Rafael E. Yanes, MD
Fernando J. Bianco, Jr, MD
BASICS
DESCRIPTION
• A lymphocoele is a localized encapsulated collection of lymphatic fluid created by disruption of lymphatic vessels.
• A collection of lymph fluid in a cavity that is not lined by epithelium
• Generally occurs following surgery such as pelvic or retroperitoneal lymphadenectomy or renal transplantation
EPIDEMIOLOGY
Incidence (1)
• Incidence: 0.6–18% after renal transplant
• Clinical incidence: 1–10% after pelvic lymphadenectomy
– May be up to 20–25% if all patients were imaged postoperatively
• After robot-assisted laparoscopic lymphadenectomy (RA-PLND) is about 5%, half becoming symptomatic
RISK FACTORS
• Recent pelvic surgery (ie, PLND, open or laparoscopic), renal transplant, retroperitoneal lymph node dissection (RPLND), RA-PLND, gynecologic procedures:
– Extended PLND > conventional PLND
– Extraperitoneal > transperitoneal procedures
– Risk increases linearly with the number of nodes retrieved.
• Prior radiation or chemotherapy
• Anticoagulation or antiplatelet therapy may increase risk
• Long-term use of steroids
• Presence of involved lymph nodes
PATHOPHYSIOLOGY
• Lymphatic fluid collects in the extraperitoneal space due to continued lymphatic leakage.
• Transperitoneal pelvic lymphadenectomy is less commonly associated with the development of a lymphocele but can occur.
• Fluid is chylous in nature.
• Occurs in up to 20% of kidney transplant recipientscaused by leakage from lymphatic vessels transsected during the transplant surgery
ASSOCIATED CONDITIONS
• Bladder cancer
• Gynecologic malignancy
• Penile cancer
• Prostate cancer
• Renal cancer
• Renal insufficiency with transplantation
• Retroperitoneal metastasis
GENERAL PREVENTION
• Meticulous lymphadenectomy with clips on proximal end of lymphatic vessels.
– Monopolar electrocoagulation may not adequately seal lymph channels.
– Bipolar or harmonic devices have been shown to be effective (bipolar devices created seals that were fivefold to 10-fold stronger than the harmonic devices)
These vessel-sealing devices (VSDs) may reduce risk.
– Use of FloSeal or other hemostatic products after lymphadenectomy may reduce the number of symptomatic lymphoceles.
• Some reports that the use of anticoagulants (eg, subcutaneous heparin) postop may increase lymphocele risk.
– Use of low-dose heparin in this setting when injected in the upper arm may reduce lymphocele risks.
• Use of suction drains does not appear to impact the development of lymphoceles.
DIAGNOSIS
HISTORY
ALERT
Lymphoceles can occur after transperitoneal laparoscopic, robot-assisted surgery.
• Recent pelvic surgery, particularly involving lymphadenectomy
• Prior chemotherapy or pelvic radiation
• Timing of onset of symptoms:
– Urine leak (urinoma), hematoma, abscess, and peritonitis typically present early
– Lymphocele can present early in the postop period, but may present several weeks or months after surgery
• Urinary frequency (if compressing bladder)
• Sensation of pelvic fullness
• Constipation
• Flank or abdominal pain (40%)
• Lower-extremity pain/swelling (37%)
• Ileus
• Fever (47%)
PHYSICAL EXAM
• Palpable abdominal mass or lower abdominal tenderness
• Lower-extremity edema
– Painful leg swelling suggests deep venous thrombosis (DVT).
– Lymphocele-related, lower-extremity swelling is usually not painful.
• Peno-scrotal or labial edema
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Serum creatinine, BUN (especially to follow renal function in transplant patient)
• Aspirated fluid creatinine and BUN, Gram stain and culture
• Lymphatic fluid typically contains protein, BUN, creatinine, electrolytes, and, occasionally, lipids as serum
• In contrast, urinoma has markedly elevated creatinine; lymphocele creatinine = serum creatinine
Imaging
• Key to diagnosis, but cannot distinguish between lymphocele and urinoma
• US: Imaging, lymphoceles appear as anechoic cystic structures that may contain thin septations and debris.
– Pelvic: To identify fluid collection that is separate from the bladder, adjacent to renal allograft
– Retroperitoneal: To evaluate hydronephrosis, if suspected
– Ideal for follow-up of resolution
– Duplex study of the lower extremities: To evaluate for DVT
• Pelvic CT: Best definition of size and location of lymphocele
– Seen as thin-walled hypodense lesions
– Negative Hounsfield units
– Thickened, enhanced wall suggest infection
• IVP: May show displacement of ureter and compression of bladder, but is seldom necessary
Diagnostic Procedures/Surgery
• Lymphangiography/lymphoscintigraphy: If other studies unclear, historic value
• Diagnostic aspiration with count and cultures
Pathologic Findings
Lymph fluid in a fibrous cavity not lined by epithelium-containing lymphatic fluid.
