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

Sclerotherapy of the Post renal Transplant Lymphoceles: A Meta-Analysis

PURPOSE

This study evaluated the effectiveness of sclerotherapy in treating lymphoceles after kidney transplantation, focusing on factors such as recurrence rates and procedural success.

MATERIALS AND METHODS

Retrospective studies using sclerotherapy as the only form of treatment for postrenal transplant lymphoceles were included. All studies used percutaneous transcatheter sclerotherapy as treatment, and the success rate of the intervention was recorded. Sixty-one references were obtained by manually searching the MEDLINE (n = 20), Embase (n = 41), and Cochrane Library databases (n = 0) for retrospective research studies that included the keywords "sclerotherapy post renal transplant lymphoceles." After removing 3 duplicates, 50 of the remaining articles were excluded after the screening, and the remaining studies were extracted for demographic data and our primary outcome of the success rate of sclerotherapy.

RESULTS

A descriptive analysis of the outcomes and complication rates associated with sclerotherapy interventions for lymphoceles is provided. A high degree of variation across the different studies was observed. According to the Kruskal-Wallis test, there was no correlation between the sclerosant used and the sclerotherapy complication rate (P = .472) or the success rate (P = .591). There was also no correlation between the gender of the patient and the success rate; however, there was a significant difference in the complication rate by gender (P < .005).

CONCLUSIONS

In conclusion, different sclerosant products have been used for therapy with no consensus on the most efficacious product because the success rate has been variable. In addition, the gender of the patient may influence the complication rates associated with sclerotherapy for lymphoceles in patients post-kidney transplant.

Lymphocele Complication After Kidney Transplant: Current Literature Review and Management Algorithm

Kidney transplant is the best treatment option for patients with end-stage renal disease. It reduces mortality and improves the quality of life. However, kidney transplant presents medical and surgical complications, and one of the most common is the posttransplant lymphocele. Lymphocele complication has an incidence of up to 20% and presents with variable clinical symptoms, which are directly associated with the size and compression effect on the adjacent organs. There are reported risk factors that favor the appearance of lymphocele. Despite known factors, there are more relevant factors (male sex, deceased donor, and corticosteroids) to carry out a stricter follow-up. The treatment of lymphoceles can vary according to the severity of the symptoms, characteristics of the collection, and the patient's clinical status. Despite the high recurrence, percutaneous intervention is the initial approach in this condition. If percutaneous aspiration, drainage, and sclerotherapy are unsuccessful, then open or laparoscopic fenestration can be performed; laparoscopy is the standard of treatment since it is highly effective and has few adverse effects.

Imaging-Guided Percutaneous Transperitoneal Balloon Fenestration of Postrenal Transplant Lymphocele: A Case Report of Experience with New Technique

Renal transplantation is the treatment of choice for improved survival and quality of life in patients with end-stage renal disease. However, perirenal fluid collections are common surgical complications after renal transplant, with about 0.6 to 18% of patients developing a lymphocele. Conventional treatments include percutaneous aspiration and drainage, laparoscopic fenestration, and open surgical decompression stepwise. Recently, a new image-guided percutaneous transperitoneal balloon fenestration technique has been described as an alternative to the laparoscopic or surgical technique. We present the case of a 25-year-old male patient diagnosed with a lymphocele after 2 months of transplantation and no resolution of the lymphocele with percutaneous aspiration and drainage. We used this new technique under ultrasound and fluoroscopy guidance, which resulted in the resolution of the lymphocele at 1 month postprocedure. This case report highlights this new technique's potential role in successfully managing the posttransplant lymphocele in a minimally invasive manner.

Lymphatic embolization for the management of symptomatic pelvic lymphocele after radical prostatectomy with lymph node dissection: Report of two cases

INTRODUCTION

Pelvic lymphocele is the most common complication of pelvic lymph node dissection after radical prostatectomy. Management of symptomatic pelvic lymphocele begins with percutaneous drainage, followed by sclerotherapy or surgical marsupialization and more recently, lymphatic embolization. In this article, we show the feasibility and results of two lymphatic embolization after prostatectomy with lymph node dissection.

