|Year : 2001 | Volume
| Issue : 1 | Page : 36-41
Lymphoceles following renal transplantation: Comparison of open surgical and laparoscopic deroofing
Raj Shekhar Gupta, J Niranjan, Aneesh Srivastava, Anant Kumar
Department of Urology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
Department of Urology and Renal Transplantation, SGPGIMS, Rai Bareilly Road, Lucknow (U.P.) - 226 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Lymphocele following renal transplantation is a well recognized complication. Due to their critical location in the pelvis lymphoceles can become symptomatic. Herein we describe our experience of managing lymphoceles following renal transplantation with special emphasis on laparoscopic deroofing.
From 1989 to 1999, 11 symptomatic lymphoceles were diagnosed in 680 renal transplant recipients. 6 patients underwent laparoscopic deroofing, 4 open internal marsupializations and 1 external drainage for infected lymphocele. Mean follow-up was 26.25 months and 10.33 months in open internal drainage and laparoscopic group respectively. Mean operative time in patients undergoing open surgical deroofing was 70.25 minutes [Table 2]. Average hospital stay was 7.5 days (5 to 10 days). There was no intraoperative complication. Mean operative time in laparoscopic group was 100 (60-120) minutes. In 5 patients (83.33%) laparoscopic deroofing could be carried out successfully. Complication occurred in I patient (16.66%). Average hospital stay was 2.66 (1-6) days. No recurrence of Lymphocele has been noted in the follow-up. We conclude that laparoscopic deroofing of post-transplant lymphocele is a safe procedure associated with minimal morbidity, better cosmesis and rapid convalescence. It should be the procedure of choice for all but infected lymphoceles.
Keywords: Lymphocele; Renal Transplantation; Laparoscopic Deroofing
|How to cite this article:|
Gupta RS, Niranjan J, Srivastava A, Kumar A. Lymphoceles following renal transplantation: Comparison of open surgical and laparoscopic deroofing. Indian J Urol 2001;18:36-41
|How to cite this URL:|
Gupta RS, Niranjan J, Srivastava A, Kumar A. Lymphoceles following renal transplantation: Comparison of open surgical and laparoscopic deroofing. Indian J Urol [serial online] 2001 [cited 2020 Jan 27];18:36-41. Available from: http://www.indianjurol.com/text.asp?2001/18/1/36/37395
| Introduction|| |
Lymphocele following renal transplantation is a well recognized complication. The reported incidence in the literature varies from 0.6% to 18%. Nakstad even found them to be the most frequent surgical complication in renal transplant recipient . Majority of the lymphocele are asymptomatic and detected on routine post-operative ultrasonography (USG) [Figure - 1]. However due to their critical location in the pelvis, they may cause compression of the transplant ureter with resultant hydronephrosis, azotemia, compression of the bladder or obstruction of the pelvic veins with edema of the ipsilateral extremity. The treatment options include simple aspiration, USG assisted percutaneous catheter drainage with or without addition of sclerosing agent,, and surgery. While open surgical deroofing was the gold standard, more recently several authors have reported successful laparoscopic deroofing of the lymphocele.,,,,,,Herein we describe our experience of managing lymphoceles following renal transplantation with special emphasis on laparoscopic deroofing.
| Patients and Methods|| |
Between January 1989 to February 1999, 680 live related renal transplantations were performed in our institute. The hospital records of all the patients were evaluated for the development of perirenal fluid collection especially for lymphocele. Details of the operative procedure, postoperative course, follow-up imaging and renal function were also noted.
The transplant procedure was carried out using the standard technique. All patients underwent baseline usg at the time of discharge and were followed as per protocol. USG was repeated whenever the clinical symptoms and signs dictated. Any perirenal fluid collection was evaluated by biochemical examination of the aspirated fluid, grams staining and culture sensitivity. A total of 20 (3.03%) lymphoceles were detected in the postoperative follow-up visits. In 11 (1.51%) patients lymphoceles were symptomatic requiring intervention. All were first kidney transplant recipients. A triple drug immunosuppression consisting of cyclosporin A. azathioprine and low dose prednisolone was used in all patients. Mean age of the patients was 36.3 years (range 23 to 48 years) There were 8 male and 3 female patients. The most common indications for intervention were azotemia and hydronephrosis of the graft [Table - 1]. Median time to development of lymphocele was 3 months from the date of kidney transplant. At our center. open internal drainage was the standard surgical management prior to 1995. However after 1995 laparoscopic deroofing of the lymphocele became the standard treatment. Out of 11 patients, 4 underwent open internal drainage, 6 patients underwent laparoscopic deroofing and 1 patient was managed by external drainage due to formation of abscess in the lymphocele cavity.
