Functional significance and risk factors for lymphocele formation after renal transplantation

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 Complication After Kidney Transplant: Current Literature Review and Management Algorithm

Kidney transplant is the best treatment option for patients with end-stage renal disease. It reduces mortality and improves the quality of life. However, kidney transplant presents medical and surgical complications, and one of the most common is the posttransplant lymphocele. Lymphocele complication has an incidence of up to 20% and presents with variable clinical symptoms, which are directly associated with the size and compression effect on the adjacent organs. There are reported risk factors that favor the appearance of lymphocele. Despite known factors, there are more relevant factors (male sex, deceased donor, and corticosteroids) to carry out a stricter follow-up. The treatment of lymphoceles can vary according to the severity of the symptoms, characteristics of the collection, and the patient's clinical status. Despite the high recurrence, percutaneous intervention is the initial approach in this condition. If percutaneous aspiration, drainage, and sclerotherapy are unsuccessful, then open or laparoscopic fenestration can be performed; laparoscopy is the standard of treatment since it is highly effective and has few adverse effects.

Comparison of Bipolar Electrocautery-Based Vascular Sealers with Conventional Ligation in Iliac Vessel Preparation of Renal Transplant Recipients

BACKGROUND

Post-transplant lymphocele is a common complication with a potentially severe course and may require percutaneous drainage or open/percutaneous surgical intervention. Closure of the lymphatics around the iliac vessels is paramount in avoiding lymphocele formation. This study aimed to evaluate the effectiveness of bipolar electrocautery-based vascular sealers (BSD) in the dissection and/or ligation of lymphatic vessels in terms of the development of lymphoceles and postoperative kidney functions in live donor kidney transplants at our center.

METHODS

A total of 63 patients who underwent kidney transplantation (KTx) between January and December 2021 were included in the study. Data, including postoperative creatinine values and postoperative ultrasonography follow-up, were recorded. Thirty-seven patients who were operated on using conventional ligation for iliac vessel preparation were included in group 1. Twenty-six patients treated using BSD for iliac vessel preparation were included in group 2. Statistical analysis was performed to compare these groups. This study complied with The Helsinki Congress and The Declaration of Istanbul.

RESULTS

There was no significant difference between the groups in terms of postoperative first-week creatinine values (1.176 mg/dL vs 1.203 mg/dL), first-month creatinine values (1.061 mg/dL vs 1.091 mg/dL), first-week collection volume (33.240 mL vs 33.430 mL), and third-month collection volume (23.120 mL vs 23.430 mL) (P > .05).

CONCLUSIONS

In KTx surgery, BSD is as safe as and faster than conventional ligation in preparation of the recipient's iliac vessels.

Symptomatic scrotal-inguino-retroperitoneal lymphocele in a kidney transplant patient-to drain but how to drain?

Scrotal-inguino-retroperitoneal (SIR) lymphocele is a rare complication following kidney transplant. This entity is characterized by a tract originating in the retroperitoneal space, through the inguinal canal and scrotum following lymph hydrodissection. Systematic review investigating SIR lymphocele yielded cases with open fenestration of the sac into the peritoneum as treatment. We described a case report of a male in his 60s with a functioning kidney transplant and SIR lymphocele, which was successfully managed in the short term with percutaneous drainage of the collection. However, the collection recurred and computed tomography scan showed a multiloculated collection that prompted surgical management. Intraoperatively, the encapsulated fluid-filled tract was excised and a drain was placed, which was removed 48 h later. The patient wore a hernia belt for 6 weeks as support. He had no recurrence of his lymphocele following serial reviews for 9 months now.

Lymphocele in Kidney Transplantation: A Comparison of Ligation and Non-ligation Technique of Iliac Lymphatic Dissection

BACKGROUND

To compare the incidence of lymphocele in kidney recipients following 2 lymphatic vessel division techniques: ligation and non-ligation.

METHODS

Retrospective reviews of the records of 402 patients with end-stage renal disease who underwent kidney transplantation from April 2015 to December 2019 at Siriraj Hospital.

