An analysis of the risk factors and management of lymphocele after pelvic lymphadenectomy in patients with gynecologic malignancies

Vascular clips for preventing lymphocele and symptomatic lymphocele in patients with gynecologic malignancies after laparoscopic pelvic lymphadenectomy

STUDY OBJECTIVE

To evaluate the effectiveness of using vascular clips to seal targeted lymphatics in gynecological malignancies for the prevention of postoperative pelvic lymphocele and symptomatic lymphocele after laparoscopic pelvic lymphadenectomy.

DESIGN

Retrospective analysis.

SETTING

Single-center academic hospital.

PATIENTS

In total, 217 patients with gynecological malignancies were included.

INTERVENTIONS

Patients were classified into two groups: group 1 (vascular clips were used to seal the targeted lymphatics) and group 2 (electrothermal instruments were used to seal the targeted lymphatics). The patients were followed up 4-6 weeks after surgery to evaluate the incidence of lymphoceles by ultrasound or CT. Symptomatic lymphoceles are defined as those that cause infection, deep vein thrombosis with or without swelling of the extremities, edema (swelling) of the extremities or perineum, hydronephrosis and/or moderate to severe pain.

MEASUREMENT AND MAIN RESULTS

One hundred and thirteen patients were enrolled in group 1, and 104 patients were enrolled in group 2. Lymphoceles were observed in 46 (21.2%) patients. Fewer lymphoceles occurred in group 1 than in group 2 [8 (7.1%) vs. 38 (36.5%), p < 0.001]. The percentage of significantly sized lymphoceles was lower in group 1 than that in group 2 [4 (3.5%) vs. 30 (28.8%), p < 0.001]. Symptomatic lymphoceles occurred in 18 patients (8.3%), and only one (1.0%) occurred in group 1, while 17 (16.3%) occurred in group 2 (p < 0.001). A multivariate analysis revealed that vascular clips were the only independent factor for preventing lymphocele (OR = 7.65, 95% CI = [3.30, 17.13], p < 0.001) and symptomatic lymphocele (OR = 22.03, 95% CI = [2.84, 170.63], p = 0.003).

CONCLUSIONS

The results indicate that the use of vascular clips may be useful for the prevention of the development of lymphocele and symptomatic lymphocele secondary to pelvic lymphadenectomy performed via laparoscopy.

Symptomatic Lymphocele After Robot-Assisted Pelvic Lymphadenectomy as Part of the Primary Surgical Treatment for Cervical and Endometrial Cancer: A Retrospective Cohort Study

STUDY OBJECTIVES

Pelvic lymph node dissection (PLND) is part of the primary treatment for early-stage cervical cancer and high-intermediate risk or high-risk endometrial cancer. Pelvic lymphocele is a postoperative complication of PLND, and when symptomatic, lymphoceles necessitate treatment. The aim of this study was to investigate the incidence and risk factors of symptomatic lymphocele after robot-assisted laparoscopic PLND in cervical and endometrial cancer.

DESIGN

Retrospective cohort study.

SETTING

Single-center academic hospital.

PATIENTS

Two hundred and fifty-eight patients with cervical cancer and 129 patients with endometrial cancer.

INTERVENTIONS

Pelvic lymphadenectomy by robot-assisted laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

The authors retrospectively included all patients with early-stage cervical cancer and high-intermediate risk or high-risk endometrial cancer who underwent pelvic lymphadenectomy by robot-assisted laparoscopic surgery between 2008 and 2022. Medical records were reviewed for the occurrence of a symptomatic lymphocele. Univariate and multivariate logistic regression analyses were conducted to identify risk factors for developing a symptomatic lymphocele. In total, 387 patients, 258 with cervical cancer and 129 with endometrial cancer, were included in the study. The overall incidence of symptomatic lymphoceles was 9.6% with a median follow-up of 47 months [interquartile range 23-61]. For the entire cohort, smoking was the only significant risk factor for symptomatic lymphoceles identified in univariate (OR 2.47, 95% CI 1.19-5.11) and multivariate analysis (OR 2.42, 95% CI 1.16-5.07). For cervical cancer, body mass index (BMI) (OR 1.09, 95% CI 1.00-1.17) and prior abdominal surgery (OR 2.75, 95% CI 1.22-6.17) were also identified as significant independent risk factors. For endometrial cancer, age was identified as a significant independent risk factor (OR 0.90, 95% CI 0.83-0.97).

CONCLUSION

This single-center cohort study demonstrated an incidence of almost 10% of symptomatic lymphoceles after robot-assisted laparoscopic PLND for cervical cancer and endometrial cancer, with a higher risk observed among patients who smoke at the time of diagnosis. Furthermore, risk factors differ between the 2 populations, necessitating further studies to establish risk models.

Intra-lymphocele microsurgical identification of causative afferent vessels for effective lymphaticovenular anastomosis in lymphocele treatment: A case report

Lymphoceles are an important complication of pelvic and abdominal surgery with a reported incidence of 11%-88%. Conventional treatment includes compression, puncture aspiration, sclerotherapy, and ligation but recurrence is not uncommon and is difficult to treat. Recently, microsurgical lymphaticolymphatic anastomosis, lymphaticovenular anastomosis (LVA) and reconstruction of lymphatic circulation with flaps are increasingly being utilized for lymphocele treatment. Effective microsurgical treatment requires precise identification of the causative afferent vessels for the most efficient circulatory by-pass. However, direct identification of these vessels using traditional lymphoscintigraphy and near infrared lymphography is challenging and often not possible. We report the case of a 55-year-old woman who presented with bilateral inguinal lymphoceles and lymphedema following pelvic surgery for vulvovaginal cancer. Bilateral multiple LVAs of the lower extremities were performed and the lower limb circumferences reduced postoperatively, however both lymphoceles still persisted. The patient was successfully treated by approaching the lymphoceles from inside the lymphocele cavity. The causative afferent lymph vessels were directly identified microsurgically by gentle pressure on the inner wall and causative afferent lymph vessel lymphaticovenular anastomosis was performed. The lymphoceles resolved promptly after surgery without complications, and no recurrence was observed on 5 years follow-up. This case report presents an innovative microsurgical approach to lymphocele treatment, including examination and techniques to identify the causative afferent lymphatic vessels for effective anastomosis. We report this case to demonstrate the importance of lymphatic vessel selection in the microsurgical treatment of lymphocele.

The incidence of perioperative lymphatic complications after radical hysterectomy and pelvic lymphadenectomy between robotic and laparoscopic approach : a systemic review and meta-analysis

BACKGROUND

Although many studies have reported perioperative complications after radical hysterectomy and pelvic lymph node dissection using robotic and laparoscopic approaches, the risk of perioperative lymphatic complications has not been well identified. The aim of this meta-analysis is to compare the risks of perioperative lymphatic complications after robotic radical hysterectomy and lymph node dissection (RRHND) with laparoscopic radical hysterectomy and lymph node dissection (LRHND) for early uterine cervical cancer.

MATERIALS AND METHODS

The authors searched the PubMed, Cochrane Library, Web of Science, ScienceDirect, and Google Scholar databases for studies published up to July 2022 comparing perioperative lymphatic complications after RRHND and LRHND while treating early uterine cervical cancer. Related articles and bibliographies of relevant studies were also checked. Two reviewers independently performed the data extraction.

RESULTS

A total of 19 eligible clinical trials (15 retrospective studies and 4 prospective studies) comprising 3079 patients were included in this analysis. Only 107 patients (3.48%) had perioperative lymphatic complications, of which the most common was lymphedema ( n =57, 1.85%), followed by symptomatic lymphocele ( n =30, 0.97%), and lymphorrhea ( n =15, 0.49%). When all studies were pooled, the odds ratio for the risk of any lymphatic complication after RRHND compared with LRHND was 1.27 (95% CI: 0.86-1.89; P =0.230). In the subgroup analysis, study quality, country of research, and publication year were not associated with perioperative lymphatic complications.

