Minimally invasive lymphocele drainage using the Da Vinci® single port platform: step-by- step technique

ABSTRACT Background: Reports in the literature describe lymphocele formation in up to half of patients following pelvic lymph node dissection (PLND) (1) in robotic-assisted radical prostatectomy (RARP), with 1-2% requiring intervention (2). The advantage of surgical approach is permanent excision of the lymphocele capsule and fewer days with pelvic drains compared to percutaneous drainage. This study aims to describe the step-by-step surgical management of symptomatic lymphoceles using a less invasive robotic platform, the Da Vinci® Single Port (SP). Material and Methods: We describe the technique of lymphocelectomy and marsupialization with the Da Vinci® SP for symptomatic lymphocele. For this study, several treatment modalities for symptomatic lymphoceles were available, including percutaneous drainage, sclerosing agents, and surgical marsupialization. All the data for this study were obtained through the procedure via Da Vinci® SP. Results: Operative time for the case was 84 minutes. Blood loss was 25ml. No intra- or post- operative complications were reported. The patient had his drain removed in under 24 hours after surgery. The mean follow-up period was 7.7 months. There were no complications or lymphocele recurrence. Conclusion: Da Vinci® SP lymphocelectomy is safe and feasible with satisfactory outcomes. The SP enables definitive treatment of the lymphocele sac (3), reducing the number of days with abdominal drains and allows further decrease in surgical invasiveness with fewer incisions and better cosmesis.

Tratamiento supermicroquirúrgico del linfocele inguinal con linfedema intercurrente: restauración de la fisiología linfática / Supermicrosurgical approach to inguinal lymphocele with lymphedema: restoring the lymphatic physiology

Resumen Introducción: El linfocele es una patología que puede ocurrir por la disrupción linfática durante una cirugía, siendo frecuente luego de una linfadenectomía inguinal. Existen diversos enfrentamientos para prevenirlo o minimizarlo, sin embargo, los resultados son inconsistentes. Caso clínico: Reportamos el caso de una mujer, con linfocele recurrente en zona inguinal derecha y linfedema distal de la extremidad secundario a una biopsia ganglionar, tratado exitosamente mediante supermicrocirugía para restaurar el drenaje linfático. La extremidad inferior tenía un exceso de volumen de 7,03%. Se realizaron estudios preoperatorios con linfografía por resonancia magnética y linfografía con verde de indocianina para identificar los vasos linfáticos y realizar anastomosis linfático-venosas (ALV). Se identificaron tres vasos linfáticos aferentes y se realizó una capsulectomía total. Se realizaron tres ALV término-terminales supermicroquirúrgicas en zona inguinal y una ALV distal en pierna. Durante seguimiento no hubo recidiva del linfocele, evidenciándose una reducción del exceso de volumen de la extremidad afectada de un 105,26%. El linfocele inguinal y linfedema pueden ser tratados exitosamente mediante supermicrocirugía, restaurando el flujo linfático de manera fisiológica, evitando la recurrencia de linfocele y mejorando los síntomas del linfedema.

Introduction: Lymphocele may occur after the disruption of lymphatic channels during a surgical procedure. After inguinal lymphadenectomy are very common, and many different approaches have been tried to prevent or minimize the formation of lymphoceles with inconsistent results. Clinical Case: We report a case of a female patient who presented with right recurrent inguinal lymphocele and lower limb lymphedema after lymph-node biopsy that was successfully treated with lymphatic supermicrosurgery restoring the lymph flow. Lower extremity had an excess volume of 7,03% compared to the healthy contralateral limb. Preoperative study with magnetic resonance lymphangiography and indocyanine green lymphography were done to identify intraoperatively lymphocele afferent and distal lymphatic vessels to perform lymphovenous anastomosis (LVA). Three different afferent lymphatics were identified and total capsulectomy was performed. Three end-to- end supermicrosurgical LVA in the groin and one distal LVA on the leg were performed. The surgery was uneventful, and there were no postoperative complications. In the follow-up, no lymphocele was noticed and lymphedema had visibly reduced with a reduction of excess volume of 105.26%. Inguinal lymphocele and lymphedema can be successfully treated with supermicrosurgery since it is a physiological approach to restore the lymphatic flow, in order to avoid lymphocele recurrence and to improve lymphedema symptoms.

Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device / 부인종양

OBJECTIVE: A number of new techniques have been developed to prevent lymphocele formation after pelvic lymphadenectomy in gynecologic cancers. We assessed whether the electrothermal bipolar vessel sealing device (EBVSD) could decrease the incidence of postoperative lymphocele secondary to pelvic lymphadenectomy. METHODS: A total of 321 patients with gynecologic cancer underwent pelvic lymphadenectomy from 2005 to 2011. Pelvic lymphadenectomy without EBVSD was performed in 134 patients, and pelvic lymphadenectomy with EBVSD was performed in 187 patients. We retrospectively compared the incidence of lymphocele and symptoms between both groups. RESULTS: Four to 8 weeks after operation, 108 cases of lymphocele (34%) were detected by computed tomography scan examination. The incidence of lymphocele after pelvic lymphadenectomy was 56% (75/134) in the tie ligation group, and 18% (33/187) in the EBVSD group. We found a statistically significant difference in the incidence of lymphocele between both groups (p<0.01). To detect the independent risk factor for lymphocele development, we performed multivariate analysis with logistic regression for three variables (device, number of dissected lymph nodes, and operation time). Among these variables, we found a significant difference (p<0.001) for only one device. CONCLUSION: Use of the EBVSD during gynecological cancer operation is useful for preventing the development of lymphocele secondary to pelvic lymphadenectomy.

Laparoscopic treatment of lymphoceles after renal transplantation

OBJECTIVE: Lymphocele formation following renal transplantation is a frequent complication and may affect as many as 49% of patients. Operative treatment of symptomatic post transplant lymphocele (PTL) consists of wide drainage of the fluid collection into the abdominal cavity by excising its wall, connecting the lymphocele cavity to the intraperitoneal space. Laparoscopic fenestration seems to be the best treatment as it combines satisfying success rates with a minimally invasive approach. The aim of the study was to review a single center experience on the laparoscopic treatment of symptomatic PTL and detail relevant aspects of the surgical technique. MATERIALS AND METHODS: The data of 25 patients who underwent laparoscopic surgical treatment for a symptomatic lymphocele following kidney transplantation were retrospectively reviewed. Demographic data and surgical results were assessed. Detailed surgical technique is provided. RESULTS: Between 1996 and 2008, 991 patients received a kidney transplant at our institution. Twenty-five patients (2.52%) developed a symptomatic lymphocele and laparoscopic drainage was performed. The indications for surgical drainage were graft dysfunction (84%), local symptoms (16%) or both (32%). The mean time until surgical therapy was 14.2 ± 6 weeks. Mean hospital stay was 1.5 ± 0.2 days. Postoperative complications occurred in only 2 patients (8%) (one ureteral injury and one incisional hernia) and required reoperation. After a mean follow-up of 36.2 ± 4 months, only 1 patient had a symptomatic recurrence. CONCLUSIONS: Laparoscopic fenestration is an effective surgical technique to treat symptomatic lymphocele following kidney transplantation with low recurrence rate and long standing results.

Uni- vs. multiloculated pelvic lymphoceles: differences in the treatment of symptomatic pelvic lymphoceles after open radical retropubic prostatectomy

PURPOSE: To evaluate the treatment of symptomatic pelvic lymphoceles (SPL) after performing radical retropubic prostatectomy (RRP) and pelvic lymphadenectomy (PLA) simultaneously. MATERIAL AND METHODS:We analyzed, in a retrospective study, 250 patients who underwent RRP with PLA simultaneously. Only patients with SPL were treated using different non- and invasive procedures such as percutaneous aspiration, percutaneous catheter drainage (PCD) with or without sclerotherapy, laparoscopic lymphocelectomy (LL) and open marsupialization (OM). RESULTS: Fifty-two patients (21 percent) had postoperative subclinical pelvic lymphoceles. Thirty patients (12 percent) developed SPL. Fifteen patients with noninfected uniloculated lymphocele (NUL) healed spontaneously after performing PCD. The remaining seven patients required sclerotherapy with additional doxycycline. After performing PCD, NUL healed better and faster than noninfected multiloculated lymphocele (NML) (success rate: 80 percent vs. 16 percent, respectively). Twenty-seven percent of patients treated initially with PCD, with or without sclerotherapy had persistent lymphocele. All patients were successfully treated with LL. Only one patient had an abscess as a major complication of a persistent SPL after PCD and sclerotherapy and was treated via an open laparotomy. CONCLUSIONS: Symptomatic NUL can be treated using PCD with or without sclerotherapy. If this therapy fails as first-line treatment, laparoscopic lymphocelectomy should be considered within a short period of time in order to achieve successful treatment. NML should be treated using a laparoscopic approach in centers where this type of expertise is available. Infected lymphoceles are drained externally. In these cases, percutaneous or open external drainage with adequate antibiotic coverage is preferable.

