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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2007  |  Volume : 18  |  Issue : 4  |  Page : 621-624
Instillation of Povidone Iodine to Treat Lymphocele and Leak of Lymph after Renal Transplantation


Associate Professor of Urology, Urology and Kidney Transplantation Ward, Imam Teaching Hospital, Tabriz, Iran

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   Abstract 

Lymphoceles are common surgical complications of renal transplantation. Recently minimal invasive therapy has been advised. We studied the safety and efficacy of instillation of povidone iodine via transcutaneous catheter for treatment of lymphoceles and leaks of lymph. We studied 10 (four males, six females) kidney transplant recipients who developed lymphoceles after transplantation and four (three males, one female) who developed leaks of lymph. We treated these cases by povidone iodine after placement of transcutaneous catheters with guidance of ultrasound and confirmed the presence of lymph by biochemical analysis. After dilution of povidone iodine to 5% with normal saline, 20cc were instilled and dwelled in the cavity for 30 minute three times daily. The lymph was then allowed to drain by gravity. For the leaks of lymph, which occurred immediately post operation, the catheters were placed during transplantation surgery. All patients were followed up for four months. After one week of instillation, all lymph leaks were completely blocked. Furthermore, nine (90%) cases of lymphocele resolved after 15 days of therapy. We conclude that instillation of diluted povidone iodine for treatment of lymphocele and leak of lymph is safe and effective and it may be considered as first choice for these conditions.

Keywords: Lymphocele, Lymph leak, Kidney, Transplantation, Lymph fistula, Therapy

How to cite this article:
Zomorrodi A, Buhluli A. Instillation of Povidone Iodine to Treat Lymphocele and Leak of Lymph after Renal Transplantation. Saudi J Kidney Dis Transpl 2007;18:621-4

How to cite this URL:
Zomorrodi A, Buhluli A. Instillation of Povidone Iodine to Treat Lymphocele and Leak of Lymph after Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Oct 14];18:621-4. Available from: http://www.sjkdt.org/text.asp?2007/18/4/621/36524

   Introduction Top


Lymphocele is a surgical complication of renal transplantation with an incidence that ranges from 0.6 to 22%, as reported else­where.[1],[2],[3],[4],[5],[6],[7] This lesion is progressive, cause compression on the veins and ureters, and induce deterioration of allograft function.[1],[2],[3],[4],[5],[6],[7]

Lymphocele develops because of inade­quate ligation of the afferent lymphatic vessels accompanying the recipients' iliac vessels, and micro- or macrodecapsulations of the allograft.[3],[4] The use of potent diuretics, in some cases, after renal transplantation can augment the lymphatic flow and may pave the way for the development of lympho­celes. [5] Furthermore, allograft rejection may cause marked increase in the allograft lymph flow that may result in the development of a lymphocele. Pedersen and Morris [8] demons­trated that lymph flow of the rejecting allo­grafts in sheep was 8-60 times higher than auto transplanted kidneys.

Lymphoceles tend to occur as a late com­plication (> 1 month) post transplantation. However, they may developed immediately post operation. Biochemical analysis is help­ful for diagnosis , since lymphoceles have the same levels of protein, urea nitrogen, crea­tinine, electrolytes, and lipids as serum has. Accordingly, it is possible to differentiate lymphoceles from urinomas, hematomas, seromas, and abscesses.

The treatment of lymphoceles is usually surgical. However, recently minimal invasive therapy has been advised with repeated aspiration of lymphoceles and instillation of different sclerotic materials. [3],[9],[10],[11]

We studied the safety and efficacy of insti­llation of povidone iodine as a sclerotic subs­tance via transcutaneous catheter for treat­ment of lymphoceles and leaks of lymph in transplanted allografts.


   Material and Method Top


We studied 10 kidney transplant recipients with lymphoceles (four males, six females) with a mean age of 41.4 year ( range from 12­58 years), and four with leaks of lymph (three males and one female) with a mean age of 43.7 year (range 25-50 years). We treated these cases by povidone iodine after place­ment of transcutaneous catheters with gui­dance of ultrasound and confirmed the pre­sence of lymph by biochemical analysis. After dilution of povidone iodine to 5% with normal saline, 20cc were instilled and dwelled in the cavity for 30 minute three times daily. The lymph was then allowed to drain by gravity. For the leaks of lymph, which occurred immediately post operation, the catheters were placed during transplan­tation surgery. All patients were followed up for four months.


   Results Top


After one week of instillation, all lymph leaks were completely blocked. Furthermore, nine (90%) cases of lymphocele resolved after 15 days of therapy.


   Discussion Top


The natural course of lymphoceles usually depends on the size of the lesion and the presence of infection. When a lymphoceles are small and sterile, they usually heal by means of spontaneous resorption. However, when they are large, they may compress adjacent structures such as the iliac vessels, bladder, ureter, or rectosigmoid. This com­pression causes manifestations that include abdominal distention, abdominal and pelvic pain, hydronephrosis, bladder dysfunction, constipation, tenesmus, edema of the ipsi­lateral leg and of the genitalia, and thrombo­embolism of iliac vessels.