RESULTS

Four hundred two patients were included in the study: 54.9% of the patients were male, and the patient's mean age was 41 years. There were 25.1% and 74.9% that received kidney grafts from living and deceased donors, respectively. The preoperative renal replacement therapies were 83.3% hemodialysis, 12.9% peritoneal dialysis, and 3.7% preemptive transplantation. Two hundred forty-nine patients received lymphatic division with the ligation technique and 153 patients received the non-ligation. Lymphoceles were found in 31 cases (7.7%). Lymphocele occurrence in the ligation group was lower than in the non-ligation group: 5.2% compared to 11.8% (P value = .017). There were 22.6% of lymphoceles that had a spontaneous resolution with no treatment.

DISCUSSION

The ligation of iliac lymphatic vessels during division reduced the incidence of lymphoceles non-ligation.

Predictors of Lymphatic Complications Following Renal Transplant: A Prospective Study Involving Predominantly Living Donor Transplants From India

Introduction Lymphatic complications (LC) are common (up to 33%) and troublesome after renal transplantation. Different studies have established varying medical and surgical risk factors, mostly by retrospective analysis on deceased donor renal transplants (DDRTs). The end-point is mostly lymphocele, with few reports documenting the equally important lymphorrhea. Methods In our prospective analytical study done over three years, most were living donor renal transplant (LDRT) pairs by a single team. The primary outcome measure was lymphocele and/or prolonged drainage for more than 15 days, with a six-month follow-up. The variables recorded were age, gender, hemodialysis duration, etiology, relationship, human leucocyte antigen (HLA) mismatch, induction regimen, acute rejection, warm ischemia time (WIT), and delayed graft function (DGF). Univariate analysis was by chi-square and t-tests as applicable, while logistic regression (both simultaneous and forward stepwise) was used for risk factor prediction. Results Eligible cases were 150, with 145 (97%) LDRT pairs. Donors were mostly female (122/150; 81%) with mean age (~43 years) higher than recipient age (~33 years). The common etiologies were diabetes (31%), hypertension (23%), and IgA nephropathy (11%). Most donors were mothers (37%) and wives (31%), and 28% of LDRT pairs had HLA mismatch >3. Mean duration of hemodialysis was about 18 months, and mean WIT was 52 minutes. Both DGF (B coefficient= -1.69, p<0.000) and WIT (B=-0.038, p=0.024) were significant predictors of the primary outcome, while drain removal before 15 days predicted lymphocele significantly (B=-2.4, p<0.000).  Conclusions LDRT has specific risk factors for lymphatic complications, which may be related to extent of recipient vascular dissection, arterial anastomotic time, and early drain removal.

Efficacy of Lymphatic Sealing Using the LigaSure in Kidney Transplantation: A Pilot Study

BACKGROUND

Iliac vessel lymphatic ligation is critical in kidney transplantation, because it is associated with the occurrence of lymphocele. Lymphocele can also affect the renal graft. This study aimed to evaluate the efficacy of lymphatic sealing using LigaSure (an electrothermal bipolar sealing device) in kidney transplantation as compared with conventional silk-tie ligation.

METHODS

This retrospective study included 100 consecutive patients from a prospectively registered database who underwent kidney transplantation at Seoul St. Mary's Hospital, South Korea, between December 1, 2019 and November 12, 2020. Comorbidities, primary renal disease, transplantation variables, surgical variables, and posttransplantation outcomes were compared between conventional and LigaSure lymphatic ligations. Subgroup analyses were performed by anastomosis pattern.

RESULTS

The mean age of patients was 47.4 ± 12.40 (range, 24-73) years. The LigaSure and conventional groups comprised 50 (50%) patients. Hypertension history, number of anastomosed renal arteries, and anastomosis patterns differed significantly between groups (P < .05). No significant difference was found in postoperative outcomes. In the subgroup analysis, greater drain volume was found at postoperative day 1 in the end-to-end internal iliac artery-renal artery anastomosis group (P = .001) because the internal iliac artery dissection results in longer lymphatic ligation. Nevertheless, no differences in drain removal time (P = .528) or lymphocele incidence were found between subgroups.

CONCLUSION

LigaSure is expected to benefit from surgery time and will be identified in subsequent studies. LigaSure can be safely and comfortably used for iliac lymphatic ligation in kidney transplantation. In conclusion, LigaSure lymphatic ligation is superior to conventional lymphatic ligation in kidney transplantation.

