Prevention of Lymphoceles Following Renal Transplantation RICHARD J. HOWARD, M.D., RICHARD L. SIMMONS, M.D., JOHN S. NAJARIAN, M.D.
From the Department of Surgery, University of Minnesota, Minneapolis, Minnesota
Lymphoceles occur following 1.2 to 18.1% of renal transplants. Of 543 kidney transplants performed at the University of Minnesota, lymphoceles occurred in three (an incidence of 0.6%). These three patients are described. We believe lymphoceles can be prevented by ligation of all lymphatic channels around the iliac artery and vein as these structures are dissected. Also the lymphatics of the donor kidney should be ligated before division. Lymphoceles are best treated by drainage into the peritoneal cavity after excision of as much of the cyst wall as possible.
three patients who developed lymphoceles after receiving renal allografts.
L YMPHOCELES have been reported to occur after 1.2 to
Case Reports
18. 1% of renal transplants (Table 1). 12,6,7,l10l6,l8 They may lead to deterioration of renal function2'8'13'16'18 and the patient with a lymphocele may be inappropriately treated for allograft rejection. Other clinical findings associated with lymphoceles in renal allograft recipients include lower abdominal swelling or mass,2 5'7'8'10'13'15'18 edema over the allograft or of the ipsilateral leg,1 2'5'15'18 hypertension,2 8 drainage from the incision,2'5'7 enlarged allograft,2 fever without an obvious source of infections,2'7'8 urinary frequency,2 ipsilateral ileofemoral thrombophlebitis,2 and weight gain.16'18 While many small lymphoceles undoubtedly go undetected, treatment of large lymphoceles in transplant recipients is important because ofpossible compromise of allograft function due to compression of the graft ureter and blood vessels, and danger of infection. We have seen three lymphoceles in 543 consecutive renal transplants. We believe lymphoceles can be prevented by ligation of all donor renal and recipient lymphatics before they are divided. We describe here the Submitted for publication November 17, 1975. This work was supported by Grant #AM 13083 from the United States Public Health Service. Reprint requests: Dr. Simmons, Department of Surgery, Box # 185, Mayo Memorial Bldg., University of Minnesota Hospitals, Minneapolis, MN 55455.
Between August 1, 1967, and July 1, 1975, 543 kidney transplants were performed in 501 patients at the University of Minnesota Health Sciences Center. Four hundred fifty-nine were first transplants. Three lymphoceles developed, an incidence of 0.6%. All occurred in patients receiving their first transplant. Case 1. A 53-year-old woman had renal failure because of polycystic kidney disease. She received a cadaveric kidney transplant January 25, 1972. Standard immunosuppression and antilymphocyte globulin (ALG) were given.1" She left the hospital 13 days after transplantation. The BUN and creatinine continued to decrease after discharge to 33 mg/100 ml and 1.5 mg/100 ml respectively. Treatment was begun February 25, 1972, with methylprednisolone and prednisone for rejection. She was again treated for rejection July 3, 1972. Rejection was confirmed by kidney biopsy. On August 16, 1972, she entered the hospital because of urinary frequency and stress incontinence. Cystoscopy was performed and the bladder was seen to be distorted by a mass. The BUN was 81 mg/100 ml and the creatinine was 2.3 mg/100 ml. A few days later a lower abdominal mass could be palpated. On September 14, 1972, the lymphocele was drained and part of the cyst wall was excised. The contents of the lymphocele were sterile. The BUN decreased to 63 mg/100 ml and the creatinine fell to 2.0 mg/100 ml. Comment: Although biopsy showed rejection, some of the renal malfunction may have been due to the lymphocele. In fact, the creatinine did decrease from 2.3 mg/100 ml to 2.0 mg/100 ml. Case 2: Polycystic kidney disease led to renal failure in a 42-year-old woman. On February 7, 1972, she received a kidney allograft from her sister. Standard immunosuppression and ALG were used posttransplant."1 She was discharged 15 days after transplantation when the BUN was 24 mg/100 ml and the creatinine was 1.1 mg/100 ml. She entered the hospital again on February 28, 1972, because the BUN had increased to 83 mg/100 ml and the creatinine had risen to 3.2 mg/100
166
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ml. Kidney biopsy showed changes compatible with acute tubular necrosis but no signs of rejection were seen. On April 3, 1972, she was admitted for weight gain. An open kidney biopsy was performed and an unsuspected lymphocele was encountered. Drainage catheters were left in for 6 days and then removed. Contents of the lymphocele were sterile. The kidney biopsy revealed rejection. The BUN was 102 mg/100 ml and the creatinine was 5.8 mg/100 ml. She was treated for rejection and the BUN decreased to 57 mg/100 ml and the creatinine fell to 3.2 mg/100 ml. A midline mass became apparent May 5, 1972. Because of a persistent urinary tract infection and autogenous right ureteral reflux, she underwent resection of her own right ureter on May 17. Two lymphoceles were incised and part of the cyst wall was resected. The BUN again increased to 76 mg/100 ml and the creatinine rose to 5.4 mg/100 ml. Despite antirejection therapy the BUN and creatinine remained elevated, and hemodialysis was required. On August 31, 1972, she received a second kidney transplant from her son. She has maintained normal renal function. Case 3: A 35-year-old woman received a renal allograft on July 20, 1972, because of renal failure due to diabetes mellitus. She was discharged 14 days after transplantation. The blood urea nitrogen (BUN) was 19 mg/100 ml and the creatinine was 1.0 mg/100 ml. She remained well until March, 1974, when she entered the hospital with a fever of 39.60. An intravenous pyelogram and barium enema demonstrated a right pelvis mass compressing the ureter and bladder and elevated the cecum. On needle aspiration of the mass 1400 ml straw-colored fluid was withdrawn. Gastrografin was instilled into the cavity and an x-ray showed the large cyst. On March 21, 1974, open drainage was carried out and penrose drains were left in place. The fluid removed from the cavity was sterile. The drains were removed after four days and the patient was discharged. A right lower quadrant mass was again detected in July, 1974. Seventeen hundred ml of dark fluid was drained from the cyst. The fluid was sterile. On July 22, 1974, catheters were placed into the cyst for drainage and triamcinolone hexacetamide was injected daily for three days. Drainage stopped after three days and the catheters were removed. The cyst recurred again and on August 6, 1974, it was incised and part of the cyst wall was removed. Culture of the cyst fluid revealed coagulase negative Staphylococcus. The lymphocele recurred once more. On September 19, 1974, more of the cyst wall was removed and the cyst was marsupialized into the peritoneal cavity. It did not recur again. On June 22, 1975, the BUN was 21 mg/100 ml and the creatinine was 1.3 mg/100 ml. Comment: This lymphocele recurred despite incision and drainage and removal of the cyst wall. Marsupialization into the peritoneal cavity pennitted reabsorption of the cavity fluid by the peritoneum and the lymphocele did not recur again.