CONCLUSIONS

A meta-analysis of the available current literature suggests that RRHND is not superior to LRHND in terms of perioperative lymphatic complications.

Lymphatic Complications Following Sentinel Node Biopsy or Pelvic Lymphadenectomy for Endometrial Cancer

Sentinel node biopsy (SNB) is performed worldwide in patients with endometrial cancer (EC). The aim of this study was to evaluate and compare the occurrence rate of lymphatic complications between SNB and pelvic lymphadenectomy (LND) for EC. The medical records of women who underwent SNB or pelvic LND for EC between September 2012 and April 2022 were assessed. A total of 388 patients were enrolled in the current study. Among them, 201 patients underwent SNB and 187 patients underwent pelvic LND. The occurrence rates of lower-extremity lymphedema (LEL) and pelvic lymphocele (PL) were compared between the patients who underwent SNB and those who underwent pelvic LND. The SNB group had a significantly lower occurrence rate of lower-extremity LEL than the pelvic LND group (2.0% vs. 21.3%, p < 0.01). There were no patients who had PL in the SNB group; however, 4 (2.1%) patients in the pelvic LND group had PL. The occurrence rates of lower-extremity LEL and PL were significantly lower in patients who underwent SNB than those who underwent pelvic LND. SNB for EC has a lower risk of lymphatic complications compared to systemic LND.

Is advanced bipolar v anced bipolar vessel sealing de essel sealing device really eff eally effective in decreasing the pelvic lymphocele ratio in open surgery for endometrial cancer?

BACKGROUND

We aim to show pelvic lymphocele (PL) rates in patients who were operated for endometrial cancer (EC) and underwent systematic paraaortic bilateral pelvic lymph node dissection (PABPLND) with advanced bipolar vessel sealing device (ABVSD).

METHODS

The medical files of all patients who underwent open surgery for EC between January 2017 and December 2021 were retrospectively analyzed. One hundred three patients who operated with the diagnosis of high-intermediate and high-risk endometrial cancer were included. Systematic PABPLND was performed with total abdominal hysterectomy with or without bilateral salpingo-oophorectomy during surgery to all patients. All operations were performed by same three surgeons who were expert in their field. While the lymph packages were removed during surgical dissection, the distal afferent and proximal efferent lymphatic channels were sealed with LigaSure™ blunt tip sealer/divider (Medtronic, Covidien, USA). The patients were scanned with computed tomography (CT) between 8 and 12 weeks postoperatively. Lymphocele diagnosis was confirmed by radiologists and largest diameter was recorded. Clinical-pathological findings of all patients were recorded.

RESULTS

Mean age and body mass index (BMI) of all participants were 58.6 ±10.2 years and 28.1± 5.6 kg/m2 . The most histopathological findings were endometrioid type (84.5%) and grade 2 (44.2%) ECs. The pelvic lymphocele (PL) was detected with CT in 24 of 103 patients at 8 to 12 weeks postoperatively. Only two PL patients were symptomatic. The first patient had symptoms of pelvic fullness and compression while the second patient had infected image. PL was located to right pelvic area in first case while the second was located on the vaginal cuff.

DISCUSSION

The dissection and sealing of major lymph vessels were achieved during the removal of all lymph packages with LigaSure™ blunt tip laparoscopic sealer/divider. The use of advanced bipolar systems can reduce the formation of PL in lymph node dissection in endometrial cancer.

The incidence of postoperative symptomatic lymphocele after pelvic lymphadenectomy between abdominal and laparoscopic approach: a systemic review and meta-analysis

OBJECTIVE

To evaluate the risks of symptomatic lymphocele after pelvic lymphadenectomy between the laparoscopic and abdominal approach in uterine cervical and endometrial cancer.

METHODS

We searched Ovid Medline, Ovid EMBASE, and the Cochrane library through April 2020. We selected the comparative studies contained information on symptomatic lymphoceles in postoperative complications. All articles searched were independently reviewed and selected by two researchers. A meta-analysis was performed using the Stata MP version 16.0 software package.

RESULTS

A total of 33 eligible clinical trials were ultimately enrolled in this meta-analysis. When all studies were pooled, the odds ratios (OR) of the laparoscopic approach for the risk of symptomatic lymphoceles compared to the abdominal approach was 0.58 [95% confidence interval (CI): 0.42-0.81, p = 0.022, I-squared = 0.0%]. The risk of postoperative symptomatic lymphoceles in the laparoscopic group tended to decrease over time in the cumulative meta-analysis. In the subgroup analysis, there was no evidence for an association between cancer type, quality of the study methodology, hysterectomy type, and postoperative symptomatic lymphoceles. However, in a recently published article, being overweight (body mass index ≥ 25) and studies conducted in oriental area were associated with a lower incidence of postoperative symptomatic lymphoceles.

CONCLUSION

Laparoscopic lymphadenectomy was associated with a significantly lower risk of postoperative symptomatic lymphoceles than abdominal lymphadenectomy (PROSPERO registration number: CRD 42,020,187,165).

Incomplete lymphatic sealing around the inferior mesenteric artery is a risk factor for chylous ascites in robotic rectal cancer surgery

INTRODUCTION

Compared with laparoscopic surgery (LS), robotic surgery (RS) is considered to have acceptable outcomes in rectal cancer, but few reports have focused on chylous ascites in RS. The aim of this study was to investigate the incidence and etiology of chylous ascites after RS.

METHODS

This retrospective study included 291 patients with rectal cancer who underwent RS (n = 165) or LS (n = 126) with high ligation of the inferior mesenteric artery (IMA). Propensity score matching (PSM) was performed to compare the two groups.

RESULTS

\Dissection around the IMA was achieved using ultrasonic coagulating shears in most LS cases, and monopolar scissors in most RS cases, sometimes using bipolar vessel sealing device or bipolar forceps. The incidence of chylous ascites was 12.2% in RS and 4.1% in LS after PSM (P = .037). When limited to the RS group, multivariate analysis identified absence of lymphatic sealing at the left side of the IMA and shorter operative time as independent risk factors for chylous ascites. Except for duration of drain placement, no outcomes differed significantly with or without chylous ascites. One patient with chylous ascites developed later infection and required antibiotic treatment.

CONCLUSION

The incidence of chylous ascites is significantly higher in RS than in LS, and RS with incomplete lymphatic sealing around the IMA is a risk factor for chylous ascites in rectal cancer. Although outcomes for patients with chylous ascites were acceptable, adequate lymphatic sealing during dissection around the IMA is crucial to prevent chylous ascites in RS.

Lymphatic Interventions in the Cancer Patient

PURPOSE OF REVIEW

The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks.

RECENT FINDINGS

Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.

Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles

PURPOSE

 Lymphoceles often occur within several weeks or even months after surgery. Mostly asymptomatic and therefore undiagnosed, they may be self-healing without any treatment. A small percentage of postoperative lymphoceles are symptomatic with significant pain, infection, or compression of vital structures, thus requiring intervention. Many different treatment options are described in the literature, like drainage with or without sclerotherapy, embolization of lymph vessels, and surgical approaches with laparoscopy or laparotomy. Inspired by reports stating that postoperative suction drainage can prevent the formation of lymphoceles, we developed a simple protocol for vacuum-assisted drainage of symptomatic lymphoceles, which proved to be successful and which we would therefore like to present.

