Laparoscopic internal drainage of lymphocele in renal transplant

Critical appraisal of consecutive 36 cases of post renal transplant lymphocele: a proposed algorithm

INTRODUCTION

Lymphyocele by definition is the collection of lymph that is contained by a pseudomembrane. Management of lymphocele varies from simple aspiration or aspiration with sclerothreapy to more invasive technique, such as internal/external drainage. We present the results of 36 patients who developed pelvic lymphocele after renal transplant.

MATERIALS AND METHODS

A total of 1720 patients underwent living related donor renal allograft transplant at our centre. Of the total 1720 transplants 36 patients developed symptomatic lymphocele and underwent definitive management. Retrospectively analysis of the clinical data of these 36 patients was done.

RESULTS

Thrirt six patients (2.09%) had a clinically significant lymphocele, which needed definitive management. All these patients underwent ultrasound guided drain placement and sclerosant injection. Fifteen out of 36 patients (41.6%) had successful treament with percutaneous drain placement. Laparoscopic marsupialization of lymphocele was done in 21 patients who failed percutaneous drain insertion therapy after diagnostic aspiration. Laparoscopic Marsupilization was successful in 18 out of 21 patients (85.7%). The 3 patients with failed laparoscopic marsupialization were managed with open surgical marsupialization.

CONCLUSION

Significant number of lymphocele post renal transplant may be asymptomatic but still cause deterioration of renal function even without causing obstructive uropathy. Lymphoceles causing renal deterioration or symptoms should be managed in a step ladder fashion starting from percutaneous drainage to laparoscopic marsupilization to open surgical approach. Asymptomatic recurrences post marsupialization are common and should be only closely observed unless they become symptomatic or cause deterioration of renal function. A systematic protocol may help in treating these patients better.

Idiopathic giant abdominal lymph cyst: a case report

INTRODUCTION

Giant lymph cysts are a relatively frequent complication after surgical procedures in the abdomen, often after kidney transplantation, but there are also cases after pelvic surgery such as lymphadenectomy and others. In the recent literature, there have been no reported cases of idiopathic giant lymphocyst.

CASE PRESENTATION

We present the case of a 76-year-old Caucasian man who had a lymph cyst he had known of for more than 15 years. Laparoscopic treatment was necessary because of hydronephrosis of the left kidney.

CONCLUSION

This case shows that laparoscopic drainage and partial resection of the lymph cyst is a safe and effective treatment.

Laparoscopic Marsupialization of Postrenal Transplantation Lymphoceles

BACKGROUND AND PURPOSE

Clinically significant post-transplantation lymphoceles are not uncommon. Surgical marsupialization with internal peritoneal drainage is the treatment of choice. We describe the successful laparoscopic formation of a peritoneal window for post-transplantation lymphocele drainage as an effective and minimally invasive procedure.

PATIENTS AND METHODS

Between August 1995 and September 2001, 135 consecutive renal transplantations were performed, and 9 patients developed clinically significant lymphoceles. Four of the nine patients were treated by laparoscopic drainage via a peritoneal window. Analysis of predisposing risk factors commonly associated with lymphoceles was performed. The surgical outcome was assessed.

RESULTS

Laparoscopic drainage was successful in all patients. The average operative time was 40 minutes. The mean hospital stay was 1.5 days for patients undergoing laparoscopic drainage versus 5 days for those having open surgical drainage. Accidental division of the right native ureter occurred in one patient, which was identified intraoperatively. None of the patients had developed recurrence of lymphocele after a mean follow-up of 10.7 months (range 6-22) months.

CONCLUSION

In patients with a clinically significant post-transplantation lymphocele of appropriate size and location, laparoscopic drainage is easy, safe, and effective. It decreases hospital stay and hastens convalescence.

Posttransplant symptomatic lymphocele treatment with percutaneous drainage and ethanol sclerosis

PURPOSE

Lymphocele following kidney transplantation is a well-known complication. We present here the long-term results of percutaneous drainage and ethanol sclerosis in posttransplant lymphoceles.

PATIENTS AND METHODS

Between October 1988 and September 2003, 18 patients with symptomatic lymphoceles were treated with percutaneous transcatheter ethanol sclerosis among 300 renal transplants followed up. Catheters were positioned under ultrasonography (US) guidance. Cavity dimensions and extravasation were evaluated by pouch graph. The day after catheter insertion, sclerotherapy with ethanol was applied. Daily output and probable complications were followed up on periodic controls, and the alcohol was instilled when required.