Risk Factors, Diagnosis, and Treatment of Lymphocele After Renal Transplantation: A Retrospective Study

INTRODUCTION

Despite recent advances, lymphoceles are the most frequent complications following renal transplantation (RT), with an incidence of 0.6% to 51%. In this study, we present risk factors, treatments, and outcomes for lymphoceles after RT at our center.

MATERIAL AND METHODS

Since January 2018, 461 RTs were performed at our center. Nine recipients were excluded. The remaining 452 RTs were analyzed retrospectively. Recipients were divided into 2 groups: a lymphocele group (n = 29) and a nonlymphocele group (n = 423). Lymphoceles were diagnosed by ultrasound. Statistical analyses were made using the SPSS 15 software program.

RESULTS

Twenty-nine (6.4%) of the 452 recipients developed lymphoceles. Seven of these 29 (24.1%) recipients were asymptomatic. The most common symptom was hydronephrosis (34.4%). Percutaneous drainage was performed in 21 recipients; sclerotherapy with percutaneous drainage was used in the remaining 8. In 5 (17.2%) recipients, there was a recurrence of lymphoceles. There were significant differences with respect to age (50-65 years; P = .016), use of a drainage catheter (P = .044), and polycystic kidney diseases (P = .049).

CONCLUSION

Lymphoceles can be treated successfully using the percutaneous drainage technique alone or in combination with povidone iodine. Drainage use, polycystic kidney disease, and age (50-65 years) were established as risk factors for lymphocele development.

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.

Aponeurotic-Cutaneous Tract Exeresis in Patients With Persistent Lymphorrhea After Kidney Transplantation: A Valid Approach in a Day Surgery Setting

BACKGROUND

Lymphatic disorders (LDs) are the most common minor complications after kidney transplantation (KT), with an incidence rate between 0.6% and 33.9%, which appears to be related to both surgical and medical factors. LDs mostly resolve spontaneously, but occasionally a surgical approach may be required.

MATERIALS AND METHODS

We report our experience with 7 KT recipients who developed persistent lymphorrhea (>150 mL/24 h) between October 2017 and March 2019. All cases were treated as outpatients with parietal fistulectomy (PF). The fibrotic aponeurotic-cutaneous tract was thoroughly excised, and the residual aponeurotic defect was closed by watertight suturing. Serial abdominal ultrasounds (US) were carried out after the procedure.

RESULTS

A small perirenal graft lymphocele of <2 cm was detected by US in all patients after 48 to 72 hours, without any evidence of either vascular or ureteral compression. During the subsequent scheduled US follow-up, lymphoceles did not increase in size, and additional interventions were not needed. Neither superficial nor deep surgical-site infections were recorded in such patients.

CONCLUSIONS

PF was found to be a safe and effective minimally invasive approach for persistent lymphorrhea after KT. It could be easily performed with local anesthesia in a day surgery setting and did not require patient hospitalization.

Consensus on definition and severity grading of lymphatic complications after kidney transplantation

BACKGROUND

The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy.

METHODS

Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres.

RESULTS

Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention.

CONCLUSION

A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.

Predictors of symptomatic lymphocele after kidney transplantation

Purpose

The development of a symptomatic lymphocele (SL) is a frequent postoperative surgical complication after kidney transplantation. It may lead to pain and discomfort and cause transplant malfunction or even secondary graft loss. A large cohort of renal recipients was investigated to identify the possible risk factors for SL.

Methods

All renal transplant patients of a single centre were retrospectively analysed for SL between January 2010 and December 2017. The SL group was compared to a control group from the same cohort.

Results

45 out of 1003 transplanted patients developed an SL (incidence 4.5%), on average 50 days after kidney transplantation. SLs developed more in older patients, in those with a PD catheter and in ADKDP as primary diagnosis. Surgical predictors for SLs were venous anastomosis on the external iliac vein, concomitant PD catheter removal, perfusion defects, shorter operating time, splint > 7 days, double J stenting, discharge with drain, low initial drain production and ureteral obstruction. Opening of the peritoneum, re-operation for postoperative bleeding and previous nephrectomy seem protective for developing SL.

Conclusion

We found multiple heterogeneous predictors for SL with a common denominator related to surgical management of the retroperitoneal space, peritoneum and the ureter. Future prospective studies are necessary to evaluate the influence of these variables on the development of SL.