Asymptomatic Lymphoceles Research Articles

Editorial Comment

The authors are to be congratulated for performing a prospective randomized trial pertaining to the incidence and possible prevention of pelvic lymphoceles following pelvic lymph node dissection (PLND) during robotic-assisted radical prostatectomy (RARP) with an absorbable hemostatic agent (Arista AH). 1 Gilbert D.R. Angell J. Seager C. Abaza R. Evaluation of absorbable hemostatic powder for prevention of lymphoceles following robotic prostatectomy with lymphadenectomy. Urology. 2016; https://doi.org/10.1016/j.urology.2016.06.071 Abstract Full Text Full Text PDF Scopus (15) Google Scholar The authors provide a nice discussion regarding the incidence of pelvic lymphoceles following RARP and PLND. Although symptomatic lymphoceles may be very costly and difficult to deal with, they are not common. In fact, the authors note the absence of symptomatic lymphoceles in this study. We may be chasing a problem that does not need to be addressed. For that reason, I loathe cross-sectional imaging following RARP and PLND. The finding of asymptomatic lymphoceles on imaging provides patients, families, and treating physician's unnecessary anxiety. One conclusion I reach from this study is that we probably should not be looking for trouble with the use of postoperative imaging.

Lymphatic Leak Occurring After Surgical Lymph Node Dissection: A Preliminary Study Assessing the Feasibility and Outcome of Lymphatic Embolization.

To analyze imaging findings of lymphatic leakage associated with surgical lymph node dissection on lymphangiography and assess the outcome of lymphatic embolization. This retrospective study comprised 21 consecutive patients who were referred for lymphatic intervention between March 2014 and April 2015 due to postsurgical lymphatic leaks. Lymphangiography was performed through inguinal lymph nodes to identify the leak. When a leak was found, lymphatic embolization was performed by fine-needle injection of N-butyl cyanoacrylate into the site of leakage or into an inflow lymphatic vessel or into a pelvic lymph node located below the leakage. Electronic medical records and imaging studies were reviewed to assess the outcome. Lymphangiography revealed single or multiple leaks in all but one patient. Lymphatic embolization was performed in 20 patients with leaks. Including the patient who did not undergo embolization, 17 patients (81.0%) showed initial response to treatment. Three patients underwent repeated embolization with successful results. The overall success rate was 95.2%. The mean duration of hospitalization after lymphatic intervention was 5.9days. During a mean follow-up period of 11months, two patients developed localized swelling in the groin following lipiodol injection. There were no complications related to lymphatic embolization. Three patients were found to have developed small, asymptomatic lymphoceles on CT or MRI that did not require further treatment. Lymphangiography is useful for detecting lymphatic leakage occurring after lymph node dissection. Furthermore, lymphatic embolization is feasible, effective, and safe for managing leaks demonstrated on lymphangiography.

Effects of an autologous fibrin sealant on lymphatic leakage after radical cystectomy: A matched case‐control study

AimThe aim of the present study was to investigate the effect of an autologous fibrin sealant (Vivostat) on the prevention of lymphatic leakage after radical cystectomy.Patients and MethodsPatients who underwent laparoscopic radical cystectomy (LRC) or robot‐assisted radical cystectomy (RARC) for the treatment of bladder cancer were enrolled. Autologous fibrin sealant was applied after the completion of bilateral pelvic lymph node dissection. The data were compared with those from matched RARC patients in a historical cohort.ResultsTen consecutive RARC or LRC were performed using an autologous fibrin sealant. A statistically nonsignificant reduction in drain output (1165.5 mL, range = 225–3150 mL) was observed compared with 10 matched historical RARC patients who did not receive the autologous fibrin sealant (1927.2 mL, range = 240–4010 mL). No difference in the number of days of in‐situ drainage or the length of hospital stay was found. Two patients in the control group developed asymptomatic lymphocele. One patient in the group treated with the autologous fibrin sealant developed deep vein thrombosis after RARC.ConclusionThe use of an autologous fibrin sealant did not reduce lymphatic leakage after radical cystectomy.

