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Lymphoceles: diagnosis and management in urologic patients

1998; Elsevier BV; Volume: 51; Issue: 5 Linguagem: Inglês

10.1016/s0090-4295(98)00090-9

1527-9995

Louis L. Glass, Abraham T.�K. Cockett,

Lymphatic Disorders and Treatments

The anatomy of the lymphatic system was elegantly described by William Hewson in 1774.1Hewson W. The Lymphatic System in the Human and in Other Animals. J Johnson, London1774Google Scholar This work, conducted at the Hunterian Anatomic institute, led to a dispute between Hewson and his mentor, William Hunter. Hunter would not allow the young anatomist to retain his personal dissections and took credit for the work. Hunter stated, "I think I have proved that the lymphatic vessels are the absorbing vessels, all over the body: that they are the same as the lacteals; and that these altogether with the thoracic duct constitute one great and general system dispersed through the whole body for absorption;…."2Hunter W. Two Introductory Lectures in His Last Course of Anatomic Lectures at His Theater in Windmill Street. J Johnson, London1784Google Scholar Despite their personal differences, it is clear that these anatomists had a thorough understanding of the lymphatic system. The never modest William Hunter proposed, "If we mistake not, in a proper time it (the lymphatics) will allow to be the greatest discovery both in physiology and pathology that anatomy has suggested, since the discovery of the circulation."2Hunter W. Two Introductory Lectures in His Last Course of Anatomic Lectures at His Theater in Windmill Street. J Johnson, London1784Google Scholar Claude Bernard further illuminated the role of the lymphatics with his global concept of a mammalian requirement for the maintenance of a constant internal milleau bathing all cells.3Bernard C. JB Bailliere et Fils, Paris1878Google Scholar Later in the nineteenth century, Starling established the relationship of colloidal and osmotic pressures between capillaries and their surrounding tissues, and its role in fluid exchange (Fig. 1). 4Starling EU: On the absorption of fluid from the connective tissue spaces. J Physiol (Lond).Google Scholar In the following century, Drinker and colleagues solidified the physiologic concept that the lymphatic capillaries serve to return protein molecules to the central circulation. It was not until 1955 that the first lymphoceles were described. A gynecologist named Mori analyzed a series of radical hysterectomy patients. He called these collections "lymphocysts," a term that was used until the 1970s.5Mori N. Clinical and experimental studies on the so called lymphocyst which develops after radical hysterectomy in cancer of the uterine cervix.J Jap Obst Gynec Soc. 1955; 2: 178-203PubMed Google Scholar The lymphatic system performs several functions including: reabsorption of excess protein, water, and electrolytes from blood capillaries, removal of macromolecules and foreign substances from tissues, and clearing of debris from areas of tissue injury. Approximately 7 L of fluid is returned to the central circulation from the lymphatics each day. The arrangement of lymphatics is quite variable from organ to organ (Fig. 2). The average human has 500 to 1000 individual lymph nodes, ranging in size from 1 mm to 2 cm (Fig. 3). Lymph nodes are interposed along the course of lymphatic vessels and act as mechanical filters. They also serve as the primary site of the immunologic response.FIGURE 3Schematic of major lymphatic vessels of thorax, abdomen, and pelvis.View Large Image Figure ViewerDownload (PPT) On the microscopic level, the lymphatic capillaries consist of a single layer of flat endothelial cells. The basement membrane is either absent or vestigial. These characteristics allow for a high permeability to large molecules and cells, and explain the propensity for infectious processes and malignancies to spread along lymphatic networks. A lymphocele is defined as a collection of lymph in a cavity that is not lined by epithelium. Lymphoceles are most commonly seen following