Radiologic imaging and percutaneous treatment of pelvic lymphocele

doi:10.1016/j.ejrad.2005.03.007

European Journal of Radiology

Volume 55, Issue 3, September 2005, Pages 340-354

https://doi.org/10.1016/j.ejrad.2005.03.007 Get rights and content

Abstract

Pelvic lymphocele, also known as lymphocyst, is a cystic structure caused by lymphatic injury usually secondary to pelvic lymphadenectomy and renal transplantation. Lymphoceles can cause morbidity and rarely mortality by compression of adjacent structures and infectious complications. This review discusses etiology and treatment options for pelvic lymphoceles including surgical and percutaneous methods with emphasis on percutaneous techniques particularly in conjunction with sclerotherapy. Percutaneous catheter drainage with sclerotherapy procedure with various sclerosing agents is described in detail. Ethanol, povidone-iodine, tetracycline, doxycycline, bleomycin, talc and fibrin glue can be used as sclerosing agents. Combination of sclerosing agents to percutaneous catheter drainage significantly improves success rate in the treatment of pelvic lymphoceles. Infected lymphoceles are usually treated solely with percutaneous catheter drainage. Percutaneous treatment can be tailored according to volume of lymphoceles. We generally prefer single session sclerotherapy and 1 day catheter drainage in lymphoceles less than 150 mL, and larger ones are treated by multi-session sclerotherapy until daily drainage decreases below 10 mL. Percutaneous treatment preferably with sclerotherapy should be considered as the first-line treatment modality for pelvic lymphoceles due to its effectiveness, widespread applicability on an outpatient basis, ease of procedure and low complication rate.

Introduction

Pelvic lymphocele is a postoperative complication that can result after pelvic lymphadenectomy and renal transplantation. Mechanism of occurrence is thought to be injury to lymphatic system. Lymphoceles can lead to morbidity by causing obstructive or infectious complications and rarely may lead to transplant kidney loss, pulmonary emboli, septicemia and death [1], [2], [3], [4], [5], [6].

Pelvic lymphocele has been first reported by Kobayashi and Inoue [7]. Mori reported the first large series consisting of 68 lymphoceles that developed after gynecologic malignancy by searching Japanese literature [8]. The first series in the English literature was reported by Gray et al. [1] and Rutledge et al. [2]. Ferguson and MacClure performed lymphangiography in patients with pelvic lymphoceles and confirmed contrast filling of lymphoceles via lymphatics [9]. In the late 1960s and early 1970s, lymphocele occurrence had been reported after renal transplantation and urologic malignancy related pelvic lymphadenectomy operations [10], [11], [12].

Section snippets

Etiology

Pelvic lymphocele is a lymph collection with a thick fibrotic wall lacking an epithelial lining. Therefore, lymphocele terminology is preferred to lymphocyst. During pelvic lymphadenectomy procedures peritoneum is sleeved from muscles and intervening lymph nodes and adipose tissue are removed. Lymphoceles usually develop after extensive lymphatic transections. The most common causes of pelvic lymphoceles are pelvic lymphadenectomy performed for staging of urologic or gynecologic malignancies

Clinical background

Lymphocele incidence varies between 0.6 and 26% after renal transplantation [12], [23], [24], [25], 0.7 and 27% after urologic extraperitoneal lymphadenectomies, and 2 and 32% after [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27] gynecologic oncology staging lymphadenectomies [27], [28], [29], [30], [31]. These differences between series result from differences in the surgical technique and extensiveness of lymphadenectomy. After the introduction

Radiologic findings

Ultrasound is the primary modality for the diagnosis of lymphocele. On ultrasound lymphoceles appear as anechoic cystic structures adjacent to vessels in the parailiac region (Fig. 1) and may contain thin septations and debris [6], [27]. Pelvic lymphoceles can be large and can extend to retroperitoneum. Lymphoceles are seen as thin-walled hypodense lesions with negative Hounsfield unit (as low as −18 HU) values on CT images (Fig. 2) usually adjacent to surgical clips in patients who underwent

Treatment modalities

There is no consensus on the optimal treatment for pelvic lymphoceles. Pelvic lymphocele can be treated by surgery or percutaneous techniques. Surgeons are used to treat lymphoceles by open or laparascopic surgery [34], [35], [36], [37], [38], [39], [40], [41], [42]. Open surgery can be in the form of internal marsupialization or external drainage. In the last two decades, interventional radiology has gained importance in the treatment of pelvic lymphoceles [6], [43], [46], [47], [48].

