First case report of chylous ascites after robot-assisted donor nephrectomy

Post-operative chyle leak following nephrectomy: Inference from tertiary care center and review of literature

OBJECTIVES

Lymphatic channels (LC) are not as prominent as blood vessels, so they tend to get damaged during surgical procedures. It can present with chyle leak in the postoperative period. We aimed to study the occurrence of chyle leak in patients undergoing nephrectomy and its management.

METHODS

During the period of January 2021 and January 2023, 158 adult patients underwent nephrectomy for various reasons like non-functioning kidney, donor nephrectomy, and malignancy. We retrospectively analyzed data of patients who had chyle leak after nephrectomies.

RESULTS

Eight patients out of the 158 patients (5.06%) undergoing nephrectomy developed chyle leak. One out of these eight patients underwent nephrectomy by open approach while seven underwent laparoscopic approach. All eight patients who had chyle leak undergone left sided nephrectomy. Six patients of chyle leak could be managed with dietary modification while two patients needed octreotide therapy for treatment. Higher Body Mass Index (BMI; p-value = 0.012), left sides nephrectomy (p-value = 0.013), h/o pyelonephritis (p-value = 0.005) were associated with higher incidence of chyle leak on univariate analysis. While on multivariate analysis no factor was found to be independently associated with chyle leak. Hospital stay was significantly prolonged in patients with chyle leak (p-value = 0.007).

CONCLUSION

Chyle leak is not a very rare complication after nephrectomy. Patients with higher BMI, who undergo left sided nephrectomies and patients who had history of pyelonephritis or infectious complications had higher incidence of chyle leak. Most cases can be managed with conservative management (CM). Chyle leak is associated with a prolonged hospital stay.

Chylous Ascites After Robot-Assisted Laparoscopic Donor Nephrectomy: Is Early Surgical Intervention Necessary?

OBJECTIVES

Chylous ascites is a rare complication that may occur after living donor nephrectomy. The continuous loss of lymphatics, which carries a high risk of morbidity, may ensue in possible immunodeficiency and protein-calorie malnutrition. Here, we presented patients who developed chylous ascites after robotassisted living donor nephrectomy and reviewed the current literature of therapeutic strategies for chylous ascites.

MATERIALS AND METHODS

We reviewed the medical records of 424 laparoscopic living donor nephrectomies performed at a single transplant center; among these, we studied the records of 3 patients who developed chylous ascites following robot-assisted living donor nephrectomy.

RESULTS

Among 438 living donor nephrectomies, 359 (81.9%) were laparoscopic and 77 (18.1%) were by robotic assistance. In the 3 cases highlighted in our study, patient 1 did not respond to conservative therapy, which consisted of diet optimization, total parenteral nutrition, and octreotide (somatostatin). Patient 1 subsequently underwent robotic-assisted laparoscopy with suture ligation and clipping of leaking lymphatic vessels, allowing the chylous ascites to subside. Patient 2 similarly did not respond to conservative treatment and developed ascites. Despite initial improvement after wound interrogation and drainage, patient 2 had continued symptoms, resulting in diagnostic laparoscopy and repair of leaky channels leading to the cisterna chyli. Patient 3 developed chylous ascites 4 weeks postoperatively and received ultrasonographic-guided paracentesis by interventional radiology, with results showing an aspirate consistent with chyle. The patient's diet was optimized, allowing for initial improvement and eventual return to normal diet.

CONCLUSIONS

Our case series and literature review demonstrate the importance of early surgical intervention after failed conservative management for resolution of chylous ascites in patients after robotassisted donor laparoscopic nephrectomy.

Chylous Ascites after Laparoscopic Donor Nephrectomy: Case Report

Chylous ascites refers to the accumulation of chyle in the abdominal cavity. Postoperative chylous ascites is most commonly associated with abdominal aortic surgeries. However, it is a rare complication following laparoscopic nephrectomy. It causes loss of fat, protein, and antibodies causing malnutrition and immunodeficiency. Thus, it is important to treat it as early as possible. We hereby report a case of chylous ascites following laparoscopic donor nephrectomy. A 55-year-old female was admitted at our center 2 weeks after undergoing left laparoscopic donor nephrectomy with abdominal distension and constipation. USG abdomen revealed free fluid in the abdomen. Paracentesis revealed chylous ascites. The patient was started on conservative treatment, including a diet rich in proteins and low in fats; conservative treatment, however, was unsuccessful. Lymphangiography and subsequent embolization of the defect were done, and she made a full recovery.