Lymphatic Embolization for the Treatment of Pelvic Lymphoceles: Preliminary Experience in Five Patients

To retrospectively assess the outcome of lymphatic embolization in the treatment of pelvic lymphoceles. From July 2014 to December 2015, a retrospective analysis was performed in 5 consecutive female patients (mean age, 54.6 y; range, 45-65 y) who underwent lymphangiography for the management of symptomatic pelvic lymphoceles that developed after gynecologic surgery. Sclerotherapy had failed in 4 patients. Lymphangiography was performed through an inguinal lymph node to reveal disrupted lymphatic vessels draining into the lymphocele. This inflow vessel was targeted with a fine needle, and N-butyl cyanoacrylate (NBCA) was injected. Outcomes and complications were assessed by reviewing electronic medical records and computed tomography (CT). Lymphangiography revealed disrupted lymphatic vessels draining into the lymphocele in all patients. A single inflow vessel was seen in 3 patients and was subsequently embolized. Catheters were successfully removed upon decrease of drainage. Multiple inflow vessels were seen in the remaining 2 patients. Therapeutic effect was anticipated in 1 patient after lymphangiography alone, whereas only the dominant feeding vessel was embolized in the other. The initial procedures failed in both patients, prompting repeat embolization with adjunctive sclerotherapy. Both patients showed improvement and had their catheters removed. Follow-up CT was available in 3 patients. Two patients showed complete regression of lymphoceles, and 1 showed an asymptomatic lymphocele. No procedure-related complications occurred during a mean follow-up period of 35 weeks (range, 2-73 wk). Lymphatic intervention was technically feasible in treating lymphoceles. However, those with multiple inflow vessels were relatively difficult to treat.

Evaluation of postoperative lymphocele according to amounts and symptoms by using 3-dimensional CT volumetry in kidney transplant recipients

PurposeTo analyze the risk factors for postoperative lymphocele, for predicting and preventing complications.MethodsWe evaluated 92 kidney transplant recipients with multidetector CT (MDCT) at 1-month posttransplantation. From admission and 1-month postoperative records, data including diabetes, dialysis type, immunosuppressant use, steroid pulse therapy, and transplantation side were collected. Lymphocele volume was measured with 3-dimensional reconstructed, nonenhanced MDCT at one month postoperatively. The correlations between risk factors and lymphocele volume and between risk factors and symptomatic lymphocele (SyL) were analyzed. The cutoff was calculated by using the receiver operating characteristic (ROC) curve for SyL volume.ResultsAmong 92 recipients, the mean volume was 44.53 ± 176.43 cm3 and 12 had SyL. Univariable analysis between risk factors and lymphocele volume indicated that donor age, retransplantation, and inferiorly located lymphocele were statistically significant. The ROC curve for SyL showed that 33.20 cm3 was the cutoff, with 83.3% sensitivity and 93.7% specificity. On univariable analysis between risk factors and SyL, steroid pulse, inferiorly located lymphocele, and >33.20 cm3 were statistically significant. Multivariable analysis indicated that steroid pulse, >33.20 cm3, and serum creatinine level at one month were significant factors.ConclusionRisk factors including donor age, retransplantation, steroid pulse therapy, and inferiorly located lymphocele are important predictors of large lymphoceles or SyL. In high-risk recipients, careful monitoring of renal function and early image surveillance such as CT or ultrasound are recommended. If the asymptomatic lymphocele is >33.20 cm3 or located inferiorly, early interventions can be considered while carefully observing the changes in symptoms.

OP07.03: Ultrasound characteristics of a symptomatic and asymptomatic lymphocele after pelvic and/or paraaortic lymphadenectomy

OP07.03: Ultrasound characteristics of a symptomatic and asymptomatic lymphocele after pelvic and/or paraaortic lymphadenectomy

Radiotherapy in Prostate Cancer Patients With Pelvic Lymphocele After Surgery: Clinical and Dosimetric Data of 30 Patients