MATERIALS AND METHOD

 Between 2008 and 2020, 35 patients with symptomatic postoperative lymphoceles were treated with vacuum-assisted suction drainage (in total 39 lymphoceles). The surgery that caused lymphocele formation had been performed between 8 and 572 days before. All lymphoceles were diagnosed based on biochemical and cytologic findings in aspirated fluid. The clinical and imaging data were collected and retrospectively analyzed.

RESULTS

 In total, 43 suction drainage catheters were inserted under CT guidance. The technical success rate was 100 %. One patient died of severe preexisting pulmonary embolism, sepsis, and poor conditions (non-procedure-related death). In 94.8 % of symptomatic lymphoceles, healing and total disappearance could be achieved. 4 lymphoceles had a relapse or dislocation of the drainage catheter and needed a second drainage procedure. Two lymphoceles needed further surgery. The complication rate of the procedure was 4.6 % (2/43, minor complications). The median indwelling time of a suction drainage catheter was 8-9 days (range: 1-30 days).

CONCLUSION

 The positive effects of negative pressure therapy in local wound therapy have been investigated for a long time. These positive effects also seem to have an impact on suction drainage of symptomatic lymphoceles with a high cure rate.

KEY POINTS

  · Suction drainage of lymphoceles is an easy and successful method to cure symptomatic lymphoceles at various locations.. · We believe this to be due to the induction of cavity collapse and surface adherence.. · In most cases rapid clinical improvement could be obtained..

CITATION FORMAT

· Franke M, Saager C, Kröger J et al. Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1586-3652.

Recommendations and Clinical Validation of Inguinal Clinical Target Volume Delineation in Penile Cancer

PURPOSE

This study determined the patterns of distribution of inguinal nodes and the optimal margin needed around the femoral vessels to propose guidelines for inguinal clinical target volume (CTV) delineation in penile cancer.

METHODS AND MATERIALS

Patients with biopsy-proven penile squamous cell carcinoma with inguinal node metastases were identified on a computed tomography scan. Distribution of nodes and distance of nodes to the nearest femoral vessel and inferior edge of pubic symphysis (IPS) were obtained. A 3-dimensional CTV margin to cover 95% of the nodes was estimated to evolve contouring guidelines. A comprehensive contouring guide with a visual atlas for inguinal CTV delineation was created. The proposed CTV was prospectively validated in 14 consecutive patients with penile squamous cell carcinoma treated with post-operative radiation therapy to the inguino-femoral region.

RESULTS

Of the 222 inguinal lymph nodes analyzed in 33 patients, 99% were located anterior (81% antero-medial, 18% antero-lateral) to femoral vessels. A majority (95%) of the antero-laterally located nodes were superior to IPS. Margin around the femoral vessels to cover 95% of the nodes for supra-IPS region in anterior, medial, and lateral directions was 29, 23, and 21 mm, respectively, and for infra-IPS region in anterior and medial directions was 21 and 23 mm, respectively. Cranial and caudal extent of CTV delineation with respect to IPS was at 48 and 50 mm, respectively for 95% nodal coverage. On prospective validation, after a median follow-up of 24 months (range, 5-31), none of the patients developed marginal recurrences. Grade 1 and grade 2 lymphedema was seen in 6 (42.8%) and 4 (28.5%) patients, respectively.

CONCLUSIONS

This study analyzed pattern of distribution of inguinal nodes and proposes guidelines for inguinal CTV delineation in penile cancer. The proposed guidelines were validated prospectively in a small cohort of patients and found to be implementable and safe.

Risk factors for lymphatic complications following lymphadenectomy in patients with endometrial cancer

OBJECTIVE

Lymph node (LN) metastasis is among the important prognostic factors for survival in endometrial cancer (EC). This study aimed to evaluate the occurrence of lymphatic complications following lymphadenectomy in patients with EC.

MATERIALS AND METHODS

EC patients were retrospectively evaluated. Lower extremity lymphedema (LEL) and pelvic lymphocele (PL) were evaluated according to the International Society of Lymphology guidelines and the National Cancer Institute Common Terminology Criteria for Adverse Events, respectively.

RESULTS

A total of 289 patients were enrolled. Surgery was performed via laparotomy and laparoscopy in 200 (69.2%) and 89 (30.8%) patients, respectively. LEL and PL occurred in 43 (14.9%) and 33 (11.4%) patients, respectively. In multivariate logistic regression analysis, circumflex iliac node (CIN) removal (odds ratio [OR]: 3.22; 95% CI: 1.43-7.98; P = 0.004) was an independent risk factor for LEL, while the surgical approach (OR: 4.46; 95% CI: 1.13-29.9; P = 0.004) was an independent risk factor for PL.

CONCLUSION

CIN dissection was a significant risk factor for LEL, while laparotomy was an independent risk factor for PL compared to laparoscopy in EC patients. This suggests that laparoscopic surgery combined with sentinel lymph node navigation surgery will prevent lymphatic complications in low-risk EC patients.

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.

Managing infected seroma post-lymphadenectomy; A retrospective cohort study and cost analysis in melanoma patients

BACKGROUND AND PURPOSE

Seromas are a common and unavoidable complication following lymphadenectomy, and often become clinically significant with superseded infection requiring re-admission for prompt intervention. However, there is no consensus as to whether a formal surgical incision and drainage (I&D), ultrasound (US)-guided aspiration or intravenous (IV) antibiotics alone is the most efficacious method of managing an infected seroma, the investigation of which formed the rationale for this study.

SUBJECTS AND METHODS

This retrospective cohort study included a consecutive series of patients readmitted for infected seroma following a lymphadenectomy for melanoma at Leeds Teaching Hospitals Trust (LTHT) from 2006 to 2017. Details on management, length of hospital stay, length of follow-up and number of clinical appointments required were examined.

FINDINGS

Seventy-one cases of infected seroma were identified from the cohort of 1691 lymphadenectomies. Initially, 21 patients (29.5%) were managed by IV antibiotics alone (failure rate of 52.4%); 18 (25.4%) with US-guided aspiration (failure rate 27.8%) and 32 (45.1%) with surgical I&D, which was 100% effective. Ultimately, 62.5% of the cohort required surgical management. Patients who underwent surgical I&D were discharged significantly faster following the procedure (3 versus 5 days for US-guided aspiration, p = 0.002) and spent fewer days in hospital overall (p = 0.022). The overall average cost was comparable across the three treatment groups.

CONCLUSIONS

Surgical management seemed preferential to conservative approaches in terms of efficacy and was not significantly more expensive overall; but carries anaesthetic risk. There may be a clinically significant difference in outcome depending on management; however, more evidence is required to investigate this.

Impact of Sentinel Node Mapping in Decreasing the Risk of Lymphocele in Endometrial Cancer

OBJECTIVE

Due to the growing evidence of sentinel lymph node (SLN) mapping in endometrial cancer (EC), our aim was to evaluate the impact of SLN mapping and other clinical-pathological variables in the risk of developing lymphocele.

METHODS

We retrospectively analyzed a series of patients with ECs who underwent lymph node staging with SLN mapping with or without systematic pelvic ± para-aortic lymphadenectomy from November 2012 to January 2020. The lymphocele diagnosis was performed by computed tomography or magnetic resonance imaging.

