| Abstract|| |
We attempt in this retrospective study to evaluate the incidence, clinical presentations, and outcome of lymphocele in renal transplant recipients. 528 patients (313 males and 215 females) have received renal allografts from 384 living and 144 cadaveric donors. Diagnosis of lymphocele was made basically by ultrasound examination, and symptomatic collections were drained either percutaneously or into the peritoneal cavity. There were 50 (9.5%) instances of lymphocele encountered between 2 weeks and 6 months after transplantation. The lymphocele presented clinically predominantly as a single pelvi-abdominal swelling in 28 (56%) cases or as a swelling associated with manifestations of utereric and/or venous compression in 18 (36%) cases, and it was more common after cadaveric transplantation. All the cases of lymphocele were successfully treated with no graft loss. Lymphocele is an uncommon complication after renal transplantation, and is formed during the early post transplantation period. If not treated, it could seriously affect the kidney function. Intraperitoneal drainage is the most effective method for the treatment of symptomatic lymphocele.
Keywords: Kidney, transplantation, lymphocele, ultrasonography, intra peritoneal
|How to cite this article:|
Samhan M, Al-Mousawi M. Lymphocele Following Renal Transplantation. Saudi J Kidney Dis Transpl 2006;17:34-7
| Introduction|| |
Lymphocele is a fluid collection between the renal graft and the urinary bladder. It is an uncommon complication (0.6% to 18%) following renal transplantation., The development of lymphocele has been ascribed to inadequate ligation of the afferent lymphatics coursing over the recipient iliac vessels or located within the allograft hilum.  Many collections remain subclinical. In fact, up to 50% of patients may show a small collection on ultrasound scanning after renal transplantation and most of them resolve spontaneously., Large collections may present clinically by deterioration of renal graft function or as a painless ipsilateral lower limb edema, at 2 weeks to 6 months after transplantation., Ultrasound is the key to diagnosis, but other radiological procedures such as the isotope renal scanning, computed tomography, intra venous urography and magnetic resonance imaging might be necessary in complicated cases. Prevention by careful ligation of lymphatics during the dissection of iliac vessels is better than intervention later for cure.
| Patients and Methods|| |
Between November 1993 and July 2004, 528 renal transplantation procedures have been performed at the single renal transplantation center in Kuwait, in 313 male and 215 female patients with age range between 3 to 76 years. Sixty-nine recipients were children under the age of 18 years. The allograft source was a live donor in 384 and a cadaveric donor in 144 patients. The procedure was a re-transplantation in 33 recipients. The surgical technique was the standard one, where the renal graft was placed in the iliac fossa and its vessels were anastomosed to the iliac vessels and the ureter was implanted into the bladder using extravesical technique. All lymphatic vessels encountered during dissection of the iliac vessels were either ligated or diathermized. Stenting of the implanted ureter was used in most of the cases. Base line ultrasound examination and isotope scanning were performed during the first few postoperative days and were repeated whenever indicated. While small asymptomatic perigraft collections were regularly observed, large and symptomatic ones were drained either by percutaneous aspiration or into the peritoneal cavity.
| Results|| |
Lymphocele collection was diagnosed in 50 (9.5%) renal recipients, between 2 weeks to 6 months after transplantation (mean 7 weeks). Diagnosis of lymphocele was made in 31 (9.9%) male and 19 (8.8%) female recipients, who were 5 to 67 years old at the time of transplantation (mean of 37.5 years). Forty-seven (8.9 %) cases were diagnosed after first transplantation and the remaining 3 (0.6 %) cases after re-transplantation. The lymphocele was diagnosed in 6 (8.7%) pediatric and 44 (9.6%) adult recipients. It was formed following 33 (8.5%) living donor and 17 (11.8%) cadaveric donor transplantations. The lymphocele collection was formed following the evacuation of the perigraft hematoma in 12 recipients, and was associated with wound dehiscence or incisional hernia in 8 cases. The clinical picture of post-renal transplantation lymphocele was variable. It presented as a palpable large painless pelvi-abdominal swelling, not associated with venous or ureteric compression, in 28 (56%) cases. In the other 18 (36%) cases the pelviabdominal swelling was associated with either deterio-ration of renal graft function (9 cases), or with ipsilateral lower limb edema (5 cases), or with both of them (4 cases). In the remaining 4 (8%) cases of lymphocele, the collection was accidentally discovered on routine ultrasound scanning. While the ureteric stent was present in 37 cases of lymphocele with no manifestations of ureteric compression, the stent was not present in any of the 13 cases that presented with impairment of kidney function secondary to ureteric compression. The diagnosis of lymphocele was confirmed by ultrasound and isotope scanning. The computed tomography scanning was performed in few complicated cases. Intraperitoneal drainage was success-fully carried out as the primary procedure in 20 recipients. Prolonged percutaneous drainage was attempted in 28 cases, but reaccumulation of the lymphocele occurred in 16 of them within few days; these were treated successfully by surgical intraperitoneal drainage. The remaining two cases of lymphocele were treated conservatively. There was no graft loss due to lymphocele in the present study group.
| Discussion|| |
The reported incidence of symptomatic lymphocele in the literature ranges from 0.6% to 18%.,, Although lymphocele collection is harmless and asymptomatic in many cases, it can seriously affect renal graft function and necessitates intervention. In some cases, its formation had followed surgical evacuation of perigraft hematoma, or was associated with surgical wound dehiscence or incisional hernia. The presence of a double -J ureteric stent at the time of lymphocele formation could protect renal function by preventing ureteric compression.
The incidence of lymphocele formation in our study was 9.5%, which is comparable to the reported incidence in the literature. In our study, the incidence of lymphocele was not influenced by the recipient gender, age, graft source, or re-transplantation. These findings are different from earlier reports indicating higher incidence of lymphocele in recipients of cadaveric allografts.  Furthermore, the majority of the lymphocele collections in our study have presented as a simple swelling with no manifestations of venous or ureteric compression.
Although percutaneous drainage was successful in a small number of cases, reaccumulation of lymphocele was noticed in the majority of patients. Intraperitoneal drainage, either as a primary intervention, or after failure of prolonged percutaneous aspiration, had resulted in permanent cure of the condition. Sclerosing of lymphocele by Povidone- iodine or alcohol solutions was not attempted in our patients because of the previously reported high incidence of recurrence (11% to 90%), the possibility of exogenous infection  and its drawback of taking 20 to 30 days before drainage ceases. Although lymphocele is a serious complication, graft function can be preserved once it is effectively drained. In our study, there was no graft loss due to lymphocele.
In conclusion, lymphocele is an uncommon complication after renal transplantation, and is formed during the early post transplantation period. If not treated, it could seriously affect the kidney function. Intraperitoneal drainage is the most effective method for the treatment of symptomatic lymphocele.
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