surgical procedures in which large amounts of lymphatic tissue are transected. In urologic practice, these collections most commonly form following renal transplantation and staging pelvic lymphadenectomy. Lymphoceles are most frequently seen following extraperitoneal procedures. Intraperitoneal lymphoceles are rare since the peritoneum has the capacity to reabsorb large quantities of fluid. In renal transplant recipients, it is believed that both donor (renal) and recipient (iliac) lymphatics contribute to lymphocele formation. Once injured, a lymphatic vessel is quite susceptible to continued leakage.6Chrobak L. Bartos V. Brzek V. Anizdova D. Coagulation properties of human thorasic duct lymph.Am J Med Sci. 1967; 253: 69-75Crossref PubMed Scopus (25) Google Scholar Lymph contains a low concentration of clotting factors and has no platelets. Lymphatic vessels are devoid of smooth muscle and therefore lack any constrictive properties. Studies have shown that lymphatic vessels may take 48 hours to seal and several weeks to regenerate following injury.7Leitner D.W. Sherwood R.C. Inguinal lymphocele as a complication of thighplasty.Plast Reconstr Surg. 1983; 72: 878-881Crossref PubMed Scopus (30) Google Scholar Other factors that may predispose patients to lymphocele formation include inadequate intraoperative lymphostasis, prior radiation or chemotherapy, anticoagulation, diuretics, and rejection of a renal allograft. The routine use of minidose heparin in patients undergoing pelvic lymphadenectomy remains controversial due to the apparently high risk of subsequent lymphocele formation. A retrospective study by Catalona and coworkers found 3 of 8 (38%) patients suffered a lymphocele when receiving perioperative subcutaneous heparin after extraperitoneal pelvic lymphadenectomy while only 1 of 30 (3.3%) patients in whom heparin was not used formed a lymphocele.8Catalona W.J. Kadmon D. Crane D.B. Effect of mini–dose heparin on lymphocele formation following extraperitoneal pelvic lymphadenectomy.J Urol. 1980; 123: 890-892Abstract Full Text PDF PubMed Scopus (86) Google Scholar Similarly, Tomic et al.9Tomic R. Granfors T. Sjodin J.G. Ohberg L. Lymph leakage after staging pelvic lymphadenectomy for prostatic carcinoma with and without heparin prophylaxis.Scand J Urol Nephrol. 1994; 28: 273-275PubMed Google Scholar prospectively studied 48 patients (24 receiving minidose heparin and 24 controls) undergoing extraperitoneal lymphadenectomy. They found a significant increase in quantity and duration of pelvic drainage as well as a seven times greater incidence of lymphoceles in the heparin group. An interesting study by Krupfl and coworkers10Kropfl D. Krause R. Hartung R. Pfeiffer R. Behrendt H. Subcutaneous heparin injection in the upper arms as a method of avoiding lymphoceles after lymphadenectomies in the lower part of the body.Urol Int. 1987; 42: 416-423Crossref PubMed Scopus (32) Google Scholar suggested that it may be safer to administer subcutaneous heparin in the arms as opposed to the thighs. They examined 21 patients who underwent a variety of radical procedures with lymph node dissections (prostatectomy, cystoprostatectomy, and retroperitoneal lymph node dissection [RPLND]). They found detectable levels of heparin in lymph drainage fluid when heparin was administered in the thighs. These levels were of sufficient magnitude to alter serum coagulability. Conversely, heparin was not detectable in drainage fluid when it was administered in the upper extremities. Serum heparin levels were comparable regardless of the route of administration. Lymph drainage was higher in the thigh group patients. Three lymphoceles and one pulmonary embolism (PE) was seen in the thigh group as opposed to one lymphocele in the arm group. Clinically, lymphoceles may have various presentations. It should be noted that most are asymptomatic. Symptoms and signs are usually secondary to local compression of adjacent structures and may include abdominal/pelvic mass or pain, leg or genital edema, deep vein thrombosis, pulmonary emboli, renal