Lymphocele incidence following renal transplantation our experience in sims/services hospital Lahore

To determine the incidence of lymphocele in patients who under went renal transplantation, as well as potential factors responsible or associated to its development. All records of 25 patients who were operated for renal transplant in SIMS/SHL between March 2006 to December 2007 were reviewed for lymphocele. The surgical technique was the standard one. All lymphatic vessels were either ligated or diathermized. Baseline post operative ultrasound after one week done or whenever indicated for lymphocele. 10% povidone iodine instilated in case of lymphocele. Patients were followed for an average of six months with history, physical examination and ultrasound on each visit. 25 patients [20 male and 5 female] have received renal allograft from live donors. There was 1[4%] instance of lymphocele; encountered at two weeks after renal transplantation. Careful ligation of lymphatic vessels both during graft preparation and during implantation can significantly contribute to reducing incidence of lymphocele following renal transplantation. Instillation of 10% povidone iodine in the lymphpcele can cure and prevent its recurrence

Symptomatic lymphocele after kidney transplantation a single-center experience

In a retrospective study, we evaluated the frequency, clinical presentation, and management of lymphocele in kidney transplant recipients operated on in a single center. Between September 1984 and June 2005, we had 2147 kidney transplantations from living donors. During the follow-up period, ultrasonography was performed in symptomatic patients and those with elevated serum creatinine level postoperatively. Other radiological procedures were done in complicated cases. Patients with lymphocele were treated by percutaneous drainage with or without injection of sclerotizing agent [povidone iodine]. If recurrence occurred, surgical intraperitoneal drainage was performed. In cases with multiloculated collection or inappropriate access for percutaneous drainage, the primary approach was surgical intraperitoneal drainage. Symptomatic lymphocele collection was seen in 17 kidney recipients of our series [0.8%; 95% confidence interval, 0.4% to 1.2%]. It presented with elevation of serum creatinine concentrations [47.1%], pain and abdominopelvic swelling [29.4%], and lower extremity edema [23.5%]. Percutaneous drainage was used for the treatment of lymphocele in 11 patients, but recurrence occurred in 7 [63.6%]. These cases were treated with open surgical drainage. In 6 patients, the primary approach was surgical intraperitoneal drainage, because of multiloculated collection or inappropriate access for percutaneous drainage. All of the patients were treated successfully and no graft loss occurred during the follow-up period. Symptomatic lymphocele is an uncommon complication after kidney transplantation. Surgical intraperitoneal drainage is the most effective approach for the management of symptomatic lymphocele

Assessment of lymphocele incidence following 450 renal transplantations

OBJECTIVE: To determine the incidence of lymphocele in the follow-up of patients who underwent renal transplantation, as well as potential factors responsible or associated to its development. MATERIALS AND METHODS: All records from patients who were treated for lymphocele in our institution between May 1989 and December 2002 were reviewed, as well as their clinical outcome following treatment. RESULTS: Among 450 patients who underwent renal transplantation in the period, only 3 required treatment, with 2 of them treated due to the collection volume, and the other due to symptoms (pain), representing an incidence of only 0.6 percent. COMMENTS: The occurrence of perirenal fluid collections following renal transplantation is frequent. In cases where treatment is required, this can generate an excessive morbidity for the patient, which motivates the development of preventive methods, such as minimally invasive therapy, for such cases. CONCLUSION: Careful ligation of lymphatic vessels both during graft preparation and during its implantation, added to post-operative drainage can significantly contribute to reducing the incidence of lymphocele following renal transplantation.

Linfadenectomía axilar en cáncer de mama: técnica y resultados / Axillary lymph node dissection for breast cancer: surgical technique and results

Objetivo: Se presenta la experiencia con la técnica de la linfadenectomía axilar para el tratamiento del cáncer de mama. Lugar de aplicación: Servicio de Patología Mamaria del Hospital Británico de Buenos Aires. Población: Se seleccionaron las historias clínicas de 1086 pacientes tratadas en forma consecutiva por céncer de mama en estadios operables, durante los últimos diez años. Métodos: Se describe la técnica quirúrgica empleada para la linfadenectomía axilar completa. Resultados: El promedio de ganglios extirpados fue de 17,7 y no hubo diferencias estadísticamente significativas en la cantidad de ganglios obtenidos según las diferentes operaciones efectuadas (mastectomías radicales, radicales modificadas o cirugía conservadora). Las complicaciones observadas fueron: Linfocele axilar; 52 por ciento; linfedema braquial leve ; 6,3 por ciento; flebitis cordonal del miembro superior; 4 por ciento; escápula alada; 0,6 por ciento. No se observaron recidivas axilares. Conclusiones: Preconizamos la linfadenectomía de los 3 niveles de axila en las pacientes con carcinomas invasores de mama, dado que esto permite una correcta estadificación, no requiere irradiación posterior de la axila, disminuyendo el edema braquial, evita la recidiva axilar y, no aumenta el tiempo ni la morbilidad operatoria

