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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 1162-1168
Symptomatic lymphocoeles post renal transplant


Department of Urology, Christian Medical College, Vellore, India

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Date of Web Publication17-Nov-2012
 

   Abstract 

The aim of this study was to evaluate the outcome of various treatment modalities of symptomatic lymphoceles and suggest an optimal management protocol. Case records of 744 renal transplant recipients who underwent surgery between January 2000 and December 2007 were retrospectively reviewed. There were a total of 36 (4.38%) lymphoceles detected in the postoperative period, of which 14 (1.88%) were symptomatic. A total of 32 procedures for the treatment of lymphocele were performed in 14 of these patients. Aspiration or percutaneous catheter drainage was performed as a primary procedure in all cases. Open marsupialization and laparoscopic marsupialization procedures were performed as secondary treatments. Percutaneous nephrostomy was required in one case before definitive treatment. Primary aspiration was successful in (n = 2) 28.5% and percutaneous drainage in (n = 3) 42.8%. Sclerotherapy was definitive in (n = 2 of 3) 66.6%. Seven of 14 patients required secondary procedure. Laparoscopic marsupialization was successful in (n = 4 of 5) 80% and open technique (n = 3) was curative in all cases. In our opinion, the first step in the management of symptomatic lymphocele in post-renal transplant recipients should be percutaneous drainage with or without drug instillation. This can stabilize renal function and optimize patients who may require surgery. Surgical marsupialization offers superior definitive treatment of lymphoceles with the least recurrence rates.

How to cite this article:
Choudhrie AV, Kumar S, Gnanaraj L, Devasia A, Chacko N, Kekre NS. Symptomatic lymphocoeles post renal transplant. Saudi J Kidney Dis Transpl 2012;23:1162-8

How to cite this URL:
Choudhrie AV, Kumar S, Gnanaraj L, Devasia A, Chacko N, Kekre NS. Symptomatic lymphocoeles post renal transplant. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 May 29];23:1162-8. Available from: http://www.sjkdt.org/text.asp?2012/23/6/1162/103554

   Introduction Top


Post-transplant lymphoceles are perigraft lymphatic fluid collections occurring following preparation of the renal bed for the graft. [1] Lymphoceles are the most common fluid collections occurring in 0.6-18% following renal transplantation. [2],[3] Injured lymphatic channels in the graft kidney hilum and the recipient iliac vessels have been implicated in the formation of lymphocele. The routine use of ultrasonography has increased the detection of these small fluid collections, [4] majority being asymptomatic. [1] They are considered to be symptomatic [5] when there is decreased urinary output, ipsilateral leg swelling or an abdominal swellling near the allograft associated with raised serum creatinine and radiological evidence of lymphocele near the transplant kidney. Symptomatic lymphoceles need treatment, with the therapeutic options being percutaneous as piration, percutaneous drainage, sclerotherapy, intra-peritoneal drainage by Tenckhoff catheter or marsupialization by open or laparoscopic surgery.

We performed this analysis with the aim to evaluate the outcome of various treatment modalities of symptomatic lymphoceles and suggest an optimal management protocol according to our experience.


   Materials and Methods Top


We retrospectively reviewed our institutional database for recipients of renal transplants performed between January 2000 and December 2007 who subsequently developed symptomatic lymphoceles. The records were reviewed for type and number of procedures, complications and outcome.

Renal transplantation was performed under general anesthesia using a standard extraperitoneal technique through a rectus-preserving incision with graft placement in the iliac fossa. Perivascular lymphatics were ligated. The standard procedure of vascular anastomosis was end-to-end anastomosis of the renal artery, with the internal iliac artery and the renal vein with the external iliac vein end to side. The ureter was anastomosed to the bladder mucosa using a modified Roy Calne extra-vesical ureteroneocystomy technique with sub mucosal tunnel. DJ stents were not placed as a routine. A 24 French tube drain was placed in situ and removed following catheter removal on the 6 th post-operative day or when the drainage was less than 50 mL. Our protocol included an ultrasound evaluation on the 5 th postoperative day. Those with a perigraft collection underwent a diagnostic aspiration to differentiate between lymph, urine and blood.

Treatment options for the patient with symptomatic lymphoceles were dependent on the severity of symptoms, presence of complications and consultant preference. An initial ultrasound-guided aspiration or pigtail catheter drainage was performed. If needed, percutaneous nephrostomy was carried out for stabilizing the renal functions. Failing these measures, they either underwent sclerotherapy or marsupialization laparoscopically or by open technique. Sclerotherapy was by instillation of 5% povidone iodine 10-15 mL or tetracycline (500 mg in 50 mL), left in situ for 30 min, after which the clamp on the catheter was removed and allowed to drain freely.


