Laparoscopic deroofing of post-transplant lymphoceles

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.

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.

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.

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.

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.

A review of laparoscopic ureteral injury in pelvic surgery

The objective of this study was to review the body of literature in reference to ureteral injury during laparoscopic surgeries and to determine: 1) the reported rates of ureteral injury; 2) the initial laparoscopic surgeries during which ureteral injury occurred; 3) the time of injury recognition (intra- versus postoperative); 4) the type, 5) the location, and 6) the mode of injury repair; and 7) the surgical laparoscopic instruments involved in ureteral injury. The appropriate medical subject heading (MSH) terms were selected and used in a search of the Medline computerized database and the online American College of Obstetricians and Gynecologists database. World literature published in the English language on ureteral injury during laparoscopic surgery between 1966 and 2003 was reviewed.A total of 70 reported instances of ureteral injury during laparoscopic surgery were identified among 2491 reported cases in which ureteral laparoscopic complications were discussed. Incidences of injury ranged from <1% to 2%. These 2491 cases of laparoscopy were presented as a mixed group, which included case reports, small series of studies, as well as longer, consecutive studies. In 18 of the 70 (25.7%) cases, the initial laparoscopic procedures during which ureteral injury occurred were not described or specified. In cases in which the type of laparoscopic surgery was specified, 14 of the 70 (20.0%) total cases of ureteral injury occurred during laparoscopically assisted vaginal hysterectomy (LAVH). Ureteral injury was identified intraoperatively in 6 of 70 (8.6%) cases, postoperatively in 49 of 70 (70.0%) cases, and, in 15 of 70 (21.4%) cases, the time of diagnosis was not specified. In 36 of the 70 (51.4%) reported injuries, the type of injury was not specified or described. In instances in which the types of injury were described, transection occurred most commonly, accounting for 14 of 70 (20.0%) injuries. The location of ureteral injury was not specified in 46 of the 70 (65.7%) cases. When location was specified, injuries most often occurred at or above the pelvic brim, accounting for 10 of the total 70 (14.3%). Electrocautery was involved in 17 of the 70 (24.3%) cases of ureteral injury, but in 34 of the 70 (48.6%) cases, the surgical laparoscopic instrument involved was not reported. A laparotomy was used to repair the ureteral injury in 43 of 70 (61.4%) cases.Ureteral injuries reported in peer-reviewed journals often lack detailed presentation of the initial laparoscopic surgeries during which ureteral injury occurred, or of the type, the location, and the instrumentation involved in ureteral injury. A high incidence of ureteral injury was found among the laparoscopic procedures analyzed in this review. Laparoscopically-assisted vaginal hysterectomy was the leading procedure in which injury occurred, and instruments involved in electrocoagulation were associated with the most injuries incurred during laparoscopic surgery.

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 treatment of lymphoceles in patients after renal transplantation

Postoperative lymphoceles after renal transplantation appear in up to 18% of patients, followed by individual indisposition, pain or impaired graft function. Therapeutic options are percutaneous drainage, needle aspiration with sclerosing therapy, or internal surgical drainage by conventional or laparoscopic approach. The laparoscopic procedure offers short hospitalisation time and quick postoperative recovery. From 1993 to 1997, 16 patients underwent laparoscopic fenestration of a post-renal transplant lymphocele, and were presented in a retrospective analysis. Three patients have had previous abdominal surgery. Following preoperative ultrasound and CT scan, 16 patients underwent laparoscopic drainage after drainage and staining of the lymphocele with methylene blue. No conversion was necessary. Mean operation time was 42 min, no intraoperative complications were seen. Oral nutrition and immunosuppression were continued on the day of surgery, and patients were discharged between the 2nd and 5th (median hospital stay 3.3 d) day after surgery. No recurrence was evident in a follow-up time of 15-54 months (median 31.4 months). Renal function remained unchanged in all patients postoperatively.

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.

Renal transplant complications. Minimally invasive management

Advancements in endourology, laparoscopic urology, and interventional radiology continue to influence the contemporary management of renal transplant complications. The successful implementation of these minimally invasive therapies significantly relies on careful patient selection; not all renal transplantation complications are suitable or amenable for this form of management--true for transplant ureteral complications and less so for other potential complications. With such a strategy, renal transplant complications can be managed efficiently and effectively with these minimally invasive modalities to minimize further recipient morbidity while also minimizing potential risk to the recipient and for the renal allograft.