RESULTS

Of 348 patients included, 178 underwent SLN mapping only and 170 underwent SLN mapping and systematic lymphadenectomy (46.5% pelvic only; 53.5% pelvic and para-aortic). Seventy-three (21%) patients had open surgery and 275 (79%) had a minimally invasive approach. After a median follow-up of 25.4 months, the overall prevalence of lymphocele was 8.6% (n = 30), with 29 cases in a pelvic location. Lymphocele was found in 3.4% (n = 6/178) of patients submitted to SLN mapping only, compared with 14.1% (n = 24/170) among those who underwent SLN with lymphadenectomy (p = 0.009). Among those patients with lymphocele, seven (23.3%) were symptomatic and five (16.6%) required drainage. All symptomatic cases occurred in lymphoceles larger than 4 cm (p = 0.001). Neither resected lymph node count nor the type of systematic lymphadenectomy were related to the presence of lymphocele. Systematic lymphadenectomy was the only factor that emerged as a risk factor for the presence of lymphocele in multivariate analysis (odds ratio 3.68, 95% confidence interval 1.39-9.79; p = 0.009).

CONCLUSIONS

Our data suggest that SLN mapping independently decreases the risk of lymphocele formation compared with full lymphadenectomy in EC.

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

Objectives:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Distribution of lymphocele following lymphadenectomy in patients with gynecological malignancies

OBJECTIVE

This study identified the distribution of lymphocele, as well as the factors associated with lymphocele formation, in patients undergoing pelvic and/or para-aortic lymph node dissection (PLND and/or PALND) for gynecologic malignancies.

METHODS

This study was retrospective, and data were collected from patients who underwent surgical procedures including lymphadenectomy due to gynecologic malignancies from March 2013 to May 2016. Lymphocele was defined by postoperative computer tomography within 2 weeks after surgery.

RESULTS

A total of 116 patients underwent lymphadenectomy, of whom, 47 (42.0%) developed lymphocele and 14 (12.1%) had symptomatic lymphocele formation. The affecting factors of lymphocele formation were PLND concomitant with PALND and a large amount of blood loss ≥600 mL (P=0.030 and P=0.006, respectively). All clinical factors were not significantly different between patients with symptomatic and asymptomatic lymphocele. Lymphocele developed more frequently in the left side (67.1%) of the body compared to the right side (48.7%), and in the pelvic area (75.9%) compared to the para-aortic area (24.1%, P<0.001, both).

CONCLUSION

Lymphocele formation is more prevalent in the left and pelvic area of the body compared to the right and paraaortic side. PLND concurrent with PALND and large amounts of blood loss were significant risk factors for lymphocele formation.

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.

Comparison of lymphatic complications between sentinel node navigation surgery and pelvic lymphadenectomy in patients with cervical cancer

BACKGROUND

Sentinel node navigation surgery (SNNS) has been frequently used in early cervical cancer. However, the incidence and potential reduction of lymphatic complications following the removal of the sentinel lymph node remain unknown. Thus, this study aimed to evaluate the occurrence of lymphatic complications post sentinel node navigation surgery in patients with early cervical cancer.

METHODS

A total of 167 patients, including 70 and 97 patients who had undergone SNNS and pelvic lymphadenectomy (PLA), respectively, were enrolled in this study. We compared the lymphatic complications (lower extremity lymphedema and pelvic lymphocele) between the SNNS and PLA groups.

RESULTS

The median number of sentinel lymph nodes removed was 2 (range: 1-14). Among the 70 patients in the SNNS group, there were 0 (0%) and 3 (4.3%) occurrences of lower extremity lymphedema and pelvic lymphocele, respectively. The occurrences of lower extremity lymphedema and pelvic lymphocele were significantly lower in the SNNS group than in the PLA group, despite circumflex iliac node removal.

CONCLUSIONS

The occurrence of lymphatic complications (lower extremity lymphedema and pelvic lymphocele) was significantly lower in the SNNS group than in the PLA group. We found that SNNS, and not PLA, was the best treatment option for preventing the development of lower extremity lymphedema and pelvic lymphocele, despite circumflex iliac node preservation.

Early Postoperative Complications and Outcomes of Kidney Transplantation in Moderately Obese Patients

BACKGROUND

Obese renal transplant recipients (body mass index [BMI] ≥30 kg/m²) are at risk of delayed graft function and postoperative complications, such as infections or delayed wound healing. There is also a tendency to exclude extremely obese patients from transplantation (KTx). Nonetheless, no association between obesity and increased mortality has been reported. The aim of this study is to evaluate the effect of BMI on the most common surgical and infectious complications after KTx.

MATERIALS AND METHODS

An observational study in 872 patients transplanted from 2010-2017 was conducted. Median BMI was 24.6 (13.9-34.3), and 8.3% of the group was obese. Patient records were searched for early postoperative complications: lymphocele or hematoma (>33 mL), urinary leakage, or urinary tract infection (UTI). Mann-Whitney U and χ² or Fisher exact tests were used. P < .05 was considered statistically significant. The study complies with the Helsinki Congress and the Istanbul Declaration.

RESULTS

Renal primary nonfunction was observed in 1.4% (12/872) of patients. Surgical or infectious complications occurred in 52.7% (453/860) of patients. No correlation between BMI and complication rate was noted. Complications were observed in 56.9% (41/72) of obese vs 52.3% (412/788) of nonobese patients (P = .448), including lymphocele in 15.3% vs 16.4% (P = .810), hematoma in 22.2% vs 19.2% (P = .530), urinary leakage in 1.4% vs 4.6% (P = .203), and UTI in 31.9% vs 32.9% (P = .873), respectively.

CONCLUSIONS

Recipient's BMI has no significant association with the most common surgical complications after KTx. There is no need to delay KTx in moderately obese patients.

Effect of using magnifying loupe glasses on lymphocele formation and surgical outcomes in gynecologic oncology

Objective:

To investigate the effect of using magnifying loupes during surgery on surgical outcomes and lymphocele formation.

Materials and Methods:

We prospectively enrolled 36 patients with gynecologic cancer who underwent pelvic and para-aortic lymphadenectomy. Age, body mass index, menopausal status, type of cancer, comorbid diseases, preoperative albumin and albumin replacement therapy, performance status, serum CA125, hemoglobin, platelets and white blood cells, surgical procedure, blood loss, blood transfusion, the count of removed lymph nodes, presence of metastatic lymph nodes, total amount of drainage, postoperative complications, operation length, and count of used hemoclips were recorded. Patients were randomized into two groups: group 1 operated using loupe glasses, and group 2, without loupes.

Results:

In the loupe-negative group, total drainage volume was 6698 mL, whereas in the loupe-positive group, it was only 1049 mL (p<0.01). Postoperatively, the mean drainage duration was 10.6±5.1 days in loupe-negative group and 4.8±2.4 days in the loupe-positive group (p=0.0001). There were no differences between the two groups in terms of surgical site infections, fascial defects, and pulmonary thromboembolism (p=0.39, 0.33, 0.59, respectively). There was no significant difference in the number of harvested lymph nodes in patients who underwent surgery with or without loupes being used. The count of used hemoclips were 50.22±8.05 and 41.38±9.7 for the loupe-negative and positive groups, respectively (p<0.01). There was no lymphocele in the loupe-positive group, but we detected 5 (27.8%) lymphocele in the loupe-negative group (p=0.05).

Conclusion:

Gynecologic oncologic surgeons can add magnifying loupe glasses to their armament and benefit from this technical device; lymphocele development, total drainage volume, length of drainage time, and clip counts can be decreased by using loupe glasses in gynecologic cancer surgery.

A Case of Left Groin Lymphocele Postoperatively

Many surgical procedures may injure lymphatic channels unexpectedly, such as lymph node dissections, transplantations, and vessel reconstructions, and will lead to iatrogenic lymphatic leakage. We hereby present a case of postoperative lymphocele diagnosed more precisely by single-photon emission computed tomography (SPECT)/CT fusion imaging.

