Incidence Of Symptomatic Lymphoceles Research Articles

Symptomatic Lymphocele After Robot-Assisted Pelvic Lymphadenectomy as Part of the Primary Surgical Treatment for Cervical and Endometrial Cancer: A Retrospective Cohort Study

Pelvic lymph node dissection (PLND) is part of the primary treatment for early-stage cervical cancer and high-intermediate risk or high-risk endometrial cancer. Pelvic lymphocele is a postoperative complication of PLND and when symptomatic, lymphoceles necessitate treatment. The aim of this study was to investigate the incidence and risk factors of symptomatic lymphocele after robot-assisted laparoscopic PLND in cervical and endometrial cancer. Retrospective cohort study. Single-center academic hospital. Two hundred and fifty-eight patients with cervical cancer and one hundred and twenty-nine patients with endometrial cancer. Pelvic lymphadenectomy by robot-assisted laparoscopic surgery. We retrospectively included all patients with early-stage cervical cancer and high- intermediate risk or high-risk endometrial cancer who underwent pelvic lymphadenectomy by robot-assisted laparoscopic surgery between 2008 and 2022. Medical records were reviewed for the occurrence of a symptomatic lymphocele. Univariate and multivariate logistic regression analyses were conducted to identify risk factors for developing a symptomatic lymphocele. In total 387 patients, 258 with cervical cancer and 129 with endometrial cancer, were included in the study. The overall incidence of symptomatic lymphoceles was 9.6% with a median follow-up of 47 months [IQR 23-61]. For the entire cohort, smoking was the only significant risk factor for symptomatic lymphoceles identified in univariate (OR 2.47, 95% CI 1.19-5.11) and multivariate analysis (OR 2.42, 95% CI 1.16-5.07). For cervical cancer, BMI (OR 1.09, 95% CI 1.00-1.17) and prior abdominal surgery (OR 2.75, 95% CI 1.22-6.17) were also identified as significant independent risk factors. For endometrial cancer, age was identified as significant independent risk factor (OR 0.90, 95% CI 0.83-0.97). This single-center cohort study demonstrated an incidence of almost 10% of symptomatic lymphoceles after robot-assisted laparoscopic PLND for cervical cancer and endometrial cancer, with a higher risk observed among patients who smoke at the time of diagnosis. Furthermore, risk factors differ between the two populations, necessitating further studies to establish risk models.

FloSeal for preventing symptomatic lymphocele after pelvic and/or para-aortic lymphadenectomy in gynecological cancers: a randomized controlled trial

To evaluate the role of FloSeal for preventing symptomatic lymphocele following pelvic and/or para-aortic lymphadenectomy in patients with gynecological cancers. Between October 2014 and April 2015, 40 patients with gynecological cancers planned for surgical management were randomly placed into FloSeal and non-FloSeal groups in a 1:1 ratio. Lymphocele incidence was evaluated using intravenous contrast-enhanced, abdominopelvic computed tomography 3–6 months after surgery. The quality of life questionnaire was completed by patients at 1, 3 and 6 months after surgery. The incidence of symptomatic lymphocele was compared using a chi-square test. All patients underwent bilateral pelvic lymph node dissection, and eight patients in each group (40%vs. 44.4%, p > 0.999) underwent para-aortic lymph node dissection. The mean number of total, right pelvic, left pelvic and para-aortic lymph nodes retrieved was similar between the groups. One patient (1/20, 5%) in the FloSeal group and three (3/18, 16.7%) in the non-FloSeal group developed lymphoceles (p = 0.328). The incidence of symptomatic lymphocele was 0% and 11% (2/18) in the FloSeal and non-FloSeal groups (p = 0.218), respectively. The mean time interval to drain removal (4.8 ± 2.0 days vs. 5.3 ± 2.2 days, p = 0.400) was shorter and the mean drain volume (1656 ± 1362 mL vs. 2022 ± 2301 mL, p = 0.550) was smaller in FloSeal group. The use of FloSeal after pelvic and/or para-aortic lymphadenectomy in patients with gynecological cancers may be effective for preventing symptomatic lymphocele. Clinical Trial registration: NCT01679483.