Sobrevida libre de enfermedad en cáncer de próstata operado (T2p o menores) / Disease free survival in prostatic operated neoplasm (T2p or minor)

Este estudio incluye una serie consecutiva de 43 enfermos con un cáncer prostático localizado, que fueron sometidos a prostatectomía radical retropúbica con tumores en estadios T1p y T2p. El objetivo fue determinar la sobrevida libre de enfermedad posterior a la cirugía radical. La edad promedio fue de 63,8 años. Hubo 8 pacientes con bordes quirúrgicos positivos (18 por ciento). El análisis estadístico mostró que existen diferencias estadísticamente significativas en la sobrevida libra de enfermedad entre los enfermos con bordes quirúrgicos positivos y los sin compromiso quirúrgico del borde. La sobrevida actuarial global libre de enfermedad muestra que al año existe una posibilidad de sobrevida libre de enfermedad de] 90 por ciento, ésta es del 85 por ciento a los 2 años, la que se mantiene hasta los 56 meses (4 años 8 meses) para obtener una sobrevida final libre de enfermedad del 71 por ciento a los 5 años. La serie tiene la particularidad de describir los estadios precoces patológicos, ya que la sobrevida libre de enfermedad en los estadios precoces clínicos (T1c-T2c) tiene gran variabilidad en los resultados, ya que la etapificación clínica presenta hasta un 30 por ciento de subetapificación, lo que impide una adecuada comparación entre las distintas series. En síntesis, creemos que la alternativa quirúrgica es la mejor terapia para los pacientes con cáncer de próstata clínicamente localizado, con una baja morbilidad, buenos resultados funcionales y con buena sobrevida libre de enfermedad

Linfocele pós-transplante renal: tratamento videolaparoscópico: relato de cinco casos e revisäo de literatura / Lymphocele post renal transplantation: videolaparoscopic treatment: report of five cases and review of the literature

Cinco pacientes submetidos a transplante renal evoluíram com linfoceles sintomáticas, quatro com hidronefrose e reduçäo da funçäo renal e um com dor e compressäo inguinal-escrotal. Foram tratados pela técnica de marsupializaçäo intraperitoneal videolaparoscópica. O tempo médio de cirurgia foi de 96 minutos (variou de45 a 210 min.) e o sangramento foi desprezível. Ocorreu em um paciente a secçäo acidental do ureter do rim transplantado, que foi tratada por cirurgia aberta, com bom resultado. Houve recidiva da linfocele em outro paciente, que foi drenada externamente com sucesso. Os pacientes receberam alta em média depois de 2,7 dias e foram acompanhados por um tempo médio de 11,4 meses, ficando todos curados

Linfocele como complicación del trasplante renal / Lymphocoele as complication of the renal transplantation

Se presenta una revisión retrospectiva de la incidencia y el manejo del linfocele en 293 trasplantes renales realizados en pacientes con insuficiencia renal crónica en el Hospital del Salvador, desde 1975 hasta junio de 1996. Se produjo linfocele como complicación postoperatoria en 9 pacientes (3.1 por ciento), siendo sospechado el diagnóstico por el cuadro clínico y confirmado por estudio de ultrasonido. El tratamiento par esta complicación fue: punción dirigida por ecografía en 3 casos, drenaje a cielo abierto en 2 y marsupialización laparoscópica en 4. Con las dos modalidades quirúrgicas tuvimos recurrencia que requirió reintervención, resolviéndose el problema en segunda instancia. No tuvimos complicaciones ni mortalidad derivadas de los procedimientos efectuados. Tenemos 8 (96 por ciento) pacientes con su injerto funcionante