Predictive Factors of Deep Vein Thrombosis in Gynecologic Cancer Survivors with Lower Extremity Edema: A Single-Center and Retrospective Study

This study was conducted to examine predictive factors of deep vein thrombosis (DVT) in gynecologic cancer survivors with lower extremity edema (LEE). In the current single-center, retrospective study, there was a total of 315 eligible patients, including 80 patients with DVT and 235 without DVT. They were therefore divided into two groups: the DVT group (n = 80) and the non-DVT group (n = 235). Then, baseline and clinical characteristics of the patients were compared between the two groups. In our study, distant organ metastasis, advanced stage, lymphadectomy, and amount of intraoperative blood loss had a positive predictive value for the occurrence of DVT in gynecologic cancer survivors presenting LEE. In conclusion, our results indicate that it is necessary to consider the possibility of LEE arising from DVT in gynecologic cancer survivors with advanced-stage cancer, distant organ metastasis, lymphadectomy, and intraoperative blood loss over 1500 mL.

Incidence of and risk factors for lymphocele formation after lateral pelvic lymph node dissection for rectal cancer: a retrospective study

AIM

Pelvic lymphocele is a common complication that develops after pelvic lymph node dissection. The incidence of pelvic lymphocele formation has been reported to be 10.5-51% after gynaecological or urological procedures. However, no evidence has been reported thus far with regard to the development of pelvic lymphocele following lateral pelvic lymph node dissection (LPND) for low rectal cancer. The aim of this study was to investigate the incidence of and risk factors for lymphocele formation after LPND for low rectal cancer and to examine its clinical management.

METHOD

We retrospectively analysed the incidence of and risk factors for pelvic lymphocele formation after LPND for rectal cancer in our hospital between January 2012 and December 2017. We also compared the size of the lymphocele between asymptomatic and symptomatic patients by using CT volumetry and examined its clinical management.

RESULTS

A total of 30 out of 98 patients (30.8%) developed pelvic lymphocele after rectal LPND. The number of resected nodes was significantly higher in patients with a pelvic lymphocele (P < 0.01). The median volume was significantly higher in patients with symptomatic pelvic lymphocele (P = 0.011). Among the nine symptomatic patients, two underwent CT-guided drainage, one underwent transurethral ureteral stent placement and one underwent laparoscopic marsupialization.

CONCLUSION

It is essential to keep in mind the possibility of pelvic lymphocele formation during follow-up of patients who undergo LPND, and to consider an appropriate treatment when these patients are symptomatic.

Treatment of lymphocele with negative pressure wound therapy post inguinal mass excision: A case-report

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Safe and effective approach for treating inguinal lymphocele.

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Excision with ligation of lymphatic vessels.

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Negative pressure wound therapy.

Introduction

A lymphocele is defined as an atypical collection of lymphatic fluid not bordered by distinct epithelial lining, which develops in anatomic compartments. Inguinal lymphocele is a common complication of surgery in the inguinal region, with an incidence ranging from 1 to 87 %. This report summarizes the management of an inguinal lymphocele post excision of an inguinal mass.

Presentation of case

Herein, we present a case in which an inguinal lymphocele developed four months post excision of an inguinal mass, which was later diagnosed as lymphoma and treated with iliac chain radiation therapy. The conservative treatment with lymphocele drainage, compression dressing and prophylactic antibiotic was initially implemented. As the patient did not respond to conservative treatment, the surgical strategy consisted of excision of lymphocele associated with lymphatic ducts ligation. Negative pressure wound therapy completed the treatment.

Discussion

Non-surgical treatment of lymphocele developing from lymphatic injure during groin dissection is not rarely unsuccessful. Surgical options include lymphocele excision with either ligation of the lymphatic ducts or lymphatic-venous shunts between afferent lymphatics and the collateral branch of great saphenous vein. Vacuum-assisted closure therapy assists the wound healing process by increasing blood flow, removing inhibiting factors of wound healing and decreasing the bacterial count.

Conclusion

Inguinal lymphocele that is not reabsorbed or does not resolve with conservative treatment should be surgically treated. Lymphocele excision with ligation of lymphatic vessels, followed by negative pressure wound therapy appears to be a safe and effective approach.

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.

Predictors of Lymphoceles in Women Who Underwent Laparotomic Retroperitoneal Lymph Node Dissection for Early Gynecologic Cancer: A Retrospective Cohort Study

Background: Lymphoceles could represent a detrimental complication after retroperitoneal lymph node dissection. Our aim was to elucidate predictors of lymphoceles. Methods: Between 2011 and 2017, medical records of consecutive women who underwent laparotomic retroperitoneal lymph node dissection for FIGO stage I or II gynecologic cancer were reviewed. Results: A total of 204 women, including those with lymphoceles (n = 31) and symptomatic lymphoceles (n = 7), were reviewed. According to multivariable analysis, parity (odds ratio = 0.59, p = 0.003), adjuvant pelvic radiotherapy (odds ratio = 2.60, p = 0.039), and peritoneal nonclosure without pelvic drainage (odds ratio = 2.31, p = 0.048) were predictors of lymphoceles. In addition, parity (odds ratio = 0.73, p = 0.03), hypertension (odds ratio = 2.62, p = 0.02), and peritoneal partial closure with pelvic drainage (odds ratio = 0.27, p = 0.02) were predictors of complications. Conclusion: Low parity, adjuvant pelvic radiotherapy, and peritoneal nonclosure without pelvic drainage were associated with increased lymphocele formation. In addition, a lower complication rate was found in the peritoneal partial closure with pelvic drainage group; thus, peritoneal partial closure with pelvic drainage might be suggested for women who undergo laparotomic retroperitoneal lymph node dissection.

Risk factors for lymphatic complications following lymphadenectomy in patients with cervical cancer

Background

The purpose of this study was to evaluate the occurrence of lymphatic complications following pelvic lymphadenectomy (PLA) in patients with cervical cancer.

Methods

A retrospective study of 169 cervical cancer patients was conducted. Lower extremity lymphedema (LEL) was diagnosed using the International Society of Lymphology guidelines, and pelvic lymphocele (PL) was evaluated using trans-vaginal ultrasonography and computed tomography.

Results

The median patient age was 46 years (range: 22-74) and median body mass index was 21.7 kg/m2 (range: 15.7-37.1). The median number of lymph nodes (LNs) removed was 27 (range: 22-74); 94 (55.6%) patients underwent circumflex iliac node (CIN) dissection; 39 (23.1%) patients received adjuvant chemotherapy; and 81 (47.9%) patients received adjuvant postoperative radiotherapy. There were 28 (16.6%) and 32 (18.9%) occurrences of LEL and PL, respectively. In multivariate logistic regression analysis, the number of LNs removed (odds ratio [OR]: 3.37; 95% CI: 1.43-8.54; P = 0.0053) and CIN removal (OR: 3.92; 95% CI: 1.55-11.4; P = 0.0033) were independent risk factors for LEL; however, no risk factors were significantly associated with PL.

Conclusions

Our results demonstrated that CIN removal and the number of LNs removed were significant risk factors for LEL in patients with cervical cancer. However, we did not identify any significant risk factors for PL in this study. We instead speculate that LN dissection itself causes PL. We suggest that establishment of comprehensive PLA without CIN dissection, or use of the sentinel lymph node concept, will prevent the occurrence of lymphatic complications in cervical cancer patients.

Risk factors, microbiology and management of infected lymphocyst after lymphadenectomy for gynecologic malignancies

Objective

To evaluate risk factors, microbiology and management of infected lymphocysts in patients undergoing systemic lymphadenectomy for gynecological cancer.

Methods

Patients with gynecological cancer who developed postoperative lymphocysts after lymphadenectomy were enrolled between January 2009 and June 2017. The clinical data of infected lymphocysts were analyzed and compared with non-infected lymphocysts. Multivariate analysis of risk factors, the microbiology and therapeutic strategies for infected lymphocysts were also evaluated.