There are several methods for treatment of lymphoceles, including surgical drainage, peritoneal marsupialization, simple aspira­tion, percutaneous catheter drainage, and per­cutaneous catheter drainage with sclerothe­rapy.[9] Needle aspiration has been proposed as a safe and effective therapeutic alternative to surgery, [10],[11] but most studies report high recurrence rate of 80%-90%, which necessi­tates repeated aspirations and results in a 25­-50% infection rate. [1],[5],[12],[13],[14] White et al [14] and Van-Sonnenberg et al [1] have reported success rates of 82% and 79%, respectively with prolonged catheter drainage.

Sclerotherapy of lymphoceles was first reported in 1982 by Pope et al[14] who successfully used multiple needle aspirations and injections of sodium tetradecyl sulfate in one patient. Lymphocele sclerosis with the use of transcutaneous catheter was first reported in 1983 by Teruel et al [3] who successfully treated two patients using povidoneiodine. The me­chanism of the sclerosant action of povidone­iodine is unclear but appears to be similar to that of the inflammatory effects of elemental iodine on the gastrointestinal tract. [15],[16] Insti­llation of povidine-iodine to prevent the development of lymphoceles has also been reported. [17] In our study, we treated success­fully lymphoceles and leaks of lymph with instillation of povidone-iodine, which was safe and effective.

We conclude that diluted povidone-iodine instillation is safe and effective for treatment lymphoceles and leaks of lymph in transplan­ted renal allografts. It may be first choice treatment for such conditions.

 
   References Top

1.van Sonnenberg E, Wittich GR, Casola G, et al. Lymphoceles: Imaging characteristics and percutaneous management. Radiology 1986; 161:593-6.  Back to cited text no. 1    
2.Shokeir AA, el-Diasty TA, Ghoneim MA. Percutaneous treatment of lymphocele in renal transplant recipients. J Endourology 1993;7:481-5.  Back to cited text no. 2    
3.Teruel JL, Escobar EM, Quereda C, Mayayo T, Ortun˜o J. A simple and safe method for management of lymphocele after renal transplantation. J Urol 1983;130 :1058-9.  Back to cited text no. 3    
4.Kuzuhara K, Inoue S, Dobashi Y, et al. Ethanol ablation of lymphocele after renal transplantation: A minimally invasive approach. Transplant Proc 1997;29:147-50.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Zincke H, Woods JE, Leary FJ, et al. Experience with lymphoceles after renal transplantation. Surgery 1975;77:444-50.  Back to cited text no. 5  [PUBMED]  
6.Bry J, Hull D, Bartus SA, Schwizer RT. Treatment of recurrent lymphoceles following renal transplantation. Remarsu­pialization with omentoplasty. Transplan­tation 1990;49:477-80.  Back to cited text no. 6    
7.Gill IS, Hodge EE, Munch LC, Goldfarb DA, Novick AC, Lucas BA. Transperi­toneal marsupialization of lymphoceles: A comparison of laparoscopic and open tech­niques. J Urol 1995;153:706-11  Back to cited text no. 7  [PUBMED]  
8.Pedersen DC, Morris B. The role of the lymphatic system in the rejection of homo­grafts: A study of lymph from renal trans­plants. J Exp Med 1970:131:936.  Back to cited text no. 8    
9.Sawhney R, D'Agostino HB, Zinck S, et al. Treatment of postoperative lymphoceles with percutaneous drainage and alcohol sclerotheraphy. J Vasc Interv Radiol 1996;7: 241-5.  Back to cited text no. 9  [PUBMED]  
10.Jensen SR, Voegeli DR, McDermontt JC, Crummy AB. Percutaneous management of lymphatic fluid collections. Cardiovasc Intervent Radiol 1986;9:202-4.  Back to cited text no. 10    
11.Spigos D, Capek V. Ultnasonognaphically guided percutaneous aspiration of lympho­celes following renal transplantation: A diagnostic and therapeutic method. J Clin Ultrasound 1976;4:45-6.  Back to cited text no. 11  [PUBMED]  
12.Braun WE, Banowsky LH, Straffon RA, et al. Lymphocytes associated with renal transplantation. Report of 15 cases and review of the literature. Am J Med 1974; 57;714-29.  Back to cited text no. 12    
13.Kay R, Fuchs E, Barry J. Management of postoperative pelvic lymphoceles. Urology 1980;15:345-7.  Back to cited text no. 13    
14.White M, Mueller PR, Fermuci JT Jr, et al. Percu-taneous drainage of postoperative abdominal and pelvic lymphoceles. AJR 1985; 145:1065-9.  Back to cited text no. 14    
15.Pope AJ, Ommiston MC, Bogod DC. Sclemotherapy in the treatment of a recurrent lymphocele. Postgrad Med J 1982;58:573-4.  Back to cited text no. 15    
16.American Medical Society Division of Drugs. Topical anti-infective agents drugs used on skin and mucous membranes. In: AMA drug evaluations. 6 th ed. Chicago: American Medical Association; 1986. p. 1526-7.  Back to cited text no. 16    
17.Chandrasekaran D, Meyyappan RM, Rajaraman T. Instillation povidine iodine to treatment and prevent lymphocele. Transplantation 2006;82:955.  Back to cited text no. 17    

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Correspondence Address:
Afshar Zomorrodi
Associate Professor of Urology, Urology and Kidney Transplantation Ward, Imam Teaching Hospital, Tabriz
Iran
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PMID: 17951955

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    Abstract
    Introduction
    Material and Method
    Results
    Discussion
    References
 

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