CASE PRESENTATION

We decided to perform lymphatic embolization in two patients with persistent symptomatic pelvic lymphocele, after percutaneous drainage. This was done through inguinal lymph node puncture using Lipiodol and N-butyl cyanoacrylate glue injection. Drainage removal was done on the day after the procedure and clinical recovery was maintained at follow-up visits, 3 and 4 months later, in both patients. Computed tomography at 6 and 10 weeks after embolization showed the disappearance of the lymphocele.

CONCLUSION

Our two case reports support the promising results of lymphatic embolization in this pathology.

Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review

PURPOSE

A broad range of therapeutic options exists for symptomatic postoperative lymphoceles. However, no consensus exists on what is the optimal therapy. In this study, we aimed to compare the efficacy of currently available radiologic interventions in terms of number of successful interventions, number of recurrences, and number of complications.

METHODS

A systematic review was conducted with a pre-defined search strategy for PubMed, EMBASE, and Cochrane databases from inception until September 2019. Quality assessment was performed using the 'Risk Of Bias In Non-randomized Studies - of Interventions' tool. Statistical heterogeneity was assessed using the I² and χ² test and a meta-analysis was considered for studies reporting on multiple interventions.

RESULTS

37 eligible studies including 732 lymphoceles were identified. Proportions of successful interventions for percutaneous fine needle aspiration, percutaneous catheter drainage, percutaneous catheter drainage with delayed or instantaneous addition of sclerotherapy, and embolization were as follows: 0.341 (95% confidence interval [CI]: 0.185-0.542), 0.612 (95% CI: 0.490-0.722), 0.890 (95% CI: 0.781-0.948), 0.872 (95% CI: 0.710-0.949), 0.922 (95% CI: 0.731-0.981). Random-effects meta-analysis of seven studies revealed a pooled relative risk for percutaneous catheter drainage with delayed addition of sclerotherapy of 1.57 (95% CI: 1.17-2.10) when compared to percutaneous catheter drainage alone. The risk of bias in this study was severe.

CONCLUSIONS

This systematic review demonstrates that the success rates of percutaneous catheter drainage with sclerotherapy are more favorable when compared to percutaneous catheter drainage alone in the treatment of postoperative pelvic lymphoceles. Overall, percutaneous catheter drainage with delayed addition of sclerotherapy, and embolization showed the best outcomes.

Intranodal lymphangio-embolisation as treatment for lymphocele after kidney transplantation: A case report

Introduction and objectives:

The rate of symptomatic lymphoceles requiring intervention after renal transplantation is reported to be only 5.6%. Controversies prevail in the current literature regarding the management of symptomatic lymphoceles post renal transplantation, with no established algorithm. The creation of a peritoneal window, frequently performed laparoscopically, is deemed the gold standard for management. We herin report the case of a lymphocele post renal transplant treated minimally invasively with intranodal lymphangio-embolisation, with a review of the current literature of this uncommon procedure.

Methods:

This was a retrospective review of this patient’s electronic medical records.

Results:

We present a 43-year-old male with end-stage kidney disease secondary to chronic glomerulonephritis, having been on hemodialysis for seven years. He underwent a deceased donor dual kidney transplant, complicated postoperatively by renal vein thrombosis in one of the grafts, resulting in early graft nephrectomy as well as a distal ureterovesical leak requiring reimplantation. On re-implantation on postoperative day 16, he was noted to have a persistent high drain ouput with a normal drain fluid creatinine. A right intranodal lymphagiogram was performed, and this demonstrated an active lymph leak around the transplanted kidney. A 33% glue (N-butyl cyanoacrylate)-Lipodiol infusion was then injected at a rate of 0.2 mL/min intranodally under fluoroscopic guidance. The patient underwent another repeat embolisation five days later for a residual lymph leak with satisfactory results. Drain output subsequently decreased, and the drain was removed.

Conclusions:

This case suggests that intranodal lymphangiography and embolisation may not only be a diagnostic tool but can be considered as an effective, minimally invasive and safe method for the treatment of lymphoceles after kidney transplantation.

Consensus on definition and severity grading of lymphatic complications after kidney transplantation

BACKGROUND

The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy.

METHODS

Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres.

RESULTS

Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention.

CONCLUSION

A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.