Results

A total of 115 patients out of 619 developed postoperative lymphocysts, the incidence of infected lymphocysts was 4.36%. Infected lymphocysts were more frequently found in patients with combined pelvic and para aortic lymphadenectomy, higher number of resected pelvic lymph nodes, lower level of postoperative serum hemoglobin and higher proportion of neutropenia. The median diameter of infected lymphocysts was significantly larger than non-infected (71.89 vs 38.47 mm, P < 0.001) and a large size (diameter over 60 mm) was identified as an independent risk factor for infected lymphocysts (OR = 3.933, P = 0.017). The microbiology of infected lymphocysts includes gram-positive cocci, gram-negative bacillus and anaerobic bacteria. Percutaneous catheter drainage was successfully performed in 20 patients with infected lymphocysts. 16 of 19 patients with large lymphoceles received combined antibiobics and PCD therapy and showed clinical remission in all cases. Patients with large size infected lymphocysts who received combined therapy experienced a significantly shorter treatment period and lower recurrent rate than those with only antibiotics (P = 0.046, P = 0.018).

Conclusions

The current study demonstrated that a diameter over 60 mm was an independent risk factor for infected lymphocysts. The predominant bacteria originated from the urogenital or skin flora. The combination of PCD with appropriate antibiotics was a convenient and effective therapeutic strategy resulting in a high success rate.

The role of pelvic lymphocele in the development of early postoperative complications

With the increasing incidence of gynecologic malignancy, radical hysterectomy represents an important part of the adequate treatment of these patients. The pelvic lymphocele is a known side effect of pelvic and para-aortic lymphadenectomy. The aim of our study was to assess the role of the lymphocele in the development of early postoperative complications.A single-center, retrospective analysis between January 2000 and May 2017 revealed 1867 patients with cervical and endometrial cancer, treated through radical or modified radical hysterectomy and pelvic lymphadenectomy. Postoperative complications and the occurrence of pelvic lymphocele were evaluated.Approximately 47.6% of patients were diagnosed with pelvic lymphocele, with only 5.2% being symptomatic. Early postoperative complications rate recorded an incidence of 8.1%, occurring more frequent if lymphocele were present (P < .001). The pelvic lymphocele represented, in univariate analysis, a risk factor for the development of pelvic abscesses, but not for deep vein thrombosis, lymphedema, or bowel obstruction. Hydronephrosis was found to be significantly correlated with the pelvic lymphocele, but we believe this urological complication to have a different underlining mechanism. Neoadjuvant radiotherapy represented in both uni- and multivariate analysis a risk factor for the occurrence of postoperative complications.In the postoperative context of oncogynecological surgery, pelvic lymphocele occur at high rates, representing a statistical risk factor for hydronephrosis and pelvic abscesses, with neoadjuvant radiotherapy being an independent risk factor for early postoperative complications.

Prospective Randomized Controlled Trial Exploring the Effect of TachoSil on Lymphocele Formation After Extended Pelvic Lymph Node Dissection in Prostate Cancer

OBJECTIVE

To explore whether TachoSil, a hemostatic patch, can reduce the incidence of lymphocele formation. Development of a lymphocele is a frequent complication after pelvic lymph node dissection (PLND) for nodal staging in prostate cancer.

MATERIALS AND METHODS

From 2013 to 2017, 100 patients with prostate cancer who were set to undergo a staging PLND before external beam radiotherapy (n = 50) or PLND concomitant with radical prostatectomy (RP) (n = 50) were prospectively randomized 1:1 between bilateral TachoSil placement or nonplacement. Primary end points were radiographic lymphocele development, lymphocele volume (1 week and 1 month postoperatively), and the duration and volume of postoperative catheter drainage.

RESULTS

Patient, tumor, and surgical characteristics of the TachoSil and the control groups did not differ significantly. In total, 65 patients (65%) experienced a radiographic lymphocele up to 3 months after surgery: 29 (58%) in the TachoSil group and 36 (72%) in the control group (P = .34). Significantly less radiographic lymphoceles were observed 1 week postoperatively for patients who underwent sole PLND and 1 month postoperatively for patients who underwent PLND with RP in the TachoSil group compared with the control group (16% vs 48%, P = .024, and 24% vs 52%, P = .047, respectively). The other postoperative characteristics presented no significant differences between the 2 groups, neither for patients undergoing sole PLND nor for patients undergoing PLND with RP.

CONCLUSION

Patients undergoing bilateral TachoSil placement after PLND seem less likely to develop a radiographic lymphocele early postoperatively. Nevertheless, the clinical relevance of the use of TachoSil remains highly debatable.

Postoperative management of radical cystectomy. Review of the evidence on the prevention and treatment of urological complications

INTRODUCTION AND OBJECTIVES

This review article focuses on the prevention and management of the most common postoperative urological complications of radical cystectomy. We reviewed the current literature and conducted an analysis of frequency, prevention and treatment of complications.

ACQUISITION OF EVIDENCE

We conducted a search on Medline to identify original articles, literature reviews and editorials focusing on the urological complications of radical cystectomy during the first 90 days after surgery. We identified those series that included more than 100 patients.

SYNTHESIS OF THE EVIDENCE

The literature regarding the prevention and treatment of complications after cystectomy is in general retrospective and nonstandardised. The level of evidence is generally low, and it is difficult to make evidence-based recommendations.

CONCLUSIONS

Progress has been made in recent years in reducing mortality and preventing the complications of cystectomy. The most common complications are gastrointestinal, for which significant efforts have been made to implement ERAS and Fast Track protocols. The complications that can most significantly change patients' quality of life are urinary stoma.

A successful case of a para-aortic lymphocele treated with autologous peripheral blood injection

A lymphocele is one of the complications of systematic pelvic or para-aortic lymphadenectomy. Although most patients are entirely asymptomatic, our patient exhibited an obstructive ileus at the jejunum compressed by a lymphocele. We report here a case of a subsequent para-aortic lymphocele treated with autologous peripheral blood injection. A 68-year-old woman with sigmoid colon cancer (T3N2bM1a) underwent laparoscopic sigmoidectomy. After 4 courses of chemotherapy (CapeOX + Bmab), para-aortic lymphadenectomy was additionally performed. One month later, an obstructive ileus occurred suddenly due to a lymphocele. A drainage catheter was placed into the lymphocele and a total of 35 mL of autologous peripheral blood was injected in 4 divided doses through the catheter. The volume of the lymphocele gradually reduced and the ileus improved after blood injection. This is the first report of a successful case of a subsequent para-aortic lymphocele treated with autologous peripheral blood injection without any complications.

Sentinel lymph node biopsy in endometrial cancer-Feasibility, safety and lymphatic complications

OBJECTIVE

To compare the rate of lymphatic complications in women with endometrial cancer undergoing sentinel lymph node biopsy versus a full pelvic and infrarenal paraaortic lymphadenectomy, and to examine the overall feasibility and safety of the former.

METHODS

A prospective study of 188 patients with endometrial cancer planned for robotic surgery. Indocyanine green was used to identify the sentinel lymph nodes. In low-risk patients the lymphadenectomy was restricted to removal of sentinel lymph nodes whereas in high-risk patients also a full lymphadenectomy was performed. The impact of the extent of the lymphadenectomy on the rate of complications was evaluated.

