VESICOLYMPHOCELE FISTULA FOLLOWING SCLEROTHERAPY FOR LYMPHOCELE

Abstract

A 54-year-old female underwent radical hysterectomy with pelvic lymph node dissection for uterine cervical carcinoma. Pathological examination demonstrated a stage Ib1 squamous cell carcinoma. Three weeks postoperatively the patient suffered right lower extremity edema and a mild intermittent fever (37.5C). She complained of 2-hour urinary frequency. Physical examination revealed mild tenderness of the right lower quadrant area. Excretory urography showed marked extrinsic compression of the right side of the urinary bladder. Computerized tomography (CT) demonstrated a huge round cystic pelvic mass 7 11 cm in diameter compressing the bladder and suggestive of a lymphocele (fig. 1). Percutaneous drainage of 500 ml clear yellow fluid was performed using an 8.5Fr pigtail catheter placed under fluoroscopic guidance. Subsequently, 40 ml 95% ethanol was instilled into the lymphocele cavity. Ethanol was exposed for 15 minutes and was then completely removed by aspiration. With sclerotherapy 4 times daily the amount of drainage progressively decreased. However, a gradual increase in the drainage amount and an abrupt high fever (39.0C) developed. Assuming that the fever may have been caused by an infection of the septated lymphocele cavity, the tube was removed. Blood culture revealed no growth, but urinalysis showed pyuria (leukocytes greater than 100 per high power field) with the growth of Staphylococcus aureus (greater than 10/ml). The mild intermittent fever persisted and the patient complained of painful urination with the intermittent passage of white greasy material. Cystoscopic examination demonstrated profuse aggregated chylousmaterials floating in the lumen of the bladder (fig. 2,A). A deep ulcerative cavity in the right lateral wall of the bladder was found, suggesting a fistula between the lymphocele cavity and the bladder lumen. Pelvic CT revealed that the right lateral bladder wall had thickened irregularly and that the lymphocele cavity had collapsed (fig. 2, B). The body temperature then normalized. Three weeks later symptoms were improved and followup cystoscopy showed that the ulcerative bladder wall was markedly healed. Eight weeks later the lesion had almost healed and the symptoms had resolved completely.