Management of pelvic lymphoceles after radical prostatectomy: a multicentre community based study

Technical Outcome, Clinical Success, and Complications of Low-Milliampere Computed Tomography Fluoroscopy-Guided Drainage of Lymphoceles Following Radical Prostatectomy with Pelvic Lymph Node Dissection

To evaluate the technical outcome, clinical success, and safety of low-milliampere CT fluoroscopy (CTF)-guided percutaneous drain (PD) placement in patients with lymphoceles following radical prostatectomy (RP) with pelvic lymph node dissection (LND). This retrospective analysis comprised 65 patients with PD placement in lymphoceles following RP under low-milliampere CTF guidance. Technical and clinical success were evaluated. Complications within a 30-day time interval associated with CTF-guided PD placement were classified according to SIR. Patient radiation exposure was quantified using dose-length products (DLP) of the pre-interventional planning CT scan (DLPpre), of the sum of intra-interventional CT fluoroscopic acquisitions (DLPintra) and of the post-interventional control CT scan (DLPpost). Eighty-nine lymphoceles were detected. Seventy-seven CT-guided interventions were performed, with a total of 92 inserted drains. CTF-guided lymphocele drainage was technically successful in 100% of cases. For all symptomatic patients, improvement in symptoms was reported within 48 h after intervention. Time course of C-reactive protein and Leucocytes within 30 days revealed a statistically significant (p < 0.0001) decrease. Median DLPpre, DLPintra and DLPpost were 431 mGy*cm, 45 mGy*cm and 303 mGy*cm, respectively. Only one minor complication (self-resolving haematoma over the bladder dome; SIR Grade 2) was observed. Low-milliampere CTF-guided drainage is a safe treatment option in patients with lymphoceles following RP with pelvic LND characterized by high technical and good clinical success rates, which provides rapid symptom relief and serves as definite treatment or as a bridging therapy prior to laparoscopic marsupialisation.

Lymphangiography and Lymphatic Embolization for the Management of Pelvic Lymphocele After Radical Prostatectomy in Prostatic Cancer

PURPOSE

To retrospectively evaluate the short-term outcomes of lymphangiography and lymphatic embolization in the treatment of pelvic lymphocele after radical prostatectomy in patients with prostate cancer.

MATERIALS AND METHODS

The data of nine, consecutive patients who underwent lymphangiography and lymphatic embolization for pelvic lymphocele after radical prostatectomy with pelvic lymph node dissection (PLND) between January 2016 and May 2018, were retrospectively reviewed. Lymphangiography was performed through inguinal lymph nodes in order to identify the lymphatic leakage. When a leakage was found, lymphatic embolization was performed using a directly punctured fine needle at the closest upstream lymph node or lymphopseudoaneurysm and with N-butyl cyanoacrylate glue.

RESULTS

Lymphangiography demonstrated extravasation and/or lymphopseudoaneurysm in all of these patients. A total of 13 sessions of lymphangiography and lymphatic embolization were performed. The median number of lymphangiography and lymphatic embolizations required to achieve clinical success was one (range, 1-3). Three patients underwent repeated embolization with successful results. The technical and clinical success rates were 100%, respectively. The median time to resolution was 7 days (range, 2-19 days). There was no recurrence and no procedure-related complications during the follow-up period (mean, 26 weeks; range, 8-77 weeks) in all patients.

CONCLUSIONS

Lymphangiography and lymphatic embolization are safe and effective for the management of pelvic lymphoceles after radical prostatectomy with PLND.

Robotic prostatectomy leading to a delayed MRSA infected lymphocele: a case report and review of the literature

Prostate cancer is the second leading cancer-related cause of death in the USA with the majority presenting as localized disease. In the last decade minimally invasive, robotic-assisted laparascopic, radical prostatectomy has become the most favored treatment choice. A complication that has been observed in 27% of patients is the formation of an asymptomatic lymphocele. It is a very rare complication for these to become infected, and when they do 80% have occurred 2-12 months post-procedure. In this case report the patient presented with fever and leukocytosis of unknown origin and was found to have a methicillin-resistant Staphylococcus aureus (MRSA) infected lymphocele over 2 years after a radical prostatectomy. The infected fluid collection was drained percutaneously and the patient was treated with a 4-week course of intravenous ceftaroline with complete resolution of symptoms.