RESULTS

The bilateral detection rate of sentinel lymph nodes was 96% after cervical tracer injection. No intraoperative complication was associated with the sentinel lymph node biopsy per se. Compared with hysterectomy alone, the additional average operative time for removal of sentinel lymph nodes was 33min whereas 91min were saved compared with a full pelvic and paraaortic lymphadenectomy. Sentinel lymph node biopsy alone resulted in a lower incidence of leg lymphedema than infrarenal paraaortic and pelvic lymphadenectomy (1.3% vs 18.1%, p=0.0003).

CONCLUSION

The high feasibility, the absence of intraoperative complications and the low risk of lymphatic complications supports implementing detection of sentinel lymph nodes in low-risk endometrial cancer patients. Given that available preliminary data on sensitivity and false negative rates in high-risk patients are confirmed in further studies, we also believe that the reduction in lymphatic complications and operative time strongly motivates the sentinel lymph node concept in high-risk endometrial cancer.

Nomogram predicting risk of lymphocele in gynecologic cancer patients undergoing pelvic lymph node dissection

Objective

The purpose of this study is to estimate the risk of postoperative lymphocele development after lymphadenectomy in gynecologic cancer patients through establishing a nomogram.

Methods

We retrospectively reviewed 371 consecutive gynecologic cancer patients undergoing lymphadenectomy between 2009 and 2014. Association of the development of postoperative lymphocele with clinical characteristics was evaluated in univariate and multivariate regression analyses. Nomograms were built based on the data of multivariate analysis using R-software.

Results

Mean age at the operation was 50.8±11.1 years. Postoperative lymphocele was found in 70 (18.9%) patients. Of them, 22 (31.4%) had complicated one. Multivariate analysis revealed that hypertension (hazard ratio [HR], 3.0; 95% confidence interval [CI], 1.5 to 6.0; P=0.003), open surgery (HR, 3.2; 95% CI, 1.4 to 7.1; P=0.004), retrieved lymph nodes (LNs) >21 (HR, 1.8; 95% CI, 1.0 to 3.3; P=0.042), and no use of intermittent pneumatic compression (HR, 2.7; 95% CI, 1.0 to 7.2; P=0.047) were independent risk factors for the development of postoperative lymphocele. The nomogram appeared to be accurate and predicted the lymphocele development better than chance (concordance index, 0.754). For complicated lymphoceles, most variables which have shown significant association with general lymphocele lost the statistical significance, except hypertension (P=0.011) and mean number of retrieved LNs (29.5 vs. 21.1; P=0.001). A nomogram for complicated lymphocele showed similar predictive accuracy (concordance index, 0.727).

Conclusion

We developed a nomogram to predict the risk of lymphocele in gynecologic cancer patients on the basis of readily obtained clinical variables. External validation of this nomogram in different group of patients is needed.

Microbiological evaluation of infected pelvic lymphocele after robotic prostatectomy: potential predictors for culture positivity and selection of the best empirical antimicrobial therapy

OBJECTIVES

To examine symptomatology and microbiology of infected lymphocele (LC) post-robotic-assisted radical prostatectomy and pelvic lymph node dissection (PLND) and to assess for potential predictors for LC fluid culture positivity. Secondly, to provide general recommendations about use of select antimicrobial therapy.

METHODS

This was a single-center, IRB-approved, retrospective, case series review conducted between October 2008 and October 2014. Data included symptomatology, microbiology of symptomatic LC in men post-robotic prostatectomy and PLND. Those with infected LC were compared to those men with symptomatic LC in the absence of infection.

RESULTS

Symptomatic LC was seen in 7% of men, and among those, infected LC was seen in 42%. Infected LC cultures showed predominance of G+ cocci such as S. aureus, coagulase-negative Staphylococcus species, S. pyogenes, S. fecalis and S. viridans. Monomicrobial infection was seen in 85%. Multivariate logistic regression showed leukocytosis [Odds: 12.3, p = 0.03, 95% CI (1.2-125)] was significant predictor for culture positivity, whereas trend toward significance for factors such CT findings of thickened walls around the LC +/- air.

CONCLUSIONS

LC infection following PLND for prostate cancer is usually monomicrobial and caused by Gram+ cocci. GI tract and skin flora are the main habitat. High index of suspicion of infected LC is undertaken in the presence of leukocytosis, fever and abnormal CT findings. Based upon our local hospital antibiogram, combination of IV ampicillin/sulbactam and vancomycin is suggested as the best initial empiric therapy in treating these patients.

A review of the postoperative lymphatic leakage

Lymphatic complications are rare, but well-known phenomena, and have been described by many researchers. However, many diagnoses of lymphatic complications are found confusing due to different definition. A literature search in Pubmed was performed for studies postoperative lympatic complications. These complications divided into two parts: lymphatic leakage and lymphatic stasis. This review is about lymphatic leakage, especially, postoperative lymphatic leakage due to the injury of lymphatic channels in surgical procedures. According to polytrophic consequences, many types of postoperative lymphatic leakage have been presented, including lymph ascites, lymphocele, lymphorrhea, lymphatic fistula, chylous ascites, chylothorax, chyloretroperitoneum and chylorrhea. In this review, we focus on the definition, incidence and treatment about most of these forms of lymphatic complications to depict a comprehensive view of postoperative lymphatic leakage. We hold the idea that the method of treatment should be individual and personal according to manifestation and tolerance of patient. Meanwhile, conservative treatment is suitable and should be considered first.

Risk factor analysis for massive lymphatic ascites after laparoscopic retroperitonal lymphadenectomy in gynecologic cancers and treatment using intranodal lymphangiography with glue embolization

Objective

To evaluate risk factors for massive lymphatic ascites after laparoscopic retroperitoneal lymphadenectomy in gynecologic cancer and the feasibility of treatments using intranodal lymphangiography (INLAG) with glue embolization.

Methods

A retrospective analysis of 234 patients with gynecologic cancer who received laparoscopic retroperitonal lymphadenectomy between April 2006 and November 2015 was done. In June 2014, INLAG with glue embolization was initiated to manage massive lymphatic ascites. All possible clinicopathologic factors related to massive lymphatic ascites were determined in the pre-INLAG group (n=163). Clinical courses between pre-INLAG group and post-INLAG group (n=71) were compared.

Results

In the pre-INLAG group (n=163), four patients (2.5%) developed massive lymphatic ascites postoperatively. Postoperative lymphatic ascites was associated with liver cirrhosis (three cirrhotic patients, p<0.001). In the post-INLAG group, one patient with massive lymphatic ascites had a congestive heart failure and first received INLAG with glue embolization. She had pelvic drain removed within 7 days after INLAG. The mean duration of pelvic drain and hospital stay decreased after the introduction of INLAG (13.2 days vs. 10.9 days, p=0.001; 15.2 days vs. 12.6 days, p=0.001). There was no evidence of recurrence after this procedure.

Conclusion

Underlying medical conditions related to the reduced effective circulating volume, such as liver cirrhosis and heart failure, may be associated with massive lymphatic ascites after retroperitoneal lymphadenectomy. INLAG with glue embolization can be an alternative treatment options to treat leaking lymphatic channels in patients with massive lymphatic leakage.

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.

Use of TachoSil® to Prevent Symptomatic Lymphocele after an Aggressive Tumor Debulking with Lymphadenectomy for Advanced Stage Ovarian Cancer. A Pilot Study

OBJECTIVE

To describe the incidence of symptomatic lymphocele (SLC) after an aggressive tumor debulking surgery and lymphadenectomy in patients with ovarian cancer and peritoneal carcinomatosis with or without TachoSil®.

MATERIAL AND METHODS

A pilot retrospective comparative observational study was performed between patients with advanced ovarian cancer International Federation of Gynecology and Obstetrics stages III-IV who underwent complete debulking surgery and radical retroperitoneal lymphadenectomy. In 18 patients, 4 TachoSil® patches were placed in the retroperitoneal area, since January 2014-October 2014. This group was compared with other 18 consecutive patients matched by age, International Federation of Gynecology and Obstetrics stage, surgical complexity, American Society of Anesthesiologists score, comorbidity, and BMI without the use of TachoSil®.