V12-09 THE ANATOMIC SCALENE TRIANGLE: A USEFUL LANDMARK FOR PELVIC LYMPHADENECTOMY DURING RETZIUS-SPARING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Oncology I (Prostatectomy) (V12)1 Sep 2021V12-09 THE ANATOMIC SCALENE TRIANGLE: A USEFUL LANDMARK FOR PELVIC LYMPHADENECTOMY DURING RETZIUS-SPARING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Jonathan Katz, Ali Merhe, Ali Mouzannar, and Mark Gonzalgo Jonathan KatzJonathan Katz More articles by this author , Ali MerheAli Merhe More articles by this author , Ali MouzannarAli Mouzannar More articles by this author , and Mark GonzalgoMark Gonzalgo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002093.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic lymphadenectomy (PLN) during Retzius-Sparing Robotic-Assisted Radical Prostatectomy (RS-RARP) may be challenging because the medial umbilical ligaments are not released, and the anterior structures are preserved. The incidence of symptomatic lymphoceles following PLN during RS-RARP has been reported to be higher than standard approaches for RARP. We describe the anatomic scalene triangle as a useful landmark to facilitate PLN during RS-RARP and compare the outcomes of PLN using this technique versus PLN for standard RARP. METHODS: This is a single center, institutional review board approved, retrospective case-control study of 200 consecutive patients undergoing RS-RARP or standard RARP. We compared perioperative factors such as age, BMI, grade group, tumor stage, lymph node yield, and incidence of symptomatic lymphoceles using t-test for continuous variables and Fisher’s exact test for categorical variables. A p-value of< 0.05 was considered statistically significant. In the RS-RARP, group the anatomic scalene triangle was used as a landmark for PLN. The scalene triangle is formed superiorly by the vas deferens, medially by the medial umbilical ligament, and laterally by the external iliac vein. The peritoneum overlying this triangle is incised superficially and an avascular plane in this space is developed. Retraction of the vas deferens and medial umbilical ligament facilitates exposure of the lymph node packet and the obturator nerve. Once the lymph node packet is isolated, surgical clips are applied and mobilization of the lymph nodes is performed cranially. Once the proximal extent of the dissection has been reached, the lymph node packet is divided and removed. RESULTS: There were no statistically significant differences between RS-RARP and standard RARP with respect to age, BMI, grade group, tumor stage, lymph node yield, or incidence of symptomatic lymphocele. Of note there were 4 symptomatic lymphoceles in the RS-RARP group and 1 symptomatic lymphocele in the standard RARP group. These were all treated with percutaneous drainage by interventional radiology. CONCLUSIONS: The anatomic scalene triangle is a useful landmark to facilitate safe and efficient PLN during RS-RARP and is associated with 4% incidence of symptomatic lymphoceles compared to prior, smaller series which demonstrated 8-16% incidence of symptomatic lymphoceles with PLN during RS-RARP. Though we observed more symptomatic lymphoceles in the RS-RARP group compared to standard RARP, this was not statistically significant. Source of Funding: NA © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1026-e1027 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Katz More articles by this author Ali Merhe More articles by this author Ali Mouzannar More articles by this author Mark Gonzalgo More articles by this author Expand All Advertisement Loading ...

Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review.

Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.

Four-point Peritoneal Flap Fixation in Preventing Lymphocele Formation Following Radical Prostatectomy

BackgroundSymptomatic lymphocele following radical prostatectomy (RP) and concomitant bilateral extended pelvic lymph node dissection (ePLND) has a significant impact on postoperative recovery and may sometimes require surgical intervention. ObjectiveTo report on the use of four-point peritoneal flap fixation (4PPFF) during RP to reduce lymphocele occurrence following PLND. Design, setting, and participantsBetween April 2010 and May 2017, 1358 patients underwent RP with concomitant bilateral ePLND. From this cohort, 193 patients who had undergone PNLD with 4PPFF were matched in a 1:1 ratio with respect to age, body mass index, initial PSA, and number of lymph nodes removed to patients who had undergone PLND without 4PPFF. Intervention4PPFF was performed by suturing the cut end of the ventral parietal peritoneum at four points (to the anterior and lateral pelvic side wall on both sides) following PLND so that the peritoneal surface was exposed to the iliac vessels and obturator fossa. Outcome measurements and statistical analysisAll patients underwent ultrasound on postoperative days 6, 28, and 90 to test for the presence of lymphocele. For univariate analysis, a χ2 test and analysis of variance were applied, as appropriate. Statistical significance was set at p<0.05, and all p values reported were two-sided. Results and limitationsThere were no significant differences between the two groups with respect to intraoperative blood loss, positive surgical margin rate, Gleason score, clinical stage, and number of positive cores. Asymptomatic lymphocele was observed in four patients (2.07%) in the 4PPFF group compared to 16 patients (8.3%) without 4PPFF (p=0.0058). Similarly, a significant difference in the incidence of symptomatic lymphocele was observed: two patients (1.03%) in the 4PPFF group versus nine patients (4.6%) without 4PPFF (p=0.0322). There were no differences in other complication rates between the two groups. The limitations of the study are its retrospective and nonrandomised nature, with postoperative follow-up based on ultrasound imaging rather than computed tomography because of ethical considerations, which could have caused observer bias. Conclusions4PPFF is a safe and effective procedure in preventing lymphocele occurrence in patients undergoing RP with PLND. The increase in exposure of the PLND raw area to the peritoneal surface following this procedure may aid in increased absorption of accumulating lymph fluid. Further prospective randomised multicentre studies are warranted to confirm our observations. Patient summaryWe report on the use of a surgical technique to decrease the collection of lymphatic fluid in the abdominal cavity following lymph node removal during radical removal of the prostate gland in patients with prostate cancer. Patients undergoing this procedure had significantly better outcomes when compared to patients operated on in the conventional approach.

