5-8), respectively. Sclerotherapy related complications were reported in eight cases (13.3%) and included five cases of accidental catheter removal, two cases of lumbosciatica, and one case of intraperitoneal diffusion of povidone-iodine. After a median (IQR) follow-up of 33 (14-60) months, treatment success was achieved in 33 cases (55%). Multivariate analysis failed to identify predictors of sclerotherapy failure. Salvage therapies included 7 s sclerotherapy and 20 surgical fenestrations with an overall success rate of 88.8% (24/27).

CONCLUSIONS

Sclerotherapy was an easy and safe procedure to treat primary symptomatic lymphocele in renal transplant recipients. Despite moderate efficacy, recurrences were easily controlled with salvage therapies. Further studies are necessary to identify predictive factors of sclerotherapy failure to directly refer patients to surgical treatment.

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.

Polidocanol foam sclerotherapy of persisting postoperative seromas after varicose vein surgery: a series of six cases

OBJECTIVE

The aim of our case series was to show the therapeutic effect and the safety of the use of polidocanol foam in ultrasound-guided sclerotherapy treatment of relatively small postoperative seromas after varicose vein surgery.

METHODS

We treated six patients with postoperative seromas after varicose vein surgery that were refractory to conventional treatments including compression dressings, repeated needle aspirations and manual lymph drainage.

RESULTS

A complete regression of the fluid collections was seen after one and two ultrasound-guided injections of polidocanol foam into the seroma cavity in two cases, respectively. Up to five treatment sessions and up to four further needle aspirations were necessary for the remaining two patients until complete regression of the seromas. No side-effects were reported.

CONCLUSION

This is the first case series to report of the regression of postoperative seromas after varicose vein surgery induced by polidocanol foam sclerotherapy.

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.

Polidocanol foam sclerotherapy is a new and effective treatment for post-operative lymphorrhea and lymphocele

BACKGROUND

The formation of post-operative lymphocele and lymphorrhea following lymph node surgery is a potentially serious complication. Until now there has been no consensus on the most effective treatment for these complications. Therefore, the aim of our clinical trial was to compare the use of polidocanol foam sclerotherapy with compression therapy to wound drainage, in the treatment of post-operative lymphoceles.

PATIENTS AND METHODS

Retrospectively we analysed the data of 33 consecutive surgical patients who had developed a post-operative lymphocele between 2004 and 2008. We offered all patients drainage with compression therapy or polidocanol foam sclerotherapy with 1-day compression to treat the post-operative lymphoceles.

RESULTS

Altogether, 12 patients were treated with polidocanol foam sclerotherapy and 21 patients were treated with drainage alone. Secretion volumes declined from initial 50-350 ml/day to 0-20 ml/day at the end of the therapy. Lymphorrhea resolved much quicker (P < 0.0001) in patients treated with polidocanol foam sclerotherapy (median 4 days, mean value 6.4 days) than in those treated with drainage (median 31 days, mean value 30.2 days). None of the patients developed a major complication.

CONCLUSION

Polidocanol foam sclerotherapy is an effective and well-tolerated new treatment for patients with post-operative lymphoceles.

Tissue glues and nonsuturing techniques

PURPOSE OF REVIEW

This article details the diverse urologic applications of tissue glues and hemostatic agents over the past 3 years in the management of genitourinary injuries, surgical wounds, and complications.

RECENT FINDINGS

Biosurgical agents designed to promote tissue adhesion and hemostasis are being increasingly employed across all surgical disciplines. Fibrin sealant is the most widely utilized biosurgical product. Gelatin matrix thrombin has proven to be an efficacious hemostatic agent. Bovine serum albumin-gluataraldehyde is a new, promising tissue glue. Complex reconstructive, oncologic and laparoscopic procedures are those most appropriate for sealant use in urology.

SUMMARY

Tissue glues and hemostatic agents are effective, safe, and their use is increasing. All urologists should have a working knowledge of these adjuncts.