Discussion
Lymphoceles are complications of the transplant operation that we believe can be avoided. The lymphoceles led to compromise of allograft function in two of the three patients and to an otherwise unneeded operation in all three. Decreased graft function due to a lymphocele has also been reported by others.1'2'5'10'13'16 While lymphoceles are known to occur following pelvic lymphadenectomy in radical pelvic surgery,3 4'14 they have been reported infrequently in association with renal transplantation.1'2,6,7,10,16-18 Lymphoceles are most likely due to leakage of lymph from recipient lymphatic channels. Madura et al. 9 Koehler and Kyaw,8 and Braun et al.2 have demonstrated by lymphangiography that host lymphatics communicated with the lymphocele. Some
TABLE 1. Incidence ofLymphoceles Following Renal Transplantation Author
Boglin et al.1 Braun et al.2 Kiser et al.6 Meyers et al.10 Schweizer et al.16 Starzl et al.17 Zincke et al.18 University of Minnesota
No. Lymphoceles
No. Patients
%
6 15 3 7 6 3 6 3
42 83 250 176 280 216 215 543
14.3 18.1
1.2 4.0 2.1 1.4 2.6 0.6
lymphoceles may well be due to divided lymphatics from the donor kidney.13'18 Pederson and Morris12 showed that lymphatic flow increases 19 times in sheep kidneys undergoing rejection compared to autografted kidneys. Diuretics and ureteral absorption are known to increase the flow of lymph in the kidney and may also contribute to the formation of a lymphocele. Rejection was confirmed by biopsy in two of our three patients with lymphoceles around the time the lymphoceles became evident. Radiation16 and hematomas13 have also been thought to play a role in the formation of lymphoceles. We believe ligation of all lymphatic channels around the recipient iliac vessels and on the donor kidney will prevent lymphoceles. Iliac lymph nodes are usually found in close proximity to the iliac artery and vein. In the absence of pathology, these nodes are small and are frequently not identified. However, usually large lymphatic channels can be identified passing over the iliac vein. When the abdominal wall muscles are divided and the peritoneum is reflected superiorly and to the left (for allografts placed in the right iliac fossa), the iliac vein and artery come into veiw. To clean the vein, ligatures are passed under the lymphatic channels and investing fascia with a right angle clamp. The ligatures are tied and the lymphatic channels and investing fascia are divided exposing the vein. Generally only two or three sets of ligatures are required to completely expose the iliac vessels. The lymphatic vessels of the donor kidney pass around the renal artery to lumbar lymph nodes. After the renal artery and vein have been identified the lymphatics around the renal artery are ligated and divided. These ligatures also encompass nerve fibers in proximity to the artery. It is important to keep these ligatures as far from the hilus of the kidney as possible in order not to ligate early branches of the renal artery. Care must also be taken to avoid catching the adventitia of the artery, because it may lead to torsion of the artery after it is placed in the recipient with compromise of flow. Generally, two or three ligatures are required for the renal lymphatics. Braun et al.2 reported a single surgical drainage can resolve a lymphocele in 75% of patients and remain free of infection in 80%. Others5'6'8'13'16'17 have also used incision and drainage. Drainage was tried initially in all three of our
168
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patients but was effective in only one. Furthermore, there is a danger of peri-renal infection associated with open drainage especially in diabetic patients that may lead to loss of life or loss of the kidney.5'8 Multiple aspirations of lymphoceles have been tried, but this technique has led to recurrence and infection.1018 We now favor marsupialization of the lymphocele into the peritoneal cavity with resection of as much of the cyst wall as possible, as advocated by Byron et al.3 Marsupialization maintains constant drainage into the peritoneal cavity should the lymphatic leak persist. It also eliminates an opening to the outside thus greatly reducing the likelihood of infection. Removing the wall of the lymphocele prevents it from reforming and ensures adequate drainage into the peritoneal cavity.
References 1. Boglin, A., Leroux-Robert, C., Redrossian, J., et al.: Compression Ureterale par un Lymphocele apres Transplantation Renal. A propos de deux cas. Nouv. Presse Medi., 1:1211, 1972. 2. Braun, W. E., Banowsky, L. H., Straffon, R. A., et al.: Lymphoceles Associated with Renal Transplantation. Report of 15 Cases and Review of the Literatures. Am. J. Med., 57:714, 1974. 3. Byron, R. L., Jr., Yonemoto, R. H., Dauajan, V., et al.: Lymphocysts: Surgical Correction and Prevention. Am. J. Obstet. Gynecol., 94:203, 1966. 4. Ferguson, J. H. and MaClure, J. G.: Lymphocele Following Lymphadenectomy. Am. J. Obstet. Gynecol., 82:783, 1961. 5. Inocencio, N. F., Pierce, J. M., Jr., Rosenberg, J. C., et al.: Renal
Ann. Surg.
*
August 1976
Allograft with Massive Perirenal Accumulation of Lymph. Br. Med. J., 3:452, 1969. 6. Kiser, W. S., Hewitt, C. B. and Montie, J. E.: The Surgical Complications of Renal Transplantation. Surg. Clin. North Am., 51