The purpose of the study was to evaluate the feasibility of irradiation after prostatectomy in the presence of asymptomatic pelvic lymphocele. The inclusion criteria for this study were: (1) patients referred for postoperative (adjuvant or salvage) intensity modulated radiotherapy (IMRT; 66-69 Gy in 30 fractions); (2) detection of postoperative pelvic lymphocele at the simulation computed tomography [CT] scan; (3) no clinical symptoms; and (4) written informed consent. Radiotherapy toxicity and occurrence of symptoms or complications of lymphocele were analyzed. Dosimetric data (IMRT plans) and the modification of lymphocele volume during radiotherapy (cone beam CT [CBCT] scan) were evaluated. Between January 2011 and July 2013, in 30 of 308 patients (10%) treated with radiotherapy after prostatectomy, pelvic lymphocele was detected on the simulation CT. The median lymphocele volume was 47 cm(3) (range, 6-467.3 cm(3)). Lymphocele was not included in planning target volume (PTV) in 8 cases (27%). Maximum dose to lymphocele was 57 Gy (range, 5.7-73.3 Gy). Radiotherapy was well tolerated. In all but 2 patients, lymphoceles remained asymptomatic. Lymphocele drainage-because of symptom occurrence-had to be performed in 2 patients during IMRT and in one patient, 7 weeks after IMRT. CBCT at the end of IMRT showed reduction in lymphocele volume and position compared with the initial data (median reduction of 37%), more pronounced in lymphoceles included in PTV. Radiotherapy after prostatectomy in the presence of pelvic asymptomatic lymphocele is feasible with acceptable acute and late toxicity. The volume of lymphoceles decreased during radiotherapy and this phenomenon might require intermediate radiotherapy plan evaluation.

Secondary cytoreductive surgery in patients with isolated platinum-resistant recurrent ovarian cancer: A retrospective analysis

To analyze the impact of secondary cytoreductive surgery (SCS) on survival outcome in a retrospective series of isolated platinum-resistant recurrent ovarian cancer. We evaluate a consecutive series of 268 ovarian cancer patients with platinum-resistant relapse. Isolated recurrence was defined as the presence of a single nodule, in a single anatomic site, and was observed in 27 cases (10.1%). In all women the presence of isolated relapse was assessed at radiological evaluation, and surgically confirmed in the SCS group. Among the 27 patients with isolated recurrence, 16 (59.3%) received chemotherapy alone, and 11 (40.7%) complete SCS followed by non-platinum based chemotherapy. No significant differences were observed in the distribution of baseline clinico-pathological characteristics, pattern of recurrent disease, duration of PFI, and type of salvage chemotherapy between the two groups. In the SCS group, 6 patients (54.5%) showed isolated peritoneal relapse and 5 women (45.4%) showed isolated lymph nodal recurrence, and were treated with peritonectomy and lymphadenectomy, according with site of relapse. Two post-operative complications (18.2%) occurred: asymptomatic lymphocele and groin wound dehiscence. SCS significantly prolonged median time to first progression (12 months vs 3 months; p-value=0.016), median time to second progression (8 months vs 3 months; p-value=0.037), and post-relapse survival (PRS) (32 months vs 8 months; p-value=0.002). Residual tumor at 1st surgery (X(2)=5.690; p-value=0.017), duration of PFI (X(2)=5.401; p-value=0.020), and complete SCS (X(2)=4.250; p-value=0.039) retains independent prognostic role for PRS in multivariate analysis. SCS prolongs PRS compared to chemotherapy alone in isolated platinum-resistant recurrent ovarian cancer.

Lymphocele Prevention After Pelvic Laparoscopic Lymphadenectomy by a Collagen Patch Coated With Human Coagulation Factors

Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy. The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration. The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request. In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

Toward a Standardized System for Reporting Surgical Outcome of Pediatric and Adolescent Live Donor Renal Allotransplantation

