Curr Urol Rep (2014) 15:445 DOI 10.1007/s11934-014-0445-y
UROSURGERY (A STENZL, SECTION EDITOR)
How to Minimize Lymphoceles and Treat Clinically Symptomatic Lymphoceles After Radical Prostatectomy Hak J. Lee & Christopher J. Kane
Published online: 17 August 2014 # Springer Science+Business Media New York 2014
Abstract The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.
Keywords Lymphocele . Prostate cancer . Robotic prostatectomy . Robotic surgery . Drainage . Marsupialization . Lymph node dissection . Infected lymphocele . Fluid collection
This article is part of the Topical Collection on Urosurgery H. J. Lee : C. J. Kane (*) Department of Urology, UC San Diego Health Systems, 200 West Arbor Drive, # 8897, San Diego, CA 92103, USA e-mail: [email protected] H. J. Lee e-mail: [email protected]
Introduction When performing major pelvic surgery such as a radial prostatectomy with PLND, there are inherent risks involved with the operation, such as vascular, nerve, or ureteral injuries and secondary postoperative complications such as a lymphocele, deep-vein thrombosis (DVT), or pulmonary embolism (PE). In all radical prostatectomies the PLND adds to the complexity of the case and can increase the overall risk of the operation. Specifically, the overall incidence rate of perioperative complications after robotic prostatectomy and PLND is reported to be approximately 4–35 % [1–3]. Out of the total number of perioperative complications, Ploussard et al. predicted that potentially 3–8 % are directly attributed to the PLND, and found that lymphoceles were the most common. Fortunately, the majority of lymphoceles that formed postoperatively were asymptomatic and resolved spontaneously [3–5]. However, the lymphoceles that do become symptomatic can lead to significant complications, such as abdominal and leg pain, lower limb edema, constipation, urinary frequency, infection or sepsis, DVT, and PE [6, 7]. Prevention of complications that increase the need for additional hospitalization and treatments is critical [8, 9]. Therefore, in this review, we will examine the potential risk factors that can potentially affect the formation of a lymphocele after PLND in robotic prostatectomy, such as the extent of lymph node dissection, the surgical approach, use of hemostatic agents, pre-operative anticoagulation, and the use of pelvic drains. Furthermore, we will discuss the different management options available for the treatment of lymphoceles, as well as our institutional experience concerning the management of clinically symptomatic lymphoceles.
445, Page 2 of 11
Curr Urol Rep (2014) 15:445
Epidemiology
The incidence of lymphocele formation can be directly attributed to the addition of PLND dissection during prostatectomy. In an RARP study by Liss et al., there were no lymphocele formations in the group where PLND was not performed, but 5.5 % and 3 % of patients in the standard PLND and EPLND groups formed clinically symptomatic lymphoceles, respectively [19]. Interestingly, an open prostate study by Khoder et al. demonstrated 14 % lymphocele formation even in the group without any PLND [18]. The difference in lymphocele formation in these two studies may be attributed to the differences in surgical modality, perioperative management, and patient selection. In another study reporting the overall RARP complication rates by Liss et al., the clinically significant lymphocele rate was reported at 0.4 % (4/1,000) [4]. However, the patient characteristics in this cohort demonstrated an overall low to intermediate prostate cancer risk stratification, where more patients were not likely to have PLND. In addition, another limitation is the possibility of underreporting from loss to follow-up, as the cases were from a tertiary referral center. Similarly, lymphocele rates can also be influenced by the method of reporting complications [20]. In a comparison of techniques, Kowalczyk et al. compared lymphocele rates in open, retropubic radical prostatectomy with those in minimally invasive radical prostatectomy (2.2 % vs 1.3 %, p
UROSURGERY (A STENZL, SECTION EDITOR)
How to Minimize Lymphoceles and Treat Clinically Symptomatic Lymphoceles After Radical Prostatectomy Hak J. Lee & Christopher J. Kane
Published online: 17 August 2014 # Springer Science+Business Media New York 2014
Abstract The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.
Keywords Lymphocele . Prostate cancer . Robotic prostatectomy . Robotic surgery . Drainage . Marsupialization . Lymph node dissection . Infected lymphocele . Fluid collection
This article is part of the Topical Collection on Urosurgery H. J. Lee : C. J. Kane (*) Department of Urology, UC San Diego Health Systems, 200 West Arbor Drive, # 8897, San Diego, CA 92103, USA e-mail: [email protected] H. J. Lee e-mail: [email protected]
Introduction When performing major pelvic surgery such as a radial prostatectomy with PLND, there are inherent risks involved with the operation, such as vascular, nerve, or ureteral injuries and secondary postoperative complications such as a lymphocele, deep-vein thrombosis (DVT), or pulmonary embolism (PE). In all radical prostatectomies the PLND adds to the complexity of the case and can increase the overall risk of the operation. Specifically, the overall incidence rate of perioperative complications after robotic prostatectomy and PLND is reported to be approximately 4–35 % [1–3]. Out of the total number of perioperative complications, Ploussard et al. predicted that potentially 3–8 % are directly attributed to the PLND, and found that lymphoceles were the most common. Fortunately, the majority of lymphoceles that formed postoperatively were asymptomatic and resolved spontaneously [3–5]. However, the lymphoceles that do become symptomatic can lead to significant complications, such as abdominal and leg pain, lower limb edema, constipation, urinary frequency, infection or sepsis, DVT, and PE [6, 7]. Prevention of complications that increase the need for additional hospitalization and treatments is critical [8, 9]. Therefore, in this review, we will examine the potential risk factors that can potentially affect the formation of a lymphocele after PLND in robotic prostatectomy, such as the extent of lymph node dissection, the surgical approach, use of hemostatic agents, pre-operative anticoagulation, and the use of pelvic drains. Furthermore, we will discuss the different management options available for the treatment of lymphoceles, as well as our institutional experience concerning the management of clinically symptomatic lymphoceles.
445, Page 2 of 11
Curr Urol Rep (2014) 15:445
Epidemiology
The incidence of lymphocele formation can be directly attributed to the addition of PLND dissection during prostatectomy. In an RARP study by Liss et al., there were no lymphocele formations in the group where PLND was not performed, but 5.5 % and 3 % of patients in the standard PLND and EPLND groups formed clinically symptomatic lymphoceles, respectively [19]. Interestingly, an open prostate study by Khoder et al. demonstrated 14 % lymphocele formation even in the group without any PLND [18]. The difference in lymphocele formation in these two studies may be attributed to the differences in surgical modality, perioperative management, and patient selection. In another study reporting the overall RARP complication rates by Liss et al., the clinically significant lymphocele rate was reported at 0.4 % (4/1,000) [4]. However, the patient characteristics in this cohort demonstrated an overall low to intermediate prostate cancer risk stratification, where more patients were not likely to have PLND. In addition, another limitation is the possibility of underreporting from loss to follow-up, as the cases were from a tertiary referral center. Similarly, lymphocele rates can also be influenced by the method of reporting complications [20]. In a comparison of techniques, Kowalczyk et al. compared lymphocele rates in open, retropubic radical prostatectomy with those in minimally invasive radical prostatectomy (2.2 % vs 1.3 %, p