PD38-02 FOUR-POINT PERITONEAL FLAP FIXATION IN PREVENTING LYMPHOCELE FORMATION FOLLOWING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V1 Apr 2018PD38-02 FOUR-POINT PERITONEAL FLAP FIXATION IN PREVENTING LYMPHOCELE FORMATION FOLLOWING RADICAL PROSTATECTOMY Jens Uwe Stolzenburg, Vinodh Kumar Adithyaa Arthanareeswaran, Anja Dietel, Toni Franz, Evangelos Liatsikos, Iason Kyriazis, Roman Ganzer, Abinaya Ravichandran Chandra, and Hoang Minh Do Jens Uwe StolzenburgJens Uwe Stolzenburg More articles by this author , Vinodh Kumar Adithyaa ArthanareeswaranVinodh Kumar Adithyaa Arthanareeswaran More articles by this author , Anja DietelAnja Dietel More articles by this author , Toni FranzToni Franz More articles by this author , Evangelos LiatsikosEvangelos Liatsikos More articles by this author , Iason KyriazisIason Kyriazis More articles by this author , Roman GanzerRoman Ganzer More articles by this author , Abinaya Ravichandran ChandraAbinaya Ravichandran Chandra More articles by this author , and Hoang Minh DoHoang Minh Do More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1749AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Symptomatic lymphocele following laparoscopic/robot assisted radical prostatectomy (RP) and concomitant bilateral extended pelvic lymph node dissection (PLND) procedure has a significant impact on the postoperative recovery and may sometime require surgical intervention. Various strategies have been tested until now to prevent postoperative lymphocele without considerable success. We report the utilization of four-point peritoneal flap fixation (4PPFF) during RP in decreasing the lymphocele formation following PLND. METHODS 4PPFF was performed by suturing the cut end of the ventral parietal peritoneum at four points (to anterior and lateral pelvic side wall on both sides) following PLND such that the peritoneal surface is exposed to the iliac vessels and obturator fossa. Between April 2010 - May 2017, 1358 patients underwent RP with concomitant bilateral extended PLND procedure. From this cohort 193 patients who had undergone PNLD with four-point PF were matched in a 1:1 ratio to patients who underwent PLND without 4PPF with respect to age, body mass index, initial PSA and number of lymph nodes removed. All patients underwent ultrasound on postoperative days 2, 6, 28 and 90 to test for the presence of any lymphoceles. Statistical analysis was performed using Medcalc statistical software (Ver. 17.9, Ostend, Belgium). For univariate analysis, chi-square test and Annova were used appropriately. Statistical significance was set at a p value less than 0.05, and all reported p values were two-sided. RESULTS There was no significant difference between the two groups with respect to intraoperative blood loss, positive surgical margin rate, Gleason score, clinical stage and number of positive cores. Incidence of asymptomatic lymphocele was observed in 4 (2.07%) patients in the 4PPFF group compared to 16 (8.3%) patients without 4PPFF (p=0.0058). Similarly, significant difference was observed in the incidence of symptomatic lymphocele; 2 (1.03%) patients in 4PPFF group vs 9 (4.6%) patients without 4PPF (p=0.0322). There was no difference in other complication rates between the two groups. CONCLUSIONS 4PPFF is a safe and effective procedure in preventing lymphocele formation in patients undergoing RP with PLND. The increased exposure of peritoneal surface to the PLND raw area following this procedure may aid in increased absorption of the accumulating lymph fluid from the PLND raw area. Further prospective randomized multicenter studies are warranted to confirm our observations. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e736 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jens Uwe Stolzenburg More articles by this author Vinodh Kumar Adithyaa Arthanareeswaran More articles by this author Anja Dietel More articles by this author Toni Franz More articles by this author Evangelos Liatsikos More articles by this author Iason Kyriazis More articles by this author Roman Ganzer More articles by this author Abinaya Ravichandran Chandra More articles by this author Hoang Minh Do More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Use of TachoSil® to Prevent Symptomatic Lymphocele after an Aggressive Tumor Debulking with Lymphadenectomy for Advanced Stage Ovarian Cancer. A Pilot Study

