Minimally Invasive Methods for the Treatment of Lymphocele After Kidney Transplantation

doi:10.1016/j.transproceed.2009.09.045

Transplantation Proceedings

Volume 41, Issue 8, October 2009, Pages 3073-3076

https://doi.org/10.1016/j.transproceed.2009.09.045 Get rights and content

Abstract

Background

One common complication after kidney transplantation is a lymphocele. The aim of our work was an analysis of incidence of lymphocele and the effectiveness of minimal invasive methods in the management of this complication.

Materials and Methods

The examined group was consisted of 158 patients (68 female and 90 male) with end-stage renal disease who underwent kidney transplantation.

Results

Twenty-one patients (13%) developed symptoms of lymphocele after transplantation procedure within an average time of 34 weeks. The clinical symptoms included a decrease in 24-hour urine collection, an increase in plasma creatinine concentration, abdominal discomfort, lymphorrhea with a surgical wound dehiscence, voiding problems of urgency or vesical tenesmus, febrile states, or symptoms of deep vein thrombosis. The following methods were applied with variable efficacy: aspiration with recurrence 75%; percutaneous drainage with 55%, effectiveness; laparoscopic fenestration with 72% satisfactory outcomes (1 patient presented an excessive bleeding after the procedure), and classic surgery with favorable results.

Conclusion

Percutaneous drainage guided by ultrasonic imaging should be recommended as the first attempt to cure a lymphocele. Laparoscopy is a feasible, safe technique that should be used after unsuccessful percutaneous drainage. A larger series of patients is required to confirm the superiority of minimal invasive methods to the classical approach.

Section snippets

Materials and Methods

Between 2003 and 2008, we studied 158 patients including 90 males and 68 females, who received either cadaveric (n = 153) or live-donor (n = 5) kidney grafts. Primary transplantations were performed on 142 patients. The graft was perfused with University of Wisconsin (UW) solution, followed by bench surgery with special care in the hilum to perform ligation of vascular and lymphatic structures with nonabsorbable sutures. The surgical technique used the retroperitoneal approach in the iliac

Results

In Table 1 we have presented the causes of kidney failure; inflammatory conditions were the most frequent etiologies, constituting almost half of all causes (45%). Among the 158 kidney transplantations, 21 patients (14%) developed clinical symptoms of lymphocele, which appeared at an average time of 34 weeks (range, 2–56 wk). The patients' clinical symptoms are shown in Table 2. In 5 patients, the lymphocele was associated with graft dysfunction namely, a decrease in 24-hour urine collection

Discussion

The management of lymphoceles in kidney transplantation patients has traditionally been open surgerical treatment, but some authors have advocated minimally invasive laparoscopic procedures.⁷ Fuller et al¹⁴ showed the advantages of a laparoscopic approach to be lower blood loss and shorter hospital stay. They recommended open surgery for noninfectious wound complications associated with a lymphocele or in a high risk of vessel or ureteral injury.¹⁴ Similar observations were noticed by