There is a lack of a standardized reporting methodology for surgical complications of pediatric renal transplantation. We applied Martin criteria and the modified Clavien-Dindo classification in pediatric renal transplantation. We retrospectively reviewed the charts of 447 patients 20 years or younger who underwent renal transplantation between March 1976 and January 2011. Martin criteria were fulfilled and complications were graded according to the modified Clavien-Dindo classification. For early complications grades I and II were considered low grade and III to V high grade. A similar grading system was adopted for late complications. A total of 84 early complications (18.5%) occurred in 77 transplant recipients (17%). Of grade I complications 37 (8.1%) were asymptomatic lymphoceles. Grade II complications were observed in 2 patients (0.4%). Grade IIIa complications included aspiration of hematoma (1 case), percutaneous nephrostomy fixed for ureteral obstruction (3), percutaneous tube drain for symptomatic lymphoceles (7) and antegrade ureteral stenting for ureteral leakage (6). Grade IIIb complications included exploration for wound dehiscence (1 case), revision of ureterovesical anastomosis (8), marsupialization of lymphoceles (4), hemorrhage (3) and vascular thrombotic accidents (6). Graft nephrectomy (grade IVa) complications occurred in 2 transplant recipients. Among 4 mortalities (grade V) only 1 patient died due to surgical complications. On multivariate analysis delayed graft function was the only predicator of high grade surgical complications (p = 0.005). High grade surgical complications affected recipient but not graft survival. Using a standardized, high quality reporting methodology is feasible in pediatric renal transplantation. However, consensus should be sought regarding medical complications and a grading system should be developed for reporting of late complications.

Prevention of lymphocele in female pelvic lymphadenectomy by a collagen patch coated with the human coagulation factors: A pilot study

The prevention of lymphoceles was tested using collagen patch coated with the human coagulation factors (TachoSil) on 58 consecutive patients with endometrial cancer who had undergone hysterectomy and pelvic lymphadenectomy (PL). Patients were randomized in two groups: standard technique plus TachoSil (30 patients, group 1) and standard technique only (28, group 2). All surgical parameters were collected and patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were: the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery and the drainage volume and duration. Same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 7 patients in group 1 and 16 in group 2, but only 3 were symptomatic in group 1 and 9 symptomatic in group 2, with statistical difference. Percutaneous drainage proved necessary in five cases: only one was in group 1 and four in group 2. Intraoperative application of TachoSil reduced rate of postoperative lymphocysts after PL, and it seems to provide a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

The Use of a Surgical Patch in the Prevention of Lymphoceles After Extraperitoneal Pelvic Lymphadenectomy for Prostate Cancer: A Randomized Prospective Pilot Study

Pelvic lymphadenectomy is frequently performed simultaneously with radical prostatectomy to determine lymph node status and the most frequently recorded postoperative complication is the development of a symptomatic lymphocele. This study evaluated TachoSil as an adjunct treatment in preventing lymphoceles after extraperitoneal pelvic lymphadenectomy for prostate cancer. A total of 60 consecutive patients who had undergone radical prostatectomy and pelvic lymphadenectomy were prospectively enrolled in this study. The patients were randomly assigned to a standard technique with the use of clips and electrocoagulation plus TachoSil, or to standard technique only. All patients underwent ultrasound examination on postoperative days 7, 14 and 28 to test for the development of symptomatic or asymptomatic lymphoceles. Drainage volume and duration were also recorded. The baseline characteristics of the 2 randomized groups were well matched. Those patients in whom we used TachoSil showed a lower drainage volume with a mean total volume of 64 +/- 45 ml (range 0 to 110) vs 190 +/- 62.72 ml (range 70 to 270, p = 0.009), and had significantly fewer symptomatic and asymptomatic lymphoceles (5 vs 19, p = 0.001). Only 5 percutaneous surgical procedures to drain the lymphoceles proved necessary, 1 of which occurred in the group with TachoSil. TachoSil seems to provide a useful additional treatment option for reducing drainage volume and preventing lymphocele development after extraperitoneal radical retropubic prostatectomy with pelvic lymphadenectomy.