Objective: To describe the incidence of symptomatic lymphocele (SLC) after an aggressive tumor debulking surgery and lymphadenectomy in patients with ovarian cancer and peritoneal carcinomatosis with or without TachoSil®. Material and Methods: A pilot retrospective comparative observational study was performed between patients with advanced ovarian cancer International Federation of Gynecology and Obstetrics stages III-IV who underwent complete debulking surgery and radical retroperitoneal lymphadenectomy. In 18 patients, 4 TachoSil® patches were placed in the retroperitoneal area, since January 2014-October 2014. This group was compared with other 18 consecutive patients matched by age, International Federation of Gynecology and Obstetrics stage, surgical complexity, American Society of Anesthesiologists score, comorbidity, and BMI without the use of TachoSil®. Results: Baseline characteristics were similar between groups. There were no statistically significant differences in terms of surgical complexity, surgical time, estimated blood loss, node removed, length of hospital stay, and complications between groups. SLC was diagnosed in 7 patients (38.8%) without TachoSil®, and in 2 patients (11.1%) with TachoSil® (p = 0.121). The use of TachoSil® was associated with a statistically significant lower re-admission rate (p = 0.041) and with a significantly shorter time to adjuvant chemotherapy (p = 0.02). Conclusions: Using TachoSil® in women with advanced stage ovarian cancer who underwent radical debulking with retroperitoneal lymph node dissection is associated with a non-statistically significant reduction in the incidence of SLC. A larger-scale randomized controlled study should be conducted to confirm our preliminary results.

Effectiveness of an absorbable fibrin sealant patch to reduce lymphoceles formation after axillary lymphadenectomy for breast cancer: a matched-pair analysis

BackgroundThis study evaluated the use of TachoSil as an adjunctive therapy for reducing axillary lymphocele formation. MethodsEighty-six patients diagnosed with breast cancer N+ and treated with axillary lymphadenectomy received a TachoSil patch in the axillary wound. Using a database of patients without placing a hemostatic patch, we applied a matched case–control in a 1-to-2 fashion. Multiple and logistic regression analyses were used to evaluate postoperative results. ResultsPatient group with TachoSil showed a significantly lower drainage volume (P < .001) and the length of stay was significantly shorter (P < .001). The number of patients with evacuative punctures was 24.5% in the group with patch versus 51.2% in the control group (P < .001). In multivariate analysis, the use of TachoSil was a significant predictor of reducing axillary drainage volume (P < .001), mean length of hospital stay (P = .001), and number of evacuative punctures of lymphocele (odds ratio .264, 95% confidence interval .144 to .484, P < .001). ConclusionThe use of TachoSil in axillary lymphadenectomy may be a safe and useful treatment option for reducing axillary drainage volume, incidence of symptomatic lymphocele, and hospital stay.

Influence of Body Mass Index, Surgical Approach and Lymphadenectomy on the Development of Symptomatic Lymphoceles after Radical Prostatectomy