Percutaneous Lymphatic Maceration and Glue Embolization for High-output Chylous Ascites after Robot-assisted Laparoscopic Nephrectomy and Lymphadenectomy

To propose minimally invasive percutaneous techniques in the management of high output chylous ascites, a known potential complication of retroperitoneal surgery associated with significant morbidity and mortality. Management has traditionally been based on successful treatment reported in the literature. However, refractory or high-output leaks often prove difficult to treat and there is little evidence on superior management. We report percutaneous maceration and embolization for the management of high-volume abdominal chyle leak after robot-assisted laparoscopic (RAL) radical nephrectomy and lymph node dissection for renal cell carcinoma. A 68-year-old male with incidentally found renal cell carcinoma underwent RAL radical nephrectomy with paraaortic lymph node dissection. He initially improved after surgery but developed significant abdominal pain and distension approximately 7 weeks postoperative. This proved to be chyloperitoneum. Conservative management was initiated, but after continued high-output (>1 L) fluid drainage, we pursued adjunct intervention involving Interventional Radiological percutaneous procedures. This included lymphatic maceration and glue embolization of leaking lymphatics. The patient tolerated the percutaneous procedures well with significant improvement in drain output ultimately leading to complete resolution of ascites without further complication. Similar interventions have previously been reported in the literature for cases of chylothorax with success. However, there is a lack of reports on utilizing this minimally invasive procedure for chyloperitoneum after retroperitoneal urologic surgery. We report our successful experience with percutaneous lymphatic maceration and embolization for high output chylous ascites after RAL radical nephrectomy with lymphadenectomy. We believe that early initiation utilizing these percutaneous techniques can achieve timely resolution and should be considered in the management of these patients.

Chyle Leak After Robotic Living Donor Nephrectomy: Literature Review And Management

Chyle leak after living donor nephrectomy is a rare complication and is associated with a significant postoperative burden. To the best of our knowledge, only 1 case of chyle leak after robotic living donor nephrectomy has been reported in the literature. In this study, we present our experience with 2 cases of chyle leak: 1 after and 1 during robotic donor nephrectomy. We discuss previously published studies and man - agement options of chyle leak in kidney donors.

3D Endoscopic Donor Nephrectomy Versus Robot-assisted Donor Nephrectomy: A Detailed Comparison of 2 Prospective Cohorts

BACKGROUND

There are 2 endoscopic surgical techniques that implement 3-dimensional (3D) vision to overcome visual misperception: 3D endoscopy and the da Vinci surgical system. 3D endoscopy has several advantages, such as the presence of tactile feedback and easy implementation, at lower costs. We aimed to assess whether 3D endoscopy could be an alternative to the robot during living donor nephrectomy.

METHODS

Between April 2015 and April 2016, we prospectively collected data on 40 patients undergoing 3D endoscopic living donor nephrectomies in 1 center, performed by a da Vinci-certified surgeon. Data on donors' perioperative results and recipient and graft survival were collected. These data were compared to 40 robot-assisted donor nephrectomies performed in the same center (between January 2012 and May 2014).

RESULTS

Baseline characteristics for both groups were comparable. Intraoperative results showed a significantly shorter median skin-to-skin time of 138.5 minutes (125.8-163.8) versus 169.0 (141.5-209.8) minutes in favor of the 3D group (P = 0.001). Warm ischemia time (P = 0.003) and hilar phase for both single (1 artery and vein) and multiple anatomies (≥1 artery and/or vein [P = 0.002 and P = 0.010, respectively]) were also significantly reduced in favor of the 3D group, with a flat learning curve. Follow-up demonstrated no readmissions nor significant differences for donors, recipients, and graft survival.

CONCLUSIONS

3D endoscopy may be a good alternative to robot-assisted donor nephrectomy because morbidity, graft, and recipient survival were comparable, with a significantly shorter median skin-to-skin time, warm ischemia time, and hilar dissection phase. Furthermore, implementation was easy and at lower costs, whereas tactile feedback was preserved.