RESULTS

Baseline characteristics were similar between groups. There were no statistically significant differences in terms of surgical complexity, surgical time, estimated blood loss, node removed, length of hospital stay, and complications between groups. SLC was diagnosed in 7 patients (38.8%) without TachoSil®, and in 2 patients (11.1%) with TachoSil® (p = 0.121). The use of TachoSil® was associated with a statistically significant lower re-admission rate (p = 0.041) and with a significantly shorter time to adjuvant chemotherapy (p = 0.02).

CONCLUSIONS

Using TachoSil® in women with advanced stage ovarian cancer who underwent radical debulking with retroperitoneal lymph node dissection is associated with a non-statistically significant reduction in the incidence of SLC. A larger-scale randomized controlled study should be conducted to confirm our preliminary results.

Optimal timing for drainage of infected lymphocysts after lymphadenectomy for gynecologic cancer

BACKGROUND

A lymphocyst (lymphocele) is a common complication of lymphadenectomy, which is a widely used surgical method for gynecologic cancers. In cases of infected lymphocysts, therapeutic strategies, including the timing and duration of antibiotics administration and cyst drainage, may vary depending on the physician. The aim of this study was to determine the optimal timing for drainage of lymphocysts infected with bacteria resistant to antibiotic treatment.

MATERIALS AND METHODS

Clinical data for 1175 patients who underwent a lymphadenectomy as part of surgery for a gynecologic malignancy between April 2000 and August 2012 at Osaka University Hospital, Osaka, Japan, were analyzed.

RESULTS

Of the 282 patients who developed a lymphocyst (24%), 35 with infected lymphocysts (12%) were analyzed. Lymphocyst infection was not associated with tumor origin, type of hysterectomy, or region of lymphadenectomy (P = 0.81, P = 0.59, and P = 0.86, respectively). The total treatment period of cases treated only with antibiotics tended to be shorter than that of cases treated with combined antibiotics and drainage, but the difference was not significant (P = 0.061). However, for severe cases which needed drainage, initiating the drainage by day 5 significantly shortened the total treatment period compared with cases started on or after day 6 (P = 0.042).

CONCLUSIONS

The appropriate time point for initiating lymphocyst drainage has been difficult to determine. The present study implies that for severe lymphocyst infections, where drainage is required in addition to antibiotics, the earlier the drainage is performed, the shorter the treatment period is. Further studies may be required to decide other optimal treatment strategies for infected lymphocysts.

Symptomatic Lymphocele Formation After Sentinel Lymph Node Biopsy for Early Stage Cervical Cancer

In early stage cervical cancer, nodal status is the most important prognostic factor, and execution of retroperitoneal lymphadenectomy is currently an integral part of surgical therapy. Sentinel lymph node biopsy has been progressively incorporated with surgical therapy and could reduce morbidity. However, the current incidence of complications exclusively related to the procedure is unknown. We report on a 29-year-old woman affected by cervical cancer (Fédération Internationale de Gynécologie et d'Obstétrique Stage 1b1), who underwent sentinel lymph node biopsy in combination with radical vaginal trachelectomy, and who later developed a symptomatic pelvic lymphocele that required surgical therapy. Conservative procedures in the pelvic lymph nodes are not free of complications, especially with regard to the formation of symptomatic lymphoceles. This report brings to light an important discussion about the exact magnitude of the complications associated with the procedure.

Delayed complication of pelvic lymphocele: Ileal conduit obstruction

Radical cystectomy is the standard treatment for muscle invasive bladder cancer. Lymphocele is a common sequalae of pelvic lymphadenectomy. We report an unusual presentation of pelvic lymphocele developing after radical cystectomy reconstructed with an ileal conduit where the patient developed obstruction of the ileal conduit loop due to external pressure of the lymphocele. Catheter drainage of the conduit relieved the symptoms and a computerized tomography scan showed a large lymphocele causing acute angulation and resultant obstruction of the ileal conduit. The patient was treated with percutaneous drainage of the lymphocele and remains symptom-free on follow-up at 1 year.

[Morbidity of pelvic lymphadenectomy and para-aortic lymphadenectomy in endometrial cancer]

The aim of this study was to evaluate the complication rate of pelvic and para-aortic lymphadenectomy in the management of endometrial cancer following the changes to the recommendations of INCa 2010. This is a retrospective study of 208 patients operated for endometrial cancer between July 2010 and March 2014 in two referral centers. Eighty lymphadenectomy were performed, 65 with hysterectomy and bilateral annexectomy and 18 lymphadenectomy were performed for restaging. Complications assessment is based on the Dindo Clavien classification. We report 17 severe complications (grade 3a and over) (P<0.001), including 14 among patients receiving lymphadenectomy. Morbidity increases with the number of lymphnodes removed and their positivity (P<0.001). The para-aortic lymphadenectomy is primarily responsible for complications (P <0.001). We describe 7 lower limbs lymphedema, 12 nerve injuries, 8 ileus, 5 venous or arterial thromboembolism, 17 blood transfusions, 13 lymphoceles including 9 infected. The rate of intraoperative complications on a first lymphadenectomy is 8% while it reached 22% for restaging. Restaging is significantly more at risk of serious complications (P=0.03) with two deaths. Twenty-four chronic disorders with impaired quality of life (2 without lymphadenectomy) are reported. They are present in 50% of restaging (P=0.033 compared to first lymphadenectomy). Lymphadenectomy is a source of severe morbidity (17.5%) with 2.5% mortality. The benefit of this surgery should probably be discussed again.

Radiotherapy in Prostate Cancer Patients With Pelvic Lymphocele After Surgery: Clinical and Dosimetric Data of 30 Patients

INTRODUCTION

The purpose of the study was to evaluate the feasibility of irradiation after prostatectomy in the presence of asymptomatic pelvic lymphocele.

PATIENTS AND METHODS

The inclusion criteria for this study were: (1) patients referred for postoperative (adjuvant or salvage) intensity modulated radiotherapy (IMRT; 66-69 Gy in 30 fractions); (2) detection of postoperative pelvic lymphocele at the simulation computed tomography [CT] scan; (3) no clinical symptoms; and (4) written informed consent. Radiotherapy toxicity and occurrence of symptoms or complications of lymphocele were analyzed. Dosimetric data (IMRT plans) and the modification of lymphocele volume during radiotherapy (cone beam CT [CBCT] scan) were evaluated.

RESULTS

Between January 2011 and July 2013, in 30 of 308 patients (10%) treated with radiotherapy after prostatectomy, pelvic lymphocele was detected on the simulation CT. The median lymphocele volume was 47 cm(3) (range, 6-467.3 cm(3)). Lymphocele was not included in planning target volume (PTV) in 8 cases (27%). Maximum dose to lymphocele was 57 Gy (range, 5.7-73.3 Gy). Radiotherapy was well tolerated. In all but 2 patients, lymphoceles remained asymptomatic. Lymphocele drainage-because of symptom occurrence-had to be performed in 2 patients during IMRT and in one patient, 7 weeks after IMRT. CBCT at the end of IMRT showed reduction in lymphocele volume and position compared with the initial data (median reduction of 37%), more pronounced in lymphoceles included in PTV.

CONCLUSION

Radiotherapy after prostatectomy in the presence of pelvic asymptomatic lymphocele is feasible with acceptable acute and late toxicity. The volume of lymphoceles decreased during radiotherapy and this phenomenon might require intermediate radiotherapy plan evaluation.