insufficiency, hydronephrosis, sepsis, bowel obstruction, urinary frequency, and vena cava or portal obstruction. The incidence of postoperative lymphocele formation has been quite variable. In renal transplant recipients, the reported incidence is from 0.6% to 18%11Schweizer R.T. Cho S.I. Kountz S.L. Belzer F.O. Lymphoceles following renal transplantation.Arch Surg. 1972; 104: 42-45Crossref PubMed Scopus (68) Google Scholar, 12Braun W.E. Banowsky L.H. Straffon R.A. Nakamoto S. Kiser W.S. Popowniak K.L. Hewitt C.T. Steward B.H. Zelch J. Magalhaes R.L. Lachance J.G. Manning R.F. Lymphocytes associated with renal transplantation Report of 15 cases and review of the literature.Am J Med. 1974; 57: 714-729Abstract Full Text PDF PubMed Scopus (138) Google Scholar, 13Howard R.J. Simmons R.L. Najarian J.S. Prevention of lymphoceles following renal transplantation.Am Surg. 1976; 18: 166-169Google Scholar, 14Zincke H. Woods J.E. Leary F.J. Aguilo J.J. DeWeerd J.H. Frohnert P.P. Hattery R.R. Experience with lymphoceles after renal transplantation.Surgery. 1975; 77: 444-446PubMed Google Scholar, 15Kay R. Fuchs E. Barry J.M. Management of postoperative pelvic lymphoceles.Urology. 1980; 15: 345-347Abstract Full Text PDF PubMed Scopus (66) Google Scholar, whereas 0.7% to 14.8% of extraperitoneal pelvic lymph node dissections16Donahue R.E. Mani J.H. Whitesel J.A. Augspurger R.R. Williams G. Fauver H.E. Intraoperative and early complications of staging pelvic lymphnode dissection in prostatic adenocarcinoma.Urology. 1990; 35: 223-227Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 17Igel T.C. Barrett D.M. Segura J.W. Benson R.C. Rife C.R. Perioperative and postoperative complications from bilateral pelvic lymphadenectomy and radical retropubic prostatectomy.J Urol. 1987; 137: 1189-1191PubMed Google Scholar, 18Paul D.B. Loening S.A. Narayana A.S. Culp D.A. Morbidity from pelvic lymphadenectomy in staging carcinoma of the prostate.J Urol. 1983; 129: 1141-1144Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 19Sogani P.C. Watson R.C. Whitmore W.F. Lymphocele after pelvic lymphadenectomy for urologic cancer.Urology. 1981; 27: 39-43Abstract Full Text PDF Scopus (56) Google Scholar experience this complication. Interestingly, one study showed that 6 of 22 patients (27%) formed lymphoceles following pelvic lymphadenectomy when studied prospectively by ultrasound examination.20Spring D.B. Schroeder D. Babu S. Agee R. Gooding G.A.W. Ultrasonic evaluation of lymphocele formation after staging lymphadenectomy for prostatic carcinoma.Radiology. 1981; 141: 479-483Crossref PubMed Scopus (50) Google Scholar The incidence of lymphocele formation following RPLND has been only 2%.21Babaian R.J. Bracken R.B. Johnson D.E. Complications of transabdominal retroperitoneal lymphadenectomy.Urology. 1981; 17: 126-128Abstract Full Text PDF PubMed Scopus (35) Google Scholar The diagnosis of lymphoceles is straightforward once the differential has been considered. The clinician must maintain a high index of suspicion in the appropriate situations. A computed tomography (CT) scan or an ultrasound examination of the abdomen and pelvis will confirm the presence and location of a fluid collection. Lymphoceles will generally appear cystic but internal echoes and septations may be present. Any suspicious collections should be aspirated under radiographic guidance. The fluid is checked for creatinine, cell count, Gram stain, and culture. These studies will identify the collection as a urinoma, hematoma, abscess, or lymphocele. Asymptomatic lymphoceles do not require any form of therapy. These patients can be followed with serial imaging studies (ultrasound or CT scan). Most of these collections will resolve spontaneously over time although some may progress. Aspiration should be used as a diagnostic tool only. There is only a 20% success rate when multiple percutaneous aspirations are performed. Furthermore, the risk of infection is quite high.22Lindstedt E. Lindholm T. Gustavson J. Lymphocele an important post transplantation complication.Scand J Urol Nephrol. 