Reduction in incidence of lymphocele following extraperitoneal radical prostatectomy and pelvic lymph node dissection by bilateral peritoneal fenestration

In our series of 1,900 endoscopic extraperitoneal radical prostatectomies (EERPE) the incidence of symptomatic lymphocele following simultaneous pelvic lymph node dissection (PLND) is between 3 and 14% depending on the extent of lymph node dissection. We report the impact of bilateral peritoneal fenestration after completion of extraperitoneal prostatectomy and PLND on the incidence of lymphocele, postoperative pain and complications. A total of 100 consecutive patients undergoing EERPE and extended PLND were allocated into two groups. In Group A (n = 50) a 4-6 cm incision was performed bilaterally over the external iliac vessels down to the obturator fossa after completion of the main procedure. In Group B (n = 50) no peritoneal incisions were made. The postoperative assessment protocol included a visual analogue pain scale administered three times daily for 6 days, analgesia requirement, and ultrasound examination on 4th and 8th days, and 3 months postoperatively. CRP and leucocyte counts were measured on 1st and 2nd postoperative days. Complications were recorded according to our standard protocol using the Clavien classification. Three patients (6%) in Group A were found to have lymphoceles, none of which were symptomatic. Significantly more patients in Group B developed a lymphocele, (n = 16, 32%, P < 0.001) of which a significant number were symptomatic (n = 7, 14%, P < 0.001) and required laparoscopic fenestration. No significant difference was observed between the pain score in either group. Mean pain scores were 3.4 versus 3.8 at 6 h, and 0.8 versus 1.1 at 6 days, respectively. No difference in analgesia requirement, serum inflammatory markers and return to normal bowel activity was observed between the groups. This study demonstrates that peritoneal fenestration significantly reduces the incidence of both symptomatic and asymptomatic lymphocele, without an increase in postoperative morbidity. As symptomatic lymphocele is one of the most common complications of extraperitoneal PLND requiring reintervention, we recommend that peritoneal fenestration should be performed routinely after extraperitoneal radical prostatectomy and PLND.

Late aortic lymphocele and residual ovary syndrome after gynecological surgery

BackgroundGynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed. However, the fate of the retained ovary is complicated by the residual ovarian syndrome (ROS) and one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22–48.5%. The differential diagnosis of a postoperative fluid collection includes, in addition to a lymphocele, urinoma, hematoma, seroma or abscess and the computed tomography (CT) findings alone is not enough.Case presentationWe describe a patient, affected by ROS concomitant with a asymptomatic lymphocele, initially confused with an aortic lymph nodes relapse, after abdominal radical hysterectomy. The patient was subjected to a surgical approach, included a diagnostic open laparoscopy and laparotomy with sovraombelico-pubic incision, wide opening of the pelvic peritoneum and retroperitoneum. Examination of the mass revealed, macroscopically, a ovary with multiloculated cystic masses filled with clear or yellow serous fluid and the layers were composed by flat or cuboidal mesothelial cells.ConclusionThe tribute of this case illustrates the atypical appearance with uncertain aetiology after complex imaging. Gynecologist and radiologist should acquaint with the appearance of fluid collection (urinoma, lymphocele, seroma, hematoma, abscess) in gynecologic oncology follow-up to properly differentiated from tumor recurrence.

Did Volume of Lymphocele After Kidney Transplantation Determine the Choice of Treatment Modality?

Lymphocele is a lymph collection that forms after surgery following injury to lymph nodes and vessels. The aim of the study was to perform a retrospective analysis of different treatment modalities of lymphocele in patients after kidney transplantation. A lymphocele located in renal graft area was observed in 25 of 386 transplanted patients (6.5%). Mean patient age was 45 (95% confidence interval [CI], 40 to 50) years. Mean observation time was 35 (95% CI, 27 to 43) months. Mean time from transplantation to diagnosis of lymphocele was 29 days (range, 4 to 127). In 13 patients (54.2%), the lymphocele was symptomatic, requiring initial treatment by repeated needle aspirations or percutaneous drainage. Among 7 patients with persistence of the lesion treatment by sclerotherapy with doxycycline, povidone-iodine, and/or ethanol was successful in 4 cases who showed maximal lymphocele volume of 500 mL. Three other patients, namely, volumes of 120, 874, and 2298 mL were referred for surgery; in two cases, internal marsupialization was performed and in one case external drainage was necessary due to abscess formation. Mean time from the diagnosis to recovery in patients requiring surgical treatment was 15 (range, 8 to 24) weeks. Eleven patients with asymptomatic lymphoceles (mean volume 45 mL; range, 8 to 140) were monitored to resolution after a mean of 4 (range, 1 to 11) weeks. All lymphoceles with the maximal volume exceeding 140 mL were clinically symptomatic. Initial percutaneous drainage with or without sclerotherapy was an effective method of treatment. Punctures, drainage, and sclerotherapy were not effective in patients with lymphoceles (>500 mL).