Post-mastectomy seroma: a look into etiology and prevention

Accumulation of serous fluid in the axillary fossa and under the mastectomy flaps, still remains a common and annoying problem [17% - 63%] after modified radical mastectomy for cancer breast patients. In our study we tried to understand the causes and methods which can reduce or prevent the occurrence of seroma after modified radical mastectomy. One hundred patients with stage II cancer breast randomized into five matched groups were included in this study.The occurrence of seroma was high with the advance of the age, with hypertension, diabetes, obesity and when radial skin incision was used. Shoulder immobilization either alone or with tranexamic acid administration pre and postoperative gave the least incidence of seroma formation [10% and zero respectively] in spite of highest reversible shoulder stiffness [15% and 10% respectively]. Closure of the axillary fossa and fixation of the skin flaps to underlying muscles also, gave good result [15%] but still inferior to shoulder immobilization.The result of use of tranexamic acid alone [20%] and the use of suction drain and compression over skin flaps" traditionally used method "still have a high incidence of postmastectomy seroma [30%]. Post mastectomy seroma rarely causes a serious problem, but can lead to more morbid sequelae as delayed wound healing "thereby delaying further therapy for carcinoma if required ", wound flap necrosis, infection and lymphedema

Linfocele pós-transplante renal: análise de 24 casos e revisäo da literatura / Lymphoceles after renal transplantation: retrospective study of 24 cases and literature review

Linfoceles säo coleçöes de linfa localizadas em cavidades epitelizadas. Possivelmente resultam da secçäo de ductos linfáticos durante a cirurgia, os quais säo inadequadamente ligados ou coagulados. As linfoceles säo incomuns após o tranplante renal, com incidência relatada de 0,6 a 18 por cento dos casos. Os autores apresentam um estudo retrospectivo de 24 casos de linfocele tratados nos últimos 18 anos, revisando etiopatogenia, diagnóstico e tratamento. Concluem que linfoceles sintomáticas, ocorrendo após transplante renal säo melhor manejadas com marsupializaçäo cirúrgica e drenagem para a cavidade peritoneal. A maioria dos pacientes säo assintomáticos e as linfoceles säo achados ocasionais de ultrasonografia rotineira do enxerto renal e, consequentemente näo requerem intervençäo terapêutica

Morbilidad en prostatectomía radical retropúbica / Morbidity in radical retropubic prostatectomy

La incidencia del cáncer de próstata ha aumentado en Chile, determinado en parte por el crecimiento de la población, por su envejecimiento y por una mayor detección desde la introducción del Antígeno Prostático Específico. El objetivo de este trabajo es describir nuestra experiencia en prostatectomía radical retropúbica, analizar sus resultados inmediatos y morbilidad. Se realizó un estudio retrospectivo de 147 pacientes sometidos a prostatectomía radical retropúbica en un período de 9 años (1985-1994). La edad promedio fue de 65.8 años (50-77). Se registraron 19 pacientes con tumores en estadio A2 (13 por ciento), 24 pacientes en estadio B (16 por ciento), 61 pacientes en estadio C (41 por ciento) y 43 pacientes en estadio D1 (29 por ciento). Los bordes quirúrgicos fueron positivos en el 20 por ciento de la serie. Fue necesario transfundir a el 49 por ciento de los pacientes. Hubo una buena continencia inmediata 78 por ciento (continencia total más incontinencia leve), en la evaluación de la continencia tardía esta mejora a un 90 por ciento con buena continencia. Se registró una morbilidad para la serie del 18.3 por ciento, las que en general fueron menores y de manejo médico. Se reoperó a 7 enfermos (4.7 por ciento). No se registró mortalidad operatoria en la serie. En la morbilidad tardía se han detectado 6 estenosis de la anastomosis, 3 de ellas tumorales y 1 linfocele infectado. Los datos presentados permiten concluir que la Prostatectomía Radical Retropúbica tiene una morbilidad aceptable, que va disminuyendo conforme aumenta la experiencia del equipo quirúrgico

Complicaciones quirúrgicas del transplante renal / Surgical complications of renal transplant

Se presentan las complicaciones quirúrgicas de 172 transplantes renales efectuados por el equipo quirúrgico del Servicio de Urología del Hospital G. Fricke de Viña del Mar, la mayor parte en el propio Servicio. Encontramos 32 complicaciones (18 por ciento) en total. En 9 casos se perdió el injerto (5,2 por ciento), presentando 3 óbitos atribuibles a la cirugía (1.74 por ciento). 2 pacientes mueren a raíz de un linfocele infectado y uno por sepsis urinaria tardía. Se analizan las causas y oportunidades en que se presentaron las complicaciones, comprobando que la mayoría aparecen en los primeros casos de cirugía del transplante