Evaluation of Lymphorrhea and Incidence of Lymphoceles: 4DryField® PH in Radical Retropubic Prostatectomy

Purpose. To investigate impact of polysaccharide hemostat 4DryField PH (4DF) applied on lymph node dissection area after radical retropubic prostatectomy (RRP) on lymphorrhea and lymphocele (LC) formation. Methods. 104 consecutive patients underwent RRP, 51 without 4DF treatment (CT-group) and 53 with 4DF treatment (4DF-group). Groups were comparable (age, risk profile, and lymph node numbers). Postoperative drain loss (PDL) and development of early and late LC were analyzed (mean follow-up at 7 months: 100%). Results. PDL was 452.5 ± 634.2 mL without and 308.5 ± 214 mL with 4DF treatment. PDL > 1000 mL only occurred in CT-group (5/51). Overall, 45 LC (26 in CT- versus 19 in the 4DF-group) were diagnosed. At day 8, LC were equally distributed between groups. Incidence of late LC, however, was twice in controls (16/51) versus 4DF-patients (8/53). Symptomatic LC (4 in untreated patients, 2 in 4DF-patients) were treated with percutaneous drainage (duration: 45 days in untreated patients versus 12 days in 4DF-patients). Conclusion. Application of 4DF on lymph node dissection areas lessened total drain loss and significantly lowered high volume drain loss. Furthermore, 4DF reduced frequency of late lymphoceles and lymphoceles requiring treatment by half, as well as duration of percutaneous drainage by more than two-thirds.

Laparoscopic marsupialisation of pelvic lymphoceles in different anatomic locations following radical prostatectomy

BACKGROUND

Pelvic lymphoceles (LCs) following radical prostatectomy (LC-RPs) are a well-described complication. Symptomatic LC-RPs are the most frequent, nonfunctional, postradical prostatectomy complications.

OBJECTIVES

Description of the clinical presentations of LC-RPs and the detailed technique of laparoscopic pelvic LC marsupialisation (LM), including perioperative results and follow-up.

DESIGN, SETTING, AND PARTICIPANTS

Data from 105 patients (age range: 57-76 yr) with symptomatic LC-RPs who underwent surgery in our institute were evaluated retrospectively. Pelvic ultrasound (US) and computed tomography scans, performed on all patients, revealed LC volumes ranging from 100 to 1200 ml. Fifty-five patients were refractory to prior percutaneous tube drainage and/or sclerotherapy. LM was performed using a three-trocar (n=60 patients) or two-trocar technique (n=45 patients).

SURGICAL PROCEDURE

With the patient in Trendelenburg position, LCs were accurately identified by inspection, compressibility, and/or laparoscopic needle aspiration. A Foley catheter was inserted. Through one or two working trocars in the left lower abdomen, an adequate peritoneal window (wide ellipse) was excised. The LC cavity was inspected and septae, membranes, and haematomas were removed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Perioperative surgical outcomes, analgesic medication, and inflammation parameters were recorded. Follow-up and success rates were estimated with US for LC recurrence.

RESULTS AND LIMITATIONS

Five pelvic LC locations could be identified: paravesical, lateral pelvic (encapsulated and uncapsulated), prevesical, and with retroperitoneal extension. These were relevant for clinical diagnosis and management options. Pelvic LCs were right-sided in 37 patients, left-sided in 15, and on both sides in 53. All LM were uneventful and operating time (mean) ranged from 15 to 265 (31.7) min, which became shorter with increasing experience. One conversion with postoperative blood transfusion was necessary. Patients were discharged between 2 and 4 (mean: 2.3) d postoperatively. Postoperative US revealed primary success in all cases. Three patients developed recurrence from 1 to 3 wk posthospitalisation; otherwise, none had treatment for LC during a mean follow-up of 20 mo. Limitations include the retrospective study design and the small number of patients.

CONCLUSIONS

LC-RPs are common and can be classified into five different patterns of clinical/anatomic presentation. LM is simple, feasible, and safe as the first-line treatment for large, noninfected, symptomatic or refractory LC-RPs with fewer complications and an overall 97% success rate.