Lymphoceles after pelvic surgery are essentially trapped collections of lymphatic fluid in the extraperitoneal space, often involving the bladder wall, and can cause symptoms including pain, irritation to adjacent organs, or infection–or remain asymptomatic. Although any pelvic surgery can potentially have a lymphocele complication and its own narrative of incidence and sequelae, the prostatectomy model is likely the best example to illustrate the concepts of how to prevent them and how to treat them.

 

 

Figure. A, right side peritoneal advancement starts at peritoneal edge near bladder with aim to rotate this peritoneum towards PLND fossa to right. B, after anchoring stitch to peritoneum, advancing second bit is to bladder wall itself, close to pedicles. C, third bit of suture returns to peritoneal edge and is anchored with clips. Peritoneum (blue arrow) will finish rotated laterally to PLND fossa. Photos courtesy of Dan Eun.

The best strategy for prevention will be to select appropriate patients to skip the pelvic lymph node dissection (PLND) after radical prostatectomy. Selection can be accomplished with any number of nomograms and generally a 3%–7% threshold of positivity.¹ Personally, I use the 2018 Briganti nomogram if a fusion biopsy was performed (https://www.evidencio.com/models/show/1555) and for systematic-only biopsies use the Memorial Sloan Kettering Cancer Center nomogram. Patients selected for PLND should understand that a therapeutic benefit remains unclear,² but the additional staging information may be valued for future treatment decisions. The trade-offs include additional operative time and an increased risk of lymphocele.²

For patients undergoing a PLND (and it should be an extended template if you are going to do one at all³), the selection of references in this article can create a straightforward management. The first common decision point will be how to secure the lymphatics. For radical cystectomy, my mentors generally used Bovie through the tissue without clips or ligatures–but less risk of a collection with no bladder trap a fluid pocket. For a radical prostatectomy, I have not been able to detect much of a difference between clips and energy when performing a straightforward transperitoneal robotic technique–and I’ve tried clipping every lymphatic encountered. The trial by Grande et al randomized between clips and bipolar coagulation at the main point of entry from the leg and found no difference.⁴ Therefore, in the interest of time I have migrated to the faster bipolar technique, and more recently the synchrocele device on the Intuitive da Vinci^® Xi device. Several authors have then addressed the question about access, and it would make sense that an extraperitoneal approach would have more lymphoceles. However, with a high-volume approach, one center was able to show equivalence to transperitoneal.⁴ Another high-volume center preferring extraperitoneal approach showed significant benefit for fenestrating the peritoneum after PLND.⁵ If you have thought about or tried reconstituting the peritoneum at the end of a case (a Retzius reconstruction, or to keep bowel out of the area), at least one group studied that effect and showed more lymphoceles.⁶

Can we do more for prevention? One of the simplest concepts has been the use of pelvic drains, and there are additional reasons for placing them including monitoring for bleeding or urinary leaks. However, at this point, there is convincing evidence that drains are not routinely required after prostatectomy–even with PLND. The systematic review by Zhong et al finalized a search with 6 articles with extended PLND and there was not a significant benefit in preventing symptomatic lymphoceles or other complications.⁷ Another systematic review by Motterle et al focused on prevention strategies and found 12 relevant studies.⁸ Their search found consistently insignificant results from various sealing techniques and agents. The other category of prevention is called “peritoneal reconfiguration” with the idea of keeping the peritoneum in contact with fluid rather than the bladder wall. There are 3 nonrandomized studies with various versions of the concept and showing significant results, and 1 randomized trial estimated to complete in late 2021. The concept is illustrated in the figure.⁹

What about treatment? In the early part of my career when open surgery was still more common than minimally invasive, a lymphocele after open surgery would be managed by percutaneous drainage and possibly sclerosis with betadine or doxycycline. These were extraperitoneal cases and the assumption was that not enough clips were placed during the PLND. If drainage and sclerotherapy did not work, another option was to perform a laparoscopic transperitoneal surgery and create windows through the peritoneum into the lymphocele. The concept is simple but the execution was often more difficult than it sounded, and it helped to utilize the drain to fill the cavity with fluid to identify it in a scarred field. In the era of the transperitoneal minimally invasive approach, we hoped that the approach alone would solve the issue. It did not, but my personal observation has been that drained lymphoceles after a transperitoneal approach generally do not need much further treatment, such as sclerotherapy. So far, I have never had to do a peritoneal window after a transperitoneal PLND. That said, urologists should be aware of the basic algorithms available that differentiate small vs large lymphoceles (>100 mL) and asymptomatic vs symptomatic presentations.¹⁰ Most likely, drainage alone will suffice, or a followup treatment with common sclerotherapy agents.¹¹ If you find yourself in an unusually persistent drainage situation and want to avoid surgery, a more novel approach is lymphatic embolization. I have seen this work at our center for a handful of cases of chylous ascites after retroperitoneal lymph node dissection, and there are case reports on using it for post-prostatectomy.¹² Finally, infected lymphoceles need more urgent drainage and appropriate antibiotics and consultation with your local hospital antibiogram. Hamada et al reviewed a single-center series and found that of all symptomatic lymphoceles, 42% were infected–mostly by gram-positive cocci.¹³