Sclerosing agents

Sclerosing agents are widely used for treatment of lymphoceles currently. The main rationale for the use of these agents is better results compared to simple catheter drainage due to obliteration of the lymphatic leak as a result of chemical effect. Instillation of sclerosing agents though drainage catheters can be used as a primary treatment or for lymphoceles that are not resolving after catheter drainage alone [56], [57].

Preprocedural preparation

Most of the time we perform the procedure on an outpatient basis with routine requirements for an interventional procedure. Patients are routinely monitorized during the procedure. Procedure is performed under conscious sedation in a dedicated interventional suite with on-site anesthesiologists. At least 6 h of starvation is required.

Technique

In our institution, we are using percutaneous drainage with ethanol (96%) sclerotherapy for the treatment of lymphoceles and so far treated over 100 lymphoceles. We

Success and recurrence rates of sclerotherapy

Ethanol and povidone-iodine are the two most commonly used sclerosing agents for the treatment of lymphoceles. Success rates with ethanol vary between 88 and 97% and recurrences are very rare (3–7%) [51], [56], [57], [58], [59]. Povidone-iodine is a readily available agent with success rates ranging from 62 to 89% [60], [61], [62], [63]. Despite lower success rates at initial treatment due to recurrences (11–38%) compared to ethanol, overall success rate increases to 88–100% after treatment of

Overview

Treatment alternatives for lymphoceles include surgical marsupialization by open or laparascopic surgery or percutaneous catheter drainage. Selection of treatment method is currently dependent on institutional preferences. Open surgery and peritoneal marsupialization can be used for the treatment of lymphoceles with good success rates; however, long hospital stay, mortality and morbidity due to surgery precludes use in all patients. Recently, laparascopic surgery is used particularly in the

Conclusion

Open surgery and peritoneal marsupialization had been the gold standard in the treatment of pelvic lymphoceles and recently use of laparascopic surgery appeared as an alternative surgical method patricularly for renal transplant associated lymphoceles. However, with any kind of surgery, patients are exposed to well-known risks of surgery and laparascopic surgery is not suitable for all lymphoceles. Therefore, percutaneous catheter drainage with sclerosing agents should be considered as the