RESULT

The mean initial size of the lymphoceles was 6 x 8 x 10 cm (range 3 x 4 x 6 to 7 x 12 x 21 cm), with a mean initial volume of 230 ml (range 40-1340 ml). Incomplete resolution was achieved in all patients after sclerotherapy in the first week (100%). The mean duration of therapy was 17 days (range 4-45 days). The mean therapy sitting was 12 (4-21), and the average alcohol volume in one sitting was 30 ml. One recurrence and one graft lost were seen in this series. Minor complications like discomfort and mild temperature elevation were determined in 10 patients. In one case, temporary double-J stent was required to alleviate the increased pressure in collecting system of transplanted kidney. No late complication was occurred.

CONCLUSION

As a less invasive method, percutaneous transcatheter ethanol sclerosis and drainage in the treatment of symptomatic lymphocele is a simple, safe and cost-effective method. Other treatment choices, like open or laparoscopic fenestration, can be used in case of failure.

Laparoscopic lymphocelectomy: a multi-institutional analysis

PURPOSE

Because symptomatic lymphoceles are infrequent, single center studies generally report small numbers of patients. We report a multi-institutional experience with and long-term outcome following laparoscopic lymphocelectomy in 81 patients.

MATERIALS AND METHODS

Data were obtained from 9 institutions at which at least 5 cases of laparoscopic lymphocelectomy had been performed. Baseline patient demographics, operative time and blood loss, special operative adjunct techniques, postoperative course, convalescence, complications and lymphocele recurrence data were collected and analyzed.

RESULTS

A total of 56 men and 25 women with a mean age of 41 years were included in the study. Lymphocele formed after renal transplantation in 78 patients (96%) and after pelvic lymph node dissection in 3 (4%). Average operating time was 123 minutes with a mean blood loss of 43 ml. Omentopexy was performed in 11 cases (13.6%). No intraoperative stenting of the transplant ureter was performed. Intraoperative complications consisted of laryngospasm, bladder injury, inferior epigastric artery injury and mild renal capsule hematoma in 1 patient each. Conversion to open surgery was required for repair of bladder injury in 1, repair of preexisting hernia in 1, unusually thickened lymphocele wall in 1 and inaccessible lymphocele location in 4 cases. Mean time to ambulation and resumption of regular diet was 1 day, and mean hospital stay was 1.5 days. Postoperative complications included trocar site hernia in 1 and urinary retention in 2. Convalescence averaged 2.5 weeks. During a mean followup of 27 months 5 patients (6%) had lymphocele recurrence.

CONCLUSIONS

Laparoscopic lymphocelectomy is safe, minimally invasive and effective. It is an excellent alternative to the conventional open surgical approach.

Percutaneous sclerotherapy of lymphoceles related to renal transplantation

PURPOSE

To determine the advantages of using transcatheter sclerotherapy to treat renal allograft-related lymphoceles.

MATERIALS AND METHODS

Eighteen patients first seen with symptomatic lymphoceles secondary to renal transplantation were treated with povidone-iodine percutaneous sclerotherapy. Percutaneous catheters were place by means of sonographic, computed tomographic, or combined fluoroscopic and sonographic guidance. Sclerotherapy was initiated while patients were in the hospital, and the patients then instilled povidone-iodine twice a day at home.

RESULTS

One patient had an inadequate trial period of therapy and was not included in the analysis. Seventeen lymphoceles were adequately sclerosed. Average length of treatment was 35 days. Three lymphoceles recurred and were effectively treated percutaneously. Follow-up studies showed no recurrence 1 month to 2 years after completion of therapy. No patient needed surgery for lymphocele repair.

CONCLUSION

Because of its safety and efficacy, percutaneous transcatheter sclerotherapy with povidone-iodine should be the treatment of choice in patients with lymphoceles that develop after renal transplantation.

Laparoscopic lymphocele drainage after renal transplantation

Lymphoceles are among the most frequent surgical complications after renal transplantation. We performed laparoscopic drainage in 5 patients with a large lymphocele in the small pelvis after successful kidney transplantation.