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Aponeurotic-Cutaneous Tract Exeresis in Patients With Persistent Lymphorrhea After Kidney Transplantation: A Valid Approach in a Day Surgery Setting
2021, Transplantation Proceedings
Lymphatic disorders (LDs) are the most common minor complications after kidney transplantation (KT), with an incidence rate between 0.6% and 33.9%, which appears to be related to both surgical and medical factors. LDs mostly resolve spontaneously, but occasionally a surgical approach may be required.
We report our experience with 7 KT recipients who developed persistent lymphorrhea (>150 mL/24 h) between October 2017 and March 2019. All cases were treated as outpatients with parietal fistulectomy (PF). The fibrotic aponeurotic-cutaneous tract was thoroughly excised, and the residual aponeurotic defect was closed by watertight suturing. Serial abdominal ultrasounds (US) were carried out after the procedure.
A small perirenal graft lymphocele of <2 cm was detected by US in all patients after 48 to 72 hours, without any evidence of either vascular or ureteral compression. During the subsequent scheduled US follow-up, lymphoceles did not increase in size, and additional interventions were not needed. Neither superficial nor deep surgical-site infections were recorded in such patients.
PF was found to be a safe and effective minimally invasive approach for persistent lymphorrhea after KT. It could be easily performed with local anesthesia in a day surgery setting and did not require patient hospitalization.
Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review
2021, European Journal of Radiology
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.
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.
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.
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.
Experience of Lymphangiography as a Therapeutic Tool for Lymphatic Leakage After Kidney Transplantation
2018, Transplantation Proceedings
Lymphatic leakage after kidney transplantation is a relatively frequent complication but sometimes resistant to treatment, and there is no fixed treatment algorithm. The effectiveness of therapeutic lymphangiography for postoperative lymphatic or chyle leakage has been reported, but few reports are available regarding patients who have undergone kidney transplantation. In this study, we report our experience with lymphangiography as a therapeutic tool for lymphatic leakage after kidney transplantation.
Intranodal lymphangiography for lymphatic leakage was performed in 4 patients (3 male, 1 female; age range, 38 to 70 years old) after living kidney transplantation at the Osaka City University Hospital in Japan. The amount of drainage before lymphangiography was 169 to 361 mL/day. The procedure for intranodal lymphangiography was as follows: the inguinal lymph node was punctured under ultrasound guidance, and the tip of the needle was instilled at the junction between the cortex and the hilum, after which Lipiodol was slowly and manually injected.
Lymphangiography was technically successful in 3 out of the 4 patients. In all successful cases, the amount of drainage decreased and leakage finally stopped without additional therapy such as sclerotherapy or fenestration. In 2 cases, we were able to directly detect the leakage site using lymphangiography. The time between lymphangiography and leakage resolution ranged from 8 to 13 days. There were neither complications of lymphangiography nor recurrence of lymphatic leakage in the successful cases.
Intranodal lymphangiography may be not only a diagnostic tool but also an effective, minimally-invasive, and safe method for treatment of lymphatic leakage resistant to drainage after kidney transplantation.
Prevention and management of lymphocele formation following kidney transplantation
2017, Transplantation Reviews
Citation Excerpt :
However, this procedure takes a long time and can cause problems related to major fluid loss and secondary infection (particularly in immunosuppressed transplant recipients). External drainage has an efficacy of 50% and a recurrence rate of 20%–60% [16,29,39,59,64] (Table 2). The instillation of a sclerosing agent, such as ethanol, povidone iodine, and tetracycline is another treatment approach [57].
Despite preventive methods, lymphoceles frequently form following kidney transplantation (KTx), with an incidence of 0.6%–51%. Here, we summarize the current strategies for preventing and managing this complication, and describe the approach used in our department. Rapid diagnosis and early treatment of lymphoceles through a well-defined approach can prevent or reduce the risk of organ loss. Diagnosis can be made by ultrasound, computed tomography, or magnetic resonance imaging and laparoscopic fenestration is the current therapy of choice when non-surgical methods fail. Preventive methods should be performed pre-, intra-, and post-operatively. A peritoneal fenestration at the end of KTx seems to be a reasonable method for preventing lymphocele formation.
Management of lymphoceles after renal transplant: Case report of a novel percutaneous image-guided treatment technique
2013, Journal of Vascular and Interventional Radiology
Citation Excerpt :
Complications from percutaneous therapy include local or pericatheter infections, and injuries to the adjacent bladder or ureter are the most commonly seen complications with open surgical or laparoscopic treatments (2). Iwan-Zietek et al (6) reported 158 patients who underwent renal transplantation, and 14% developed clinical symptoms of a lymphocele. These authors concluded that percutaneous drainage should be recommended as the first attempt to cure a lymphocele (55% effectiveness); however, laparoscopic fenestration is a feasible (72% effectiveness) and safe technique that should be used after unsuccessful percutaneous drainage.
A 65-year-old African American man with end-stage renal disease underwent renal transplantation and developed a perigraft lymphocele with an associated progressive increase in serum creatinine 6 weeks after surgery, which failed to resolve with percutaneous drainage and surgical therapy. Fluoroscopic and ultrasound-guided percutaneous transperitoneal balloon fenestration with a 22-mm, 2-cm-long balloon catheter resulted in resolution of the lymphocele as shown by ultrasound at 3 and 5 months.
Post-kidney transplantation lymphocele due to a lymphatic filariasis
2010, Transplantation Proceedings
Citation Excerpt :
As a minimally invasive surgery, this treatment does not interfere with subsequent internal drainage through open or laparoscopic approaches. After treatment kidney graft function markedly improves and the comfort and quality of life are ameliorated in every patient.10 Routine peritoneal windows formed at the time of transplantation can decrease the incidence of an unrelated filariasis lymphocele.22
Lymphocele is a well-known complication of renal transplantation. Presenting symptoms are nonspecific; most patients are entirely asymptomatic. Herein, we have reported a case of lymphocele due to an asymptomatic lymphatic Wuchereria bancrofti filariasis with deterioration of graft function. A 53-year-old man with end-stage renal disease secondary to vascular disease was admitted 40 days after transplantation with vague, isolated abdominal pain. An abdomen and pelvis ultrasound examination demonstrated a cystic structure in the renal hilus. Graft function deteriorated, so the patient underwent puncture of the lymphocele followed by povidone iodine sclerotherapy. In the percutaneous drainage, we noted a fine whitish strand 4-mm thick similar to the shape of the stent, a part of which seemed to go into the transplantation fossa. Parasitological examination showed an adult female worm of W bancrofti measuring 6 cm. The test for microfilaremia was negative. The patient was treated for 10 days with a combination of Ivermectin and Albendazole associated with Doxycycline. The collection rapidly decreased after worm treatment. This case describes a post–renal transplantation lymphocele due to asymptomatic lymphatic filariasis.

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View full text

Renal transplantationComplication: OtherMinimally Invasive Methods for the Treatment of Lymphocele After Kidney Transplantation

Abstract

Background

Materials and Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

J Urol

Clin Imag

J Urol

Transpl Proc

Assesment of lymphocele incidence following 450 renal transplantations

Int Braz J Urol

Intraperitoneal cathter drainage of lymphocele: an outpatient procedure

Transplant Int

Laparoscopic fenestration of post transplant lymph

Surg Endosc

Laparoscopic treatment of lymphoceles in patients after renal transplantation

Clin Transplant

Laparoscopic treatment of lymphocele after kidney transplantation

Surg Endosc

A systemic approach to minimizing wound problems for de novo sirolimus-treated kidney transplant recipients

Transplantation

Renal transplantation
Complication: Other
Minimally Invasive Methods for the Treatment of Lymphocele After Kidney Transplantation