Purpose: Identification of factors influencing lymphocele formation requiring intervention after radical prostatectomy. Methods: 302 patients undergoing radical retropubic prostatectomy (RRP, n = 174) or transperitoneal robot-assisted laparoscopic prostatectomy (RALP, n = 128) by the same surgeon were retrospectively reviewed. Incidence of symptomatic lymphoceles (SLC) was compared with clinical and pathological data (contingency analyses, Wilcoxon-Kruskal-Wallis test). Results: Sixteen patients (5.3%) developed SLC. SLC occurred significantly more frequently after RRP compared to RALP (8.0 vs. 0.8%, p = 0.0008). Patients with SLC had more lymph nodes (LN) removed median (17 vs. 13, p = 0.009) and a significantly lower BMI (median 24.4 vs. 26.4, p = 0.0008). Presence of LN metastases (n = 18 patients, 6.0%) showed no statistical impact on SLC. In a multivariate analysis surgical method, the number of resected LN and the BMI remained independent predictors of SLC formation. Conclusions: The lower incidence of SLC after RALP compared to RRP probably results from peritoneal drainage of lymphatic fluid. The correlation of removed LN and SLC might be explained by increased injury of lymphatic vessels during more extended LN dissection. Why patients with lower BMI are more prone to develop SLC still remains unclear. However, early postoperative mobilization in nonobese patients might be a contributing factor.

452 Incidence of symptomatic lymphoceles after radical prostatectomy depends on surgical method, extent of resection and body mass index

452 Incidence of symptomatic lymphoceles after radical prostatectomy depends on surgical method, extent of resection and body mass index

OT2-07-01: Pasireotide Long Acting Release (LAR) in Breast Cancer Patients To Prevent Lymphocele after Mastectomy and Axillary Node Dissection: A Randomized, Multicenter, Phase II Study.

Abstract Background: Lymphocele is the principal post-operative morbidity following axillary node dissection. According to the literature, incidence can vary from 4 to 89%. Encouraging results in terms of reducing postoperative lymphoceles as well as drainage duration and volume using octreotide have been recorded recently. A new molecule, namely pasireotide, developed by Novartis Pharma AG, Basle Switzerland, is a somatostatin analog possessing high binding affinity to 4 of the 5 somatostatin receptors. Trial design: We are performing a prospective, randomized 1:1, double blind, multicenter trial against placebo with a Bayesian design. Eligibility criteria: any female patient scheduled for breast surgery with mastectomy and axillary node dissection indicated at the pre-surgical stage. Specific aims: The purpose of this trial is to assess the efficacy of a single pre-surgical injection of pasireotide LAR 60 mg im in reducing the postoperative incidence of symptomatic lymphoceles following mastectomy with axillary node dissection for breast cancer. Patients are followed up for 4 weeks Statistical methods: The statistical analysis will be carried out sequentially after observing the principal criterion (i.e. success is defined as a total volume of lymphocele following single or repeated aspiration ≤ 60 cc in the 28 days following surgery or a routine aspiration volume on the 28th day ≤ 120cc) of each patient included for each randomization group, with or without treatment. It involves estimating the probability of a response in each group using a Bayesian design based on a beta-binomial model. With the Bayesian approach, the response rate in each group (πi) is considered as a random variable, with a priori density focused on the anticipated response rate of 80% in the group receiving treatment and 60% in the non-treatment group, which will be sequentially updated as the observations are made according to a so-called a posteriori law. Present accrual and target accrual: The sample size consists of a total of 90 patients with 45 patients in the active treatment group and 45 patients in the placebo one. To date more than 50% of the patients have been included. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-07-01.

Prophylactic Peritoneal Fenestration to Prevent Morbidity After Kidney Transplantation: A Randomized Study

Formation of lymphocele (accumulation of lymphatic fluid) is a common surgical complication following kidney transplantation. This open randomized trial evaluated the effect of prophylactic fenestration on lymphocele formation. Adult recipients of kidney grafts from deceased donors were randomized to undergo peritoneal fenestration during the transplantation or to standard surgical procedure without fenestration. The incidence of symptomatic lymphocele in the two groups was compared at 1 year after transplantation. A protocol-based ultrasound examination was performed in the 1st, 5th, and 10th postoperative week. Any hypoechoic perirenal collection was registered. One hundred thirty recipients were randomized to peritoneal fenestration (n = 69) or standard therapy (n = 61). Six patients were excluded. Nine of 58 (15.5%) patients in the standard group developed symptomatic lymphoceles requiring treatment during the first postoperative year, versus 2 of 66 (3.0%) in the fenestration group (relative risk = 0.20, 95% confidence interval: 0.04-0.82, P = 0.015). Seven major surgical procedures and five percutaneous drainages due to lymphoceles were performed in the standard group, compared with two percutaneous drainages in the fenestration group. The prevalence of fluid collections in the fifth postoperative week was significantly higher in the standard group (66% vs. 37%; relative risk = 0.57, 95% confidence interval: 0.37-0.71, P = 0.005). Prophylactic fenestration reduced the risk of lymphoceles and the need for invasive procedures to treat this condition. The results need to be confirmed in a population of transplant recipients on lower steroids and with the use of wound drains.