1976; 10: 94-96Crossref PubMed Scopus (9) Google Scholar The management of symptomatic lymphoceles has changed dramatically over the past two decades. Percutaneous lymphocele drainage was first reported in 1983.23Aronowitz J. Kaplan A.L. The management of pelvic lymphocele by the use of percutaneous indwelling catheter inserted with ultrasound guidance.Gynecol Oncol. 1983; 16: 292-295Crossref PubMed Scopus (22) Google Scholar This technique offers a 70% success rate and is minimally invasive. The main disadvantage is that resolution often takes several weeks to months. The addition of sclerosing agents to percutaneous drainage has become increasingly popular. Tetracycline was initially used.24McDowell G.C. Babaian R.J. Johnson D.E. Management of symptomatic lymphocele via percutaneous drainage and sclerotherapy with tetracycline.Urology. 1991; 37: 237-239Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 25Shokeir A.A. el-Diasty T.A. Ghonein M.A. Percutaneous treatment of lymphocele in renal transplant recipients.J Endourol. 1993; 7: 481-482Crossref PubMed Scopus (49) Google Scholar The safety of this agent had been established with its use in pleurodesis. The typical dose is 0.5 to 2 g in 50 mL normal saline. Doxycycline and minocycline have also been used.26Folk J.J. Musa A.G. Management of persistent lymphocele by sclerotherapy with doxycycline.Eur J Obstet Gynecol Reprod Biol. 1995; 60: 191-193Abstract Full Text PDF PubMed Scopus (32) Google Scholar, 27Lin J.J. Sorbi J.P. Uy P.R. Cabal F.J. Kaskel W.C. Waltzer W.C. Rapaport F.T. Arbeit L.A. Doxycycline sclerotherapy of lymphocele after renal transplantation and its inhibition of gelatinase activity.Transplant Proc. 1993; 25: 3320-3324PubMed Google Scholar In addition to their antimicrobial activity, these agents also inhibit tissue collagenase, which may be highly active in lymphoceles. Povidone-iodine has become a popular sclerosing agent.28Burgos J. Teruel J.L. Mayayo T. Lovaco F. Berenguer A. Orte L. Tallado M. Ortuno J. Diagnosis and management of lymphoceles after renal transplantation.Br J Urol. 1988; 61: 289-293Crossref PubMed Scopus (44) Google Scholar, 29Teruel J.L. Escobar E.M. Quereda C. Mayayo T. Ortuno J. A simple and safe method for management of lymphocele after renal transplantaiton.J Urol. 1983; 130: 1058-1059PubMed Google Scholar, 30Gilliland J.D. Spies J.B. Brown S.B. Yrizarry J.M. Greenwood L.H. Lymphoceles percutaneous treatment with povidone-iodine sclerosis.Radiology. 1989; 171: 227-229Crossref PubMed Scopus (109) Google Scholar In addition to its antiseptic properties, this compound chelates proteins. It is approved by the US Food and Drug Administration (FDA) for use on the skin, oropharynx, and vagina. Other agents that have been used in lymphocele sclerosis include 198Au (the radioactive isotope of gold), 95% ethanol,31Kuzuhara S. et al.Conservative treatment of lymphocele after renal transplantation using 95% ethanol instillation.Transplant Proc. 1994; 26: 1988-1990PubMed Google Scholar fibrin glue,32Giberson W.G. McCarthy P.M. Kaufman B.U. Fibrin glue for treatment of persistent lymphatic drainage.J Pediatr Surg. 1988; 23: 1188-1189Abstract Full Text PDF PubMed Scopus (19) Google Scholar and sodium tetracetyl sulfate. In summary, sclerotherapy of lymphoceles is successful in 80% to 90% of cases regardless of the agent used. It is minimally invasive but again often requires weeks to months of therapy before resolution. Some surgeons are hesitant to use sclerotherapy in renal transplant recipients because the scarring often makes future procedures more difficult. Open surgical internal marsupialization of lymphoceles is the historical gold standard therapy. The lymphocele is internally drained into the peritoneal cavity by excising a segment of peritoneum. The peritoneum then reabsorbs the fluid. Omentoplasty is often used in conjunction to maintain patency (FIGURE 4, FIGURE 5). The disadvantages of this technique is that it may be used only for sterile lymphoceles. Furthermore, the recovery period is that of any open abdominal surgery. Open external lymphocele drainage