   Results Top


There were a total of 744 renal transplants between January 2000 and December 2007. There were 36 (4.38%) lymphoceles detected in the post-operative period. Twenty-two patients were asymptomatic and had spontaneous resolution of the lymphocele. Only one lymphocele persisted asymptomatically with normal renal functions and thus was not treated. There were 14 (1.88%) patients who presented with increased serum creatinine associated with evidence of lymphocele and/or hydronephrosis of the transplant kidney. One of these patients had ipsilateral leg swelling and two patients also had an abdominal swelling near the allograft. None of these had abdominal discomfort, lymphorrhea with surgical wound dehiscence, urgency, vesical tenesmus or fever. Even the patients with abdominal swellings did not have any other symptoms. The mean age of the recipients in the group in which lymphoceles developed was 38 years (range 22-58 years). Time of detection ranged from ten days to 182 days. All 14 patients were on hemodialysis pre-transplant. Eleven patients received triple immunosuppression including cyclosporine or Tacrolimus, azathioprine or Mycophenolate and steroids as induction immunosuppression, and three patients had rapamycin and steroids. There were seven rejection episodes in these 14, six of which were pulsed with high-dose methylprednisolone and one received ATGAM (lymphocyte immune globulin, anti-thymocyte globulin). Majority of the lymphoceles were detected after the treatment of rejection episodes, two of the three patients on Rapamycin had rejection episode and subsequent lymphocele development.

Ultrasound was the primary mode of diagnosis, although three also had non-contrast-enhanced computed tomography (CT). None of the patients had CT urography or magnetic resonance urography. The volume of the lymphocele (mean 498 mL) ranged from 130 mL to 1.6 L. Hydronephrosis was detected in 11 patients. Three of the lymphoceles were multiseptated. [Table 1]
Table 1: Treatment options and their success rate.

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Ultrasound-guided primary aspiration of the lymphocele was definitive in two of seven (28.57%) patients. Three of seven (42.85%) patients who underwent ultrasound-guided primary pigtail catheter insertion were cured. Two of three (66.6%) patients had drug instillation and required no further treatment (Inj. Oxytetracyclin in one and multiple instillations of 5% povidone iodine in the others.). Percutaneous catheter blockage occurred on three occasions requiring replacement, but these were not complicated by infection. Definitive treatment in the form of marsupialization was required in seven patients (eight procedures). Laparoscopic marsupialization was successful in four of five patients (80%). All three patients who underwent an open marsupialization were cured [Figure 1]. One patient required percutaneous nephrostomy for stabilizing renal functions as there was decreased output with moderate hydronephrosis and rising creatinine. Only three patients did not undergo multiple procedures to treat the lymphocele. In all, 32 procedures were performed at an average of 2.28 procedures per patient.
Figure 1: Flow chart of treatment and outcomes.

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In the follow-up ranging from two to eight years, there was one patient with a 60 mL residual lymphocele with mild hydronephrosis but with stable renal functions. The mean nadir creatinine was 1.53 mg/dL (range 0.9-2.4 mg/ dL) before the detection of lymphocele and, at detection of the lymphocele, the mean creatinine was 2.1 mg/dL (range 1.6-3.8 mg/dL). Following treatment, the mean serum creatinine came down to 1.62 mg/dL (range 0.9-2.2 mg/dL).


   Discussion Top


In our transplant program, during the studied period, the incidence of lymphoceles was 4.38% (n = 36), of which 1.88% (n = 14) were symptomatic, which is similar to that reported in the literature (0.6-18%). [2],[3] This low figure may possibly be due to our ligating all major lymphatic vessels during bed preparation. Those recipients with symptomatic lymphoceles underwent either percutaneous aspiration or pigtail insertion followed by surgical treatment where necessary. Percutaneous approach was successful in 50%, and the remaining required surgical treatment.

Associated risk factors include acute rejection, [6] acute tubular necrosis-delayed graft function, [3] cadaveric or living related donor, [3] perivascular dissection of the iliac vessels, [6] diuretics, [7] renal decapsulation, [8] high-dose steroid therapy, [3] sirolimus, [9] retransplantation [3] and adult polycystic kidney disease [10],[11] in the recipient. Acute rejection as a trigger for lymphocele formation was noted in seven of these 14 patients in our series. There were no wound complications associated with lymphoceles as noted by others, ranging from 3.8% to 8.5%. [12],[13]

Symptomatic lymphoceles need treatment. However, the mode of treatment is varied. There has been no prospective randomized control trial and no protocol is available for the treatment of symptomatic lymphoceles. The modality for the treatment of lymphoceles may be percutaneous or surgical. In recent years, ultrasound-guided percutaneous approach is the accepted modality initially. [14] Percutaneous approach consists of either simple aspiration or pigtail catheter drainage, which may be augmented with sclerotherapy.