A Comparative Study of Laparoscopic Extraperitoneal Laparoscopy With the Use of Ultrasonically Activated Shears

Previous studies have demonstrated the efficacy and safety of extraperitoneal laparoscopic lymphadenectomies. The rate of peri- and postoperative complications with these procedures is below 15%. One of the most common postoperative complications, lymphocele, occurs in 3.8% to 21 % of patients, and can be symptomatic or nonsymptomatic. Nonsymptomatic lymphoceles require no treatment. Although the incidence of symptomatic lymphocele has decreased with the use of systematic preventive marsupialization, this procedure does not seal the lymphatic vessels and thus does not prevent lymphatic leakage during lymph nodes dissection. A device employing ultrasonic energy, the ultrasonically activated shears (the harmonic scalpel) has been investigated for management of symptomatic lymphoceles after pelvic lymphadenectomy in patients with gynecological malignancies. This device achieves both coagulation and cutting without instrument exchanges. In a small number of studies, use of the ultrasonic shears has reduced the occurrence of lymphoceles and accomplished sealing, thereby reducing lymphatic leakage. The aim of this study was to investigate the effectiveness of the ultrasonic shears in reducing the occurrence of symptomatic lymphoceles in patients who had undergone para-aortic laparoscopic lymphadenectomies (PALLs) in a prospective setting. The postoperative complications of PALLs were also investigated. A total of 98 patients who had received PALLS were divided into 2 groups. The ultrasonic group was comprised of 36 patients receiving PALLs that were performed with the activated shears. Outcomes in the study group were compared with a historical control group comprised of 62 patients receiving PALLs performed with the standard coagulation procedure. There were no statistically significant differences in the following perioperative and postoperative parameters between the ultrasonic group and control group: Operating time (129.9 ± 38.1 vs. 109.8 ± 38.1 minute, P = 0.22), hospital stay (5.1 ± 2.7 vs. 4.48 ± 3.6 days, P = 0.34), lymph nodes removed (19.8 ± 9.7 vs. 21.1 ± 8.8, P = 0.50) and positive lymph nodes (1.03 ± 2.9 vs. 0.89 ± 2.0, P = 0.78). In addition, no difference in blood loss occurred. No patients in the study group, but 7 patients in the control group experienced symptomatic lymphoceles that required medical treatment (P = 0.03). Four control patients had radiologic drainage and 1 received surgical drainage. The rate of peri/postoperative complications was 9%, which is comparable with rates of PALL reported in major studies. These findings are consistent with those of a number of major studies showing that the ultrasonically activated shears are effective for the performance of PALL. These and previous data suggest to the investigators that combined use of the shears together with systematic preventive marsupialization may significantly lower the frequency of postoperative symptomatic lymphoceles and other complications.

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.

Novel Technique to Prevent Lymphocele Recurrence after Laparoscopic Lymphocele Fenestration in Renal Transplant Patients

To describe the use of nonabsorbable polymer ligating (NPL) clips to prevent recurrence after laparoscopic lymphocele fenestration and to determine the efficacy and safety of this treatment in renal-transplant patients at our center. From December 2000 to October 2005, nine patients with a mean age of 38.5 years (range 26-54 years) and symptomatic lymphoceles were treated laparoscopically among 144 renal-transplant patients. The overall incidence of symptomatic lymphocele was 6.2% (9/144). The mean time from transplantation to diagnosis was 55.5 days (range 20-98 days). Patient and lymphocele characteristics, complications, recurrence rate, and outcomes of this procedure were analyzed retrospectively. Laparoscopic treatment was successful in eight patients; the other was converted to open surgery. One patient sustained an allograft-ureteral injury. The mean operative time was 90.7 minutes (range 75-120 minutes), and the mean postoperative stay was 4.1 days (range 1-7 days). Lymphocele recurrence was found in the first two patients after laparoscopic surgery without NPL clips. With a mean follow-up of 42.3 months (range 31-51 months), no recurrence was observed in patients in whom NPL clips were used to maintain the patency of the peritoneal window. No late laparoscopy-related complications occurred. Laparoscopic lymphocele fenestration with NPL clips is a safe, technically easy, and efficacious procedure for the treatment of symptomatic lymphoceles after renal transplantion.