Laparotomy and internal drainage was performed through midline infraumblical incision with the patient under general anesthesia. After identification, a portion of the cyst wall was widely excised and free drainage established into the peritoneal cavity. The wall was over sewn with continuous suture of chromic catgut no. 3'0'. A pedicle of omentum was fixed in the cavity with suture.
Our technique of laparoscopic deroofing of lymphocele has been reported previously. The patient is kept in supine position and general anesthesia is preferred. Foley catheter is inserted to decompress the bladder and a nasogastric tube to keep the stomach empty. Access to peritoneal cavity is gained through a small subumblical incision through which a verress needle is inserted at an angle of 45° in empty pelvis. The position should be checked by aspiration and infusion of 5 ml of saline. CO, is insufflated at the rate of 6 liters per minute and intra-abdominal pressure is maintained below 15 mm Hg. A 10-mm umblical trocar is placed for 30° angle laparoscope with attached video camera for initial inspection. A second 10mm trocar is placed under vision along the right midclavicular line just below the level of umbilicus. This allows the endoclip applier to be introduced later. The position of the third trocar is dictated by the position of the lymphocele. We place the third trocar in the hypogastrium either between the umbilicus and symphysis or laterally along the edge of the rectus muscle. The lymphocele is identified as a bulge [Figure - 2]. The patient is then placed in 20° trendelenburg position and tilted to the side opposite to the lymphocele. Any adhesions are carefully dissected away using dissecting forceps. An aspirating needle is inserted in the lymphocele and fluid aspirated to confirm the location. About 100 to 150 cc of saline can be pushed in to make the bulge more obvious. Using electric hook the wall of lymphocele is incised broadly for 4 to 5 cm. A part of the wall of the lymphocele is excised by keeping the wall taut with the grasper [Figure - 3]. With the help of dissecting forceps al I loculi or septa are broken down. The cavity is irrigated with normal saline and all fluid is sucked.
The free inferior edge of omentum is slipped in the cavity. The omentum is fixed to the edges of the cavity by application of 5 to 6 endoclips [Figure - 4]. The CO, is allowed to escape through the sheaths, which are removed and the incisions are closed. 10-mm ports require a deep fascial suture and skin can be sutured with subcuticular absorbable suture or steristripped.
All patients were followed with renal function tests and USG at I week and 3 months postoperatively [Figure - 5] Following that imaging was repeated as and when the clinical symptoms and signs dictated.
| Results|| |
Overall the duration of follow-up was 16.70 (1 to 60) months. In 4 patients undergoing open internal drainage the mean follow-up was 26.25 (9 to 60) months. Followup was 10.33 (3 to 24) months in 6 patients undergoing laparoscopic deroofing.
Mean operative time in patients undergoing open surgical deroofing was 70.25 minutes [Table - 2]. Average hospital stay was 7.5 days (5 to 10 days). There was no intraoperative complication. Postoperatively one patient developed fever, which responded to antibiotics, and another patient developed superficial wound infection, which required opening of suture and delayed closure.
Mean operative time in laparoscopic group was 100 (60120) minutes. In 5 patients (83.33%) laparoscopic deroofing could be carried out successfully. In I patient, no definite bulge could be identified, despite instillation of 100 ml of methylene blue. Intraoperative USG showed lymphocele to be located anterolateral to the graft. Patient was managed with percutaneous catheter drainage with sclerotherapy. This patient continues to do well with no recurrence of lymphocele.
Complication occurred in I patient (16.66%). Bladder injury occurred while excising a part of the lymphocele wall. There was problem in identification due to adhesion and thick lymphocele wall. The injury was recognized and repaired at laparotomy without any sequelae. Average hospital stay was 2.66 (1-6) days. No recurrence of lymphocele has been noted in the follow-up.
| Discussion|| |
Symptomatic lymphoceles occurred in 1.51% of our patients, which is well within the 1% to 12% range described in the literature. Lymphocele form as a result of leakage of lymph from the severed lymphatics during preparation of the graft bed or from the hilar lymphatics of the donor kidney. Other contributory factors include renal capsular tears, acute rejection episodes, lower extremity arteriovenous fistula and use of diuretics and anticoagulants. In our study 1 patient (9.09%) each had renal capsular tear and acute rejection episode prior to development of the lymphocele.
Majority of the lymphocele are asymptomatic and do not require any treatment. Because of their location in the pelvis, near the bladder and the graft. they may cause compression of the graft ureter, bladder and the iliac veins. The clinical presentation can vary from azotemia, graft hydronephrosis. ipsilateral leg swelling to pain and fever due to infection in the lymphocele.