Endoscopic Extraperitoneal Radical Prostatectomy: Initial Experience after 70 Procedures

After our initial experience with 70 transperitoneal laparoscopic radical prostatectomies we developed a totally extraperitoneal retropubic approach to radical prostatectomy using laparoscopic instruments. We report our initial experience with 70 endoscopic extraperitoneal radical prostatectomy procedures. A total of 70 patients underwent endoscopic extraperitoneal radical prostatectomy. Mean patient age was 63.4 years (range 49 to 76). Mean preoperative prostate specific antigen was 12.48 ng./ml. (range 1.4 to 50.7). There were no specific selection criteria for the procedure. The steps of the procedure are preparation of the preperitoneal space with the help of a balloon trocar, trocar placement (a 3 x 5 and a 2 x 12 mm. port), pelvic lymph node dissection, exposure of the prostate and the bladder neck, incision of the endopelvic fascia, ligation of Santorini's plexus, bladder neck dissection, mobilization of the seminal vesicles, incision of Denonvilliers' fascia, sectioning of the prostatic pedicles with or without preservation of the neurovascular bundles, dissection of Santorini's plexus and apex, urethrovesical anastomosis with 7 to 9 interrupted sutures and removal of the specimen via an extraction bag. During the 70 endoscopic prostatectomies 11 hernia defects were treated in 9 patients concomitantly. There was no conversions and no re-interventions. Mean operative time was 155 minutes (range 90 to 260). One patient required transfusion with 2 units of blood cells. Pathological stage was pT2a in 19 patients, pT2b in 14, pT3a in 25, pT3b in 9 and pT4 in 3. Positive surgical margins were found in 2 of the 33 patients (6.1%) with pT2 tumors and in 13 of the 37 (35.1%) with pT3 and pT4 tumors. Postoperatively edema and hematoma of the penis in 10 cases was treated conservatively. Furthermore, 4 patients had asymptomatic lymphoceles, 1 required lymphocele drainage and 2 had partial obturator nerve paralysis, which resolved spontaneously. In 1 patient deep venous thrombosis developed. The preliminary results of this series are promising. Operative and perioperative morbidity was low. Functional results and oncological control were similar to the results of laparoscopic radical prostatectomy. The data demonstrate that endoscopic extraperitoneal radical prostatectomy can be performed with efficacy and results equal to those of laparoscopic radical prostatectomy, while providing the benefits of a totally extraperitoneal approach. Therefore, totally endoscopic extraperitoneal radical prostatectomy represents a technical improvement of laparoscopic technique because it completely obviates intra-abdominal complications and combines the advantages of minimally invasive laparoscopy and the retropubic open approach.

Effect of simple omentoplasty and omentopexy in the prevention of complications after pelvic lymphadenectomy

This multicenter collaborative study prospectively evaluated the effect of omentoplasty and omentopexy on the prevention of complications after pelvic lymphadenectomy. Sixty-four consecutive patients (42 cervical and 22 endometrial cancer) were enrolled and examined periodically for 12 months. All patients underwent simple, semiradical, or Okabayashi's radical hysterectomy and complete pelvic lymphadenectomy. The infracolic omentum was longitudinally divided in half and omentoplasty was performed so that bilateral omental flaps would reach the pelvic floor. The omental flaps were inserted into the retroperitoneal space and the edges of the flaps were sutured to the psoas muscle. The omental flap was then covered by the peritoneum. Incidence of lymphocele, lymphedema, and severe complications associated with lymphocele, such as infection or urinary stenosis, was evaluated at intervals for at least one year after surgery.Among the 64 patients, 12 patients received pelvic radiation because of occult lymph node metastasis. Planned omentoplasty was not possible in one patient because her omentum was too small; therefore, only unilateral omentopexy was performed. Asymptomatic lymphoceles only were detected by ultrasonogram in 12 patients (18.8%). Three patients (4.7%) had a symptomatic but pressure-only lymphocele. Hydronephrosis and bladder compression probably due to lymphocele were observed in one patient, respectively (3.1%), but resolved within 6 months. Lymphedema was observed in seven patients (10.9%) and persisted for more than 6 months in two patients (3.1%). We conclude that this simple technique of omentoplasty and omentopexy appeared to be effective in reducing the incidence of complications after pelvic lymphadenectomy.