has also been used in the past. This procedure is generally not recommended. The infection rate is high (25%) and there may be several weeks of fluid drainage leading to major fluid and protein loss.33Olsson C.A. Willscher M.K. Filoso A.M. Cho S.I. Treatment of post-transplant lymphoceles internal versus external drainage.Transplant Proc. 1976; 8: 501-504PubMed Google Scholar The success rate was rather good at 80%.FIGURE 5Diagrammatic presentation of an extended right-sided omental pedicle advanced over the transplant and into the underlying lymphocele cavity.View Large Image Figure ViewerDownload (PPT) Laparoscopic internal marsupialization of a lymphocele was first reported by McCullough et al. in 1991.34McCullough C.S. Soper N.J. Clayman R.V. So S.S.K. Jenderisak M.D. Hanto D.W. Laparascopic drainage of a posttransplant lymphocele.Transplantation. 1991; 51: 725-727Crossref PubMed Scopus (106) Google Scholar To date, 44 cases have been reported in the literature with an overall success rate of 88%.35Waples M.J. Wegenke J.D. Vega R.J. Laparascopic management of lymphocele after pelvic lymphadenectomy and radical retropubic prostatectomy.Urology. 1992; 39: 82-84Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 36Fahlenkamp D. Raatz D. Schonberger B. Loening S.A. Laparoscopic lymphocele drainage after renal transplantation.J Urol. 1993; 150: 316-318PubMed Google Scholar, 37Gruessner R.W. Fasola C. Benedetti E. Foshager M.C. Gruessnner A.C. Matas A.J. Najarian J.S. Goodale R.L. Laparoscopic drainage of lymphoceles after kidney transplantation indication and limitations.Surgery. 1995; 117: 288-295Abstract Full Text PDF PubMed Scopus (67) Google Scholar, 38Gill I.S. Hodge E.E. Munch L.C. Goldfarb D.A. Novick A.C. Lucas B.A. Transperitoneal marsupialization of lymphoceles a comparison of laparoscopic and open techniques.Urology. 1995; 153: 1706-1711Abstract Full Text Full Text PDF Scopus (18) Google Scholar, 39Bardot S.F. Montie J.E. Jackson C.L. Seiler J.C. Laparoscopic surgical technique for internal drainage of pelvic lymphocele.Urology. 1992; 147: 908-909Google Scholar This technique has been used in both renal transplant and extraperitoneal lymphadenectomy patients, and no major complications have been reported. These patients are benefited by the low morbidity and rapid convalescence associated with laparascopic surgery. Technically, three ports are used along with ultrasound guided needle placement into the lymphocele. This allows for expansion and decompression of the lymphocele to facilitate identification. A 3 to 4 cm peritoneal window is excised and the periphery of the peritoneum is cauterized. The laparoscope is advanced into the lymphocele cavity and gentle circular motions can be used to disrupt loculations. Omentoplasty can also be performed laparoscopically. Failures with this procedure have generally occurred in renal transplant patients in which the lymphocele is either posterior or inferior to the allograft and there is no interface with the peritoneal cavity.37Gruessner R.W. Fasola C. Benedetti E. Foshager M.C. Gruessnner A.C. Matas A.J. Najarian J.S. Goodale R.L. Laparoscopic drainage of lymphoceles after kidney transplantation indication and limitations.Surgery. 1995; 117: 288-295Abstract Full Text PDF PubMed Scopus (67) Google Scholar Those patients with inaccessible lymphoceles are best managed by an open procedure in which a cuffed peritoneal dialysis catheter is placed into the lymphocele with drainage into the peritoneal cavity (Fig. 6). 40Nicholson M.L. Veitch P.S. Treatment of lymphocele associated with renal transplant.Br J Urol. 1990; 65: 240-241Crossref PubMed Scopus (14) Google Scholar, 41Lucas B.A. Gill I.S. Munch L.C. Intraperitoneal drainage of recurrent lymphoceles using an internalized Tenckhoff catheter.Urology. 1994; 151: 970-972Google Scholar Lymphoceles are a fairly common complication following extraperitoneal lymphadenectomy and renal transplantation. The best prevention is meticulous lymphostasis and selective use of minidose heparin. Asymptomatic lymphoceles may simply be observed.