DIFFERENTIAL DIAGNOSIS
• Abscess
• Cystic malignancy
• Hematoma
• Lymphocele
• Urinoma due to urinary leakage
• Seroma
TREATMENT
GENERAL MEASURES
• Treat DVT if present.
• Foley catheter if the patient has significant voiding dysfunction
• Asymptomatic small lymphoceles should be monitored (<100–150 mL volume). Many will resolve spontaneously.
MEDICATION
First Line
• Lymphocele management is primarily interventional with limited role for medications unless associated with infection or sclerosis (see below) (2).
• Systemic antibiotics (with percutaneous drainage) if lymphocele is infected.
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Treatment of symptomatic or large lymphoceles is immediate percutaneous drainage (3).
– Reported success rates with aspiration and drainage tube are approaching 80%, with a mean drainage duration ranging from a few days to several months.
– Increased risk of infection, especially in immunocompromised (transplant) patients.
• Sclerosis therapy can be used to treat extraperitoneal lymphoceles
– Sclerotherapy (povidone–iodine, 95% ethanol, tetracycline 0.5–2 g in 50 mL NS, bleomycin 1 U/mL, fibrin glue):
– Cavity is aspirated, then filled gently with a sclerosing agent.
– Sclerosis is usually contraindicated.
Multiseptated lymphoceles: Drainage, lack of access to all chambers
When the ureter is in close contact with a wall of the lymphocele (periureteral fibrosis, ureteral obstruction)
Incomplete lymphoceles should not be treated by sclerosis.
• Transperitoneal laparoscopic marsupialization (4)
– If unsuccessful sclerosis or not amenable to percutaneous drainage
– Three transperitoneal ports provide access for excision of the peritoneal window and optional omental wick placement to keep peritoneal window open.
– Success: 77–100%
• Open marsupialization (internal drainage) into the peritoneum is the historic gold standard:
– A window of peritoneum is excised, allowing the lymph to be reabsorbed by the peritoneum.
• Infected lymphoceles require percutaneous or open surgical drainage.
• Omentoplasty:
– Placing a portion of omentum in the window decreases recurrence maintaining patency.
– Success: 75–100%
ONGOING CARE
PROGNOSIS
• Most smaller asymptomatic lymphoceles resolve spontaneously.
• >90% success with marsupialization
COMPLICATIONS
• DVT/PE
• Lymphostasis of the lower extremity
• Infection
• Ureteral obstruction
• Bowel obstruction
FOLLOW-UP
Patient Monitoring
Repeat imaging: Ultrasound or CT in 2–4 mo after treatment to detect recurrence.
Patient Resource
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2498000
REFERENCES
1. Musch M, Klevecka V, Roggenbuck U, et al. Complications of pelvic lymphadenectomy in 1,380 patients undergoing radical retropubic prostatectomy between 1993 and 2006. J Urol. 2008;179:923–928.
2. Glass LL, Cockett AT. Lymphoceles: Diagnosis and management in urologic patients. Urology. 1998;51(5A):135–140.
3. Loeb S, Partin AW, Schaeffer EM, et al. Complications of pelvic lymphadenectomy: Do the risks outweigh the benefits? Rev Urol. 2010;12(1):20–24.
4. Hamilton BD, Winfield HN. Laparoscopic marsupialization of pelvic lymphoceles. Tech Urol. 1997;2(4):220–224.
ADDITIONAL READING
Taneja SS. Complications of lymphadenectomy. In: Taneja SS, ed. Complications of Urologic Surgery: Prevention and Management. 4th ed. Philadelphia, PA: Saunders/Elsevier; 2010.
See Also (Topic, Algorithm, Media)
• Edema, External Genitalia
• Lymphocele, Pelvic Images 
• Urinoma (Perinephric Pseudocyst)
CODES
ICD9
457.8 Other noninfectious disorders of lymphatic channels
ICD10
I89.8 Oth noninfective disorders of lymphatic vessels and nodes
CLINICAL/SURGICAL PEARLS
• Use of clips on identifiable lymphatic channels can minimize the occurrence of postoperative lymphoceles.
• A transperitoneal approach for lymphadenectomy is not protective against the formation of a lymphocele because loculation of lymphatic fluid can still occur.
• Symptomatic lymphoceles may require percutaneous or laparoscopic drainage.