Laparoscopic retroperitoneal lymph node dissection.

Retroperitoneal lymph node dissection is the most sensitive and specific diagnostic modality for detecting occult lymph node metastases in clinical stage I testicular tumor. In stage II disease, residual tumors after chemotherapy have to be removed surgically. To reduce the morbidity of these procedures we have replaced open surgery by laparoscopy. Between August 1992 and December 1999 125 patients underwent laparoscopic RPLND (stage I: 76 pts., stage II: 49 pts.) Laparoscopic RPLND could be completed as planned in all but two patients in whom bleeding required conversion to open surgery. Once the learning curve had been overcome, mean operative time decreased significantly from 476 to 219 min for stage I and averaged 226 min in stage IIB disease. Only minor postoperative complications occurred such as asymptomatic lymphoceles (7 pts.) and chylous ascites (6 pts.). Mean post-op hospital stay was 3.3 and 3.5 days, respectively (stages I and II). Mean followup is currently 46 months for stage I and 35 months for stage II tumors. Over this period a single retroperitoneal recurrence was observed (stage I), which, however, was not due to surgical failure, but to false negative histologic findings. All other patients have remained free of relapse. Laparoscopic RPLND is a demanding procedure with a long and steep learning curve. It has proved feasible also after chemotherapy. The diagnostic accuracy of laparoscopic RPLND was as good as that of the open procedure, while the morbidity is significantly lower. Tumor control was not compromised by the laparoscopic approach.

LAPAROSCOPIC RETROPERITONEAL LYMPHADENECTOMY AFTER CHEMOTHERAPY FOR STAGE IIB NONSEMINOMATOUS TESTICULAR CARCINOMA

We investigated laparoscopic retroperitoneal lymphadenectomy after chemotherapy for stage IIB testicular carcinoma in terms of operative feasibility, overall morbidity and tumor control. Between February 1995 and April 1998, 24 patients underwent laparoscopic retroperitoneal lymphadenectomy following initial chemotherapy for stage IIB (2 to 5 cm.) solitary or unilateral lymph node metastases. Mean tumor diameter was 2.4 cm. before and 1.1 cm. after chemotherapy. Laparoscopic retroperitoneal lymphadenectomy was performed in all patients, including those with complete remission. Laparoscopic retroperitoneal lymphadenectomy could be completed as planned in all patients and there was no need for conversion to open surgery. Operative time was 150 to 300 minutes (mean 240). Blood loss was minimal and no blood transfusions were required. The only postoperative complications were chylous ascites (5 patients) which resolved with conservative management (low fat diet) and a small asymptomatic lymphocele. Histological examination revealed necrosis in 71%, mature teratoma in 25% and active tumor in 4% of patients. Antegrade ejaculation was preserved in all patients. Mean postoperative hospital stay was 4 days, return to normal activities between 1 and 3 weeks, and time to complete recovery between 5 and 10 weeks. All patients were well without evidence of disease at a mean followup of 24.4 months. Laparoscopic retroperitoneal lymphadenectomy after chemotherapy proved feasible in select patients presenting with solitary or unilateral lymph node metastases and was associated with a low morbidity. Tumor control was not compromised by the laparoscopic approach.

Radiological diagnosis and therapy of postoperative abdominal lymphoceles

Eighty-one patients with postoperative abdominal lymphoceles were examined by CT and ultrasound. Both methods provide accurate information regarding localisation and extent of the lymphocele. In 51 patients conservative treatment under sonographic or CT observation was carried out. In seven patients, irradiation lead to complete regression. In 21 patients, interventional radiological therapy was carried out with simultaneous irradiation in seven cases. In five patients surgery was necessary. Asymptomatic lymphoceles should be treated conservatively and only after the appearance of clinical symptoms should interventional radiological or surgical measures be carried out.