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This study evaluated the effectiveness of sclerotherapy in treating lymphoceles after kidney transplantation, focusing on factors such as recurrence rates and procedural success.
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A descriptive analysis of the outcomes and complication rates associated with sclerotherapy interventions for lymphoceles is provided. A high degree of variation across the different studies was observed. According to the Kruskal–Wallis test, there was no correlation between the sclerosant used and the sclerotherapy complication rate (P = .472) or the success rate (P = .591). There was also no correlation between the gender of the patient and the success rate; however, there was a significant difference in the complication rate by gender (P < .005).
In conclusion, different sclerosant products have been used for therapy with no consensus on the most efficacious product because the success rate has been variable. In addition, the gender of the patient may influence the complication rates associated with sclerotherapy for lymphoceles in patients post–kidney transplant.
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The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.
Intranodal Lymphangiography and Embolization for the Treatment of Early Postoperative Lymphatic Leaks after Pelvic Surgery
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To assess outcome and predictors of outcome after lymphatic embolization (LE) for early postoperative lymphatic leak after pelvic surgery.
Lymphangiography (LG) procedures performed between May 2015 and February 2020 for postoperative intraperitoneal lymphatic leaks after pelvic surgery were reviewed. Treatment indication was lymphatic drainage of >500 mL/d persisting for >1 week. LE was performed by injecting glue into the iliac lymph node. Fisher exact and Wilcoxon rank-sum tests were used for comparative analysis, and logistic regression was used to assess predictors of outcome.
LG was performed in 71 patients. A leak was demonstrated in 69 patients who underwent LE. The mean drainage was 1,329 mL/d ± 773. Catheters were removed in 49 (69.0%) patients after 1 procedure and in 69 (97.2%) patients after a mean of 1.3 procedures. The mean drainage at the time of catheter removal was 157 mL/d ± 100. Failure occurred in 12 (16.9%) cases, including 2 (2.8%) cases of unsuccessful catheter removal and 10 (14.1%) cases of catheter reinsertion owing to recurrent ascites (n = 3) and lymphoceles (n = 7). Older age and drainage of >1,500 mL/d were associated with failure (P = .004). Drainage of >1,500 mL/d was associated with a post-LE catheter dwell time of longer than 1 week (P = .024). Minor adverse events were noted in 4 (5.6%) patients who presented with transient leg swelling.
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Women with gynecologic cancers often experience complications associated with their primary disease process or from the cancer-directed treatment. In addition, many women have medical comorbidities, are obese, or are elderly, all of which may further complicate treatment decisions and therapy. Minimizing these problems requires the clinician to astutely evaluate the patient, be proactive in prevention strategies, and provide early intervention. Complications of disease are, in fact, commonly the primary presenting symptom (chief complaint) of a gynecologic cancer. Common symptoms of gynecologic cancers include vaginal bleeding (cervical and endometrial cancers), urinary tract obstruction or fistulae (cervical cancer), or intestinal obstruction or weight loss (ovarian cancer). Although some complications have been discussed previously in this text, it seems appropriate to devote a chapter exclusively to complications of disease and therapy. Not all possible complications can be covered, and readers are referred to texts that expand on them; however, the more common complications and their management are discussed.
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Lymphoceles result from either trauma to the lymphatic vessels or after vein graft harvest, which occurs in 10% to 16% of patients. When a lymphocele persists despite conservative treatment, patients can experience undue distress. We have reported the case of successful treatment using lymphatic venous anastomosis (LVA) of an intractable lymphocele that had been refractory to conservative treatment, including stretch bandaging, drainage, and local injection for 2 years after great saphenous vein harvest. The lymphocele resolved shortly after the LVA without any adverse effects. LVA can be a useful and minimally invasive alternative treatment of lymphocele after harvesting the great saphenous vein.
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Radiologic imaging and percutaneous treatment of pelvic lymphocele

Abstract

Introduction

Section snippets

Etiology

Clinical background

Radiologic findings

Treatment modalities

Sclerosing agents

Preprocedural preparation

Technique

Success and recurrence rates of sclerotherapy

Overview

Conclusion

Am J Obst Gynecol

Am J Obst Gynecol

Urology

J Urol

Am J Obstet Gynecol

Am J Med

Urology

J Urol

J Urol

Am J Surg

Urology

J Urol

Am J Obstet Gynecol

Urology

J Urol

Surgery

J Urol

Gynecol Oncol

J Urol

Gynecol Oncol

J Pediatr Surg

Eur J Obstet Gynecol Reprod Biol

J Vasc Intervent Radiol

J Vasc Intervent Radiol

J Vasc Intervent Radiol

Urology

J Vasc Intervent Radiol

J Urol

Eur J Obstet Gynecol Reprod Biol

Eur J Radiol

Am J Kidney Dis

J Urol

Postoperative pelvic lymphocysts

AJR

Lymphoceles: Imaging characteristics and percutaneous management

Radiology

Pelvic lymphocyst

Clin Gynecol Obstet

Clinical and experimental studies on so called lymphocyst which develops after radical hysterectomy in cancer of uterine cervix

J Jap Obst Gynec Soc

Renal allograft with massive perirenal accumulation of lymph

Br Med J