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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 3  |  Page : 585-587
Post-cadaveric kidney transplant lymphocele which did not respond to percutaneous drainage


Mashad University of Medical Sciences, Ghaem Medical Center, Mashad, Iran

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Date of Web Publication7-May-2012
 

How to cite this article:
Shamsa A, Asadpour A A, Oraee F. Post-cadaveric kidney transplant lymphocele which did not respond to percutaneous drainage. Saudi J Kidney Dis Transpl 2012;23:585-7

How to cite this URL:
Shamsa A, Asadpour A A, Oraee F. Post-cadaveric kidney transplant lymphocele which did not respond to percutaneous drainage. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Jul 12];23:585-7. Available from: http://www.sjkdt.org/text.asp?2012/23/3/585/95822
To the Editor,

Lymphocele is a common surgical compli­cation after renal transplantation. Its incidence varies between 0.6 and 18%, [1] and it is higher after cadaveric donor transplants. [2] It presents as an abdominal mass, external genital and ipsilateral lower leg edema and/or elevated blood urea nitrogen (BUN) and creatinine. We herewith report a case of lymphocele after cadaveric kidney transplant that did not res­pond to conservative therapy.

Z.M., a 32-year-old female homemaker from a rural area of Torbat-Heydariyeh, was referred to us for management of end-stage renal di­sease (ESRD). The etiology of ESRD was not known. She was on maintenance hemodialysis, twice-weekly, for the preceding two years. She underwent a cadaveric donor kidney transplant on 22-11-2009 in the Ghaem Hospital, Mashad University of Medical Sciences. The renal allograft was placed in the right iliac fossa and a small artery and vein were anastomosed to the external iliac artery and external iliac vein, respectively. Diuresis started after declamping. Immunotherapy comprised of mycophenolate mofetil, prednisolone and cyclosporine.

Twelve days post-transplant, a small fluid collection was found at the lower pole of the transplanted kidney by ultrasound. There was no hydronephrosis. She was discharged 20 days after transplantation with normal BUN and creatinine. Two months later, she was admitted because of elevated BUN and creatinine (4.2 mg/dL). Ultrasound examination revealed about 100 mL fluid collection at the lower pole of the transplant kidney with mild hydronephrosis. Her urine output was between 2 and 3 L daily. After pulse therapy with solumedrol, the serum creatinine decreased to 3 mg/dL.

Drainage of the fluid was performed percutaneously. No sclerosing materials were used. Biochemical analysis of fluid confirmed that it was a lymphocele. Fifteen days later, ultra­sound examination revealed collection of about 150 mL fluid, which had reappeared around the transplanted kidney with hydronephrosis and elevated serum creatinine (3.5 mg/dL) [Figure 1] and [Figure 2].
Figure 1: Ultrasound showing lymphocele near the urinary bladder.

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Figure 2: Ultrasound showing transplanted kidney with hydronephrosis.

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Open drainage with a small midline incision was performed and bulging of lymphocele was detected [Figure 3]. Fenestration was performed and 5 cm × 5 cm of lymphocele wall was re­moved, after which the lymphocele wall and peritoneum were anastomosed together with continuous interlocking suture. The serum creatinine came down and reached 1.04 mg/dL. After one week, she was discharged and she in good condition so far.
Figure 3: Intra-operative photograph showing bulging of the lymphocele.

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Collection of fluid extra-peritoneally after kidney transplantation was called lymphocele by Hume in 1968. [1] Fluid examination can dif­ferentiate between urinoma and lymphocele, because of identical creatinine levels as the serum in a lymphocele but elevated creatinine level in a urinoma. Post-transplant lymphocele (PTL) usually occurs three months after trans­plantation, and it is more common when the external iliac artery is used for anastomosis. Additional predisposing factors include cada­veric donor, presence of Cytomegalovirus (CMV) infection in the recipient, delayed graft function, failure to ligate or cauterize lym­phatic vessels around the external iliac artery as well as disruption of allograft hilum during preparation. [1] Our case had three risk factors: external iliac arterial anastomosis, CMV infec­tion and cadaveric graft.

Most lymphoceles get absorbed spontaneously, but symptomatic lymphoceles, i.e. infection, ureteral compression or rarely, urinary retention, [3] need to be treated. PTL can be detected by palpation, ultrasonography or CT scan as well as aspiration and biochemical analysis. In some pediatric centers, PTL is treated successfully with percutaneous drainage and sclerotherapy, but recollection is common.

We have some experience in treating lympha­tic leakage from the wound by injection of povidon iodine periodically but, in this case, we did not use it because of recent pulse steroid therapy and high risk of infection. [4]

If drainage of lymphocele is ineffective, fenestration by open surgery or by laparoscopy is necessary. [5] When the patient has a history of previous surgery and abdominal adhesions, lymphatic orientation by using isusulphane blue is feasible and suture ligation is simple. [6]

In conclusion, PTL is preventable by ligation of all lymphatic vessels along the recipient artery and imparting due care to the hilum of the allograft. Treatment may be conservative by percutaneous drainage and sclerotherapy and, when necessary, by open or laparoscopic unroofing.

 
   References Top

1.Bailey SH, Mone MC, Holman JM, Nelson EW. Laparoscopic treatment of post-renal transplant lymphoceles. New York Inc. Surg Endosc 2003;17:1896-9.  Back to cited text no. 1
    
2.Øyen O, Siwach V, Line PD, et al. Improve­ment of post-transplant Iymphocele treatment in the laparoscopic era. Transplant Int 2002;15: 406-10.  Back to cited text no. 2
    
3.Hwang EC, Kang TW, Koh YS, et al. Post-transplant lymphocele: An unusual cause of acute urinary retention mimicking urethral injury. Int J Urology 2006;13:468-70.  Back to cited text no. 3
    
4.Shokeir AA, Osman Y, Ali-El-Dein B, El-Husseini A, El-Mekresh M, Shehab-El-Din AB. Surgical complications in live-donor pediatric and adolescent renal transplantation: study of risk factors. Pediatr Transplant 2005:9;33-8.  Back to cited text no. 4
    
5.Duepree HJ, Fornara P, Lewejohann JC, Hoyer J, Bruch HP, Schiedeck TH. Laparoscopic treatment of lymphoceles in patients after renal transplantation Laparoscopic treatment of lymphoceles in patients after renal transplan­tation. Clin Transplant 2001:15:375-9.  Back to cited text no. 5
    
6.Cakmaka A, Akyola C, Canb OS, Hazinedaroglua SM. Identification of post-transplant lymphocele using lymphatic mapping with isosulphane blue. Ankara, Turkey Clin Transplant 2009:23:137-9.  Back to cited text no. 6
    

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Correspondence Address:
Ali Shamsa
Mashad University of Medical Sciences, Ghaem Medical Center, Mashad
Iran
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This article has been cited by
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