Laparoscopic surgery after orthotopic liver transplantation

Laparoscopic surgery is currently a widely accepted approach to several surgical fields because of its advantages in terms of postoperative pain reduction and easy patient recovery. This approach may be useful even in solid-organ transplantation surgery as a diagnostic or treatment procedure in some surgical complications. From July 1991 to December 1998, we performed 142 liver transplantations on 129 patients. During the postoperative period, many complications occurred. Here we report two cases of intestinal occlusion caused by adhesions and three cases of lymphocele, all approached with laparoscopic surgery. In all cases but one, we were able to complete the surgery by laparoscopic means; in one of the two occlusions, the procedure was switched to laparotomy because of a choledochojejunal anastomosis lesion. The three cases of lymphocele must be considered in a particular manner because such cases, to our knowledge, have never been described in the literature. They always presented with a late-onset right pleural effusion and were located in the retrohepatic, retrogastric, and left paracaval areas, close to the esophageal hiatus. In conclusion, we believe a laparoscopic approach is a useful strategy to solve some surgical complications in patients who underwent orthotopic liver transplantation; however, the use of laparoscopic surgery in this field is strictly connected to the surgeon's experience and versatility.

Laparoscopic drainage of giant lymphocele after renal transplantation

Lymphocele is a relatively frequent complication of kidney transplantation. A 46-year-old man presented 2 years after kidney transplantation with a giant septated lymphocele. The patient underwent successful laparoscopic drainage of the collection and was discharged home on the day of the procedure. Laparoscopic drainage is a safe and effective treatment for complex lymphocele after kidney transplantation.

Laparoscopy in renal transplant patients

OBJECTIVES

To evaluate the use of laparoscopic techniques in patients with a renal transplant.

METHODS

Since 1992, 358 patients have undergone urologic laparoscopy at our hospital. Among these, 37 procedures (10.4%) were performed in patients with a renal transplant: 14 bilateral nephrectomies for severe drug-resistant hypertension, 9 marsupializations of symptomatic lymphoceles, 6 renal allograft biopsies in patients with clotting abnormalities, 6 unilateral nephrectomies, and 2 nephroureterectomies for recurrent episodes of pyelonephritis and symptomatic vesicoureteral reflux, respectively.

RESULTS

Five complications (14%) and three conversions (8%) occurred. Patients who underwent successful laparoscopic operations began mobilization and oral intake on the day after the operation. The hospital stay ranged from 1 to 6 days. In the nephrectomy groups, perioperative urine outputs remained stable and post-operative urine outputs were increased as compared with those in the perioperative period (P < 0.05). Post-operatively, serum creatinine remained stable or improved in patients who underwent nephrectomy or marsupialization of lymphocele.

CONCLUSIONS

Our results indicate that laparoscopic techniques are safe and effective in the treatment of patients with a renal transplant. Renal allograft function apparently is not affected by laparoscopic procedures.

Laparoscopical marsupialization of symptomatic post-transplant lymphoceles

Post-transplant lymphoceles after kidney transplantations occur with an incidence between 2 and 15%. In the last two years we observed four patients with symptomatic lymphoceles. After an infection or urinoma had been ruled out all cases were operated on laparascopically. All goals of open surgery in lymphoceles were achieved by this minimally invasive technique within an operating time between 40 and 70 min. No complications or recurrences occurred during a mean follow-up period of 17.8 months. Symptomatic post-transplant lymphocele is a rare event and represents an ideal indication for laparoscopic marsupialization.

Treatment of lymphocele in renal transplant recipients by laparoscopic fenestration after transcutaneous staining

Lymphocele is a rare cause of impairment of graft function after renal transplantation. Treatment ranges from external drainage to laparoscopic internal marsupialization. A therapeutic approach to the treatment of symptomatic lymphocele is described, which employs external drainage, if necessary followed by methylene blue staining and laparoscopic internal drainage, should conservative treatment fail. Five patients developed post-transplant lymphocele of varying size and were treated according to this protocol. Identification of the blue lymphocele at laparoscopy was straightforward and complete marsupialization was performed. After a mean follow-up of 8.4 months all patients are free from symptoms and have well functioning grafts.