Ultrasonography is the most reliable method of diagnosing post-transplant lymphocele. USG findings of hypoechoic to anechoic masses with through transmission, occasionally with septa and dependant or scattered debris are suggestive but not specific for the diagnosis [Figure - 5]. Lymphocele with substantial debris and internal echoes are more likely to be infected. USG offers the advantage of being noninvasive, safe and unaffected by the degree of renal dysfunction. If required USG guided aspiration can also be done. Radionuclide renal scan and CT scan complement USG but are rarely needed.
The treatment of lymphocele has evolved over the years. Although lymphoceles can be initially managed by percutaneous aspiration with or without instillation of sclerosant agent such as povidone-iodine, the recurrence rates are high; 50% to 100% after simple aspiration and 10% to 15% following sclerotherapy. Percutaneous sclerotherapy was initially tried in 3 of our patients. In all 3, there was recurrence of lymphocele. Infected lymphoceles are managed by percutaneous catheter drainage or open external drainage. For sterile lymphoceles. internal drainage into peritoneal cavity is definitive. Once the lymph has reached into the peritoneal cavity, it can be absorbed into general circulation by the subdiaphragmatic lymph channels.
Open internal drainage thus became the gold standard. However, open surgery has significant morbidity, prolonged hospital stay and may be associated with recurrence of lymphocele. Melvin et al reported on cumulative data of seven reports comprising 52 patients. Complication rate was 3.8% and recurrence rate was 3.8%. Langle reported recurrence rate of 10%. In our 4 patients undergoing open internal drainage though the operative time was less (70.25 min) the hospital stay was prolonged (7.5 days). There were no intraoperative complications and 1 (25%) patient had post-operative wound infection.
Since its first description in 1991, laparoscopic deroofing has emerged as an attractive alternative to open surgical deroofing and may well become the gold standard. The operative time is slightly longer than that for open surgery: however the post-operative morbidity is minimal and convalescence more rapid. Gill et al reported that laparoscopic technique is associated with longer operating time (194.6 vs. 176.9 min), but decreased blood loss (23.1 vs. 74.6 ml), shorter hospital stay (2 vs. 6.1 days) and faster convalescence (2 vs. 6.9 weeks) compared to open surgery. There was no post-operative complication. Various studies have reported reasonable operating times, low complication rates and shorter convalescence [Table - 3]., Our results support the findings of earlier studies.
Ornentopexy was performed in all the patients in our study. The purpose is to maintain the patency of the peritoneal window. However in a recent study by Gill, omentopexy was performed in only 14% of the cases without any increase in the recurrence of the lymphocele.
Intraoperative complication occurred in 1 (16.66%) patient in the laparoscopy group. Bladder injury occurred while dissecting the thick lymphocele wall. The injury was detected and repaired at laparotorny without any sequelae. Bladder injury has also been reported by Langle et al and Gill. Intraoperative USG localization of the lymphocele may help prevent inadvertent cystotomy. Intraoperative percutaneous needle distension may further help identifying the lymphocele laparoscopically.
There was no ureteral injury in our series, which has been reported earlier. To identify ureter intraoperatively some workers have suggested preoperative or intraoperative retrograde stenting of the ureter. In our series ureteral stenting was performed in I patient. We feel that it may not be necessary. Gill et al reported on 81 laparoscopic cases where no intraoperative stenting of the ureter was done and no ureteric injury occurred.
Mean follow-up was 10.33 months in the laparoscopic group. Till date no recurrence of lymphocele has been noted. Our data reinforces that laparoscopic deroofing of post-transplant lymphocele is a safe alternative, which provides a shorter hospital stay, rapid convalescence and decreased morbidity without compromising the efficacy. One must appreciate the limitation of the technique. Accessibility to the lymphocele should be judged by a combination of intraoperative USG and laparoscopic assessment. Intraoperative percutaneous needle aspiration and distension can further define the peritoneal interface of the lymphocele. Before excising a part of the wall of the lymphocele, laparoscopic needle aspiration should be done to confirm the location of the lymphocele and judge the thickness of the wall. When safe access is not possible, open approach is preferred, Infected lymphocele is drained externally. Only with realization of the limitations, laparoscopic deroofing can be safe and efficacious.
| Conclusion|| |
Laparoscopic deroofing of post-transplant lymphocele is a safe procedure associated with minimal morbidity, better cosmesis and rapid convalescence. It should be the procedure of choice for all but infected lymphoceles.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2], [Table - 3]