Simple aspiration has largely been abandoned as the success rate of single or multiple aspirations ranges from 0% to 20%. [5],[6],[15] Only in 28.5% of our patients was primary aspiration successful.

Pigtail catheter drainage as a treatment modality was first reported in 1983. [16] The cure rate has been varied from 100% [17] success to complete failure. [18] Our success with pigtail catheter drainage was 42.85%. Its main advantage was that it was minimally invasive, able to stabilize and optimize patients for definitive surgical therapy. The disadvantages were recurrence, infection [19] and delayed resolution that may take several weeks. [20] There is an additional morbidity of the drainage tube slipping out or blockage, requiring replacement, as seen in three of our cases.

Sclerotherapy was reported in 1983 [21] using Povidone iodine. Povidone iodine, a popular sclerosant, [22] acts by chelating proteins and has a recurrence rate of 37.5% [21] after initial instillation and 18.7% after the second treatment. [23] Sclerotherapy was successful in 66.7% of our patients. The other sclerosing agents used include tetracycline, [24] Doxycycline, [25] minocycline, [26] fibrin glue, [15],[27] sodium tetradecyl sulfate, [28] 95% ethanol instillation, [29],[30] factor XIII and fibrinogen in cases of failure [31] and 198Au colloid. [32] Sclerotherapy of lymphoceles is successful in 80-90% of cases, regardless of the agent used. [1] Opponents of sclerotherapy avoid it due to the possible risk of fibrosis around the transplant ureter, [32] making future procedures difficult and, additionally, it may require weeks of therapy before resolution. Although described, percutaneous inter-nal drainage using a Tenckhoff or a Hickmann catheter [33],[34] to drain the lymphocele into the peritoneal cavity by a subcutaneous tunneling technique was not required in any of our cases. In our series, percutaneous treatment was successful in 50% of the patients, which allowed renal functions to stabilize and averted another surgical procedure, especially in the setting of acute rejection.

Other surgical treatment options include marsupialization - open or laparoscopic. Open marsupialization of lymphoceles was the gold standard in the past, and seems to have been supplanted by the laparoscopic lymphocele drainage. Internal drainage of an infected lymphocele is contraindicated and external drainage warranted. Furthermore, the recovery period is that of any open abdominal surgery. Open drainage has a complication rate of 4% and a recurrence rate of 15%. [35] Bowel adhesions may obstruct the peritoneal window, leading to recurrence of lymphocele. [4] All three patients in our series had successful open marsupialization. In the past, open external drainage of lymphocele was used but was associated with increased infection rate (25%) and major fluid and protein loss. [36]

McCullough et al [37] reported the first laparoscopic lymphocele drainage in 1991. The benefits of laparoscopic lymphocele drainage include shorter hospital stays, significantly lower intraoperative blood loss, detailed visualization of the anatomy and favorable cosmesis. It appears to have lower incidences of symptomatic recurrences with rates between 4% and 6.7%, [35],[38] but higher prevalence of iatrogenic lesions to the urinary tract. [39] In the largest single institution series, no statistically significant difference between the recurrence rates of laparoscopic or open techniques was seen. [35] In our series, laparoscopy was successful in 80%. We had one recurrence following laparoscopic drainage as the peritoneal window was non-dependent.

This series analyzing the outcomes of the various treatment modalities had all the deficiencies of a retrospective study. The most apparent limitation was the absence of a defined protocol or a step ladder hierarchical pattern to the modality of treatment. Despite these limitations, what is apparent is that not all require surgical marsupialization and at the same time the ultrasound-guided percutaneous approach has not replaced surgical therapy. Both these modalities have their place in the treatment of symptomatic lymphocele. A protocol has been suggested [Figure 2] that avoids aspirating the lymphocele. One or two sessions of sclerotherapy with povidone iodine in those with unilocular lymphoceles would be logical followed by marsupialization where required. Our opinion is that, in post-renal transplant recipients, the first step in the management of symptomatic lymphoceles should be percutaneous drainage with or without drug instilllation. This will stabilize renal function and optimize patients who may require surgery and can be, in itself, curative. However, surgical marsupialization offers a superior one step definitive treatment of lymphoceles with the least recurrence rates.
Figure 2: Suggested protocol.

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   References Top

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Correspondence Address:
Nitin S Kekre
Department of Urology, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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DOI: 10.4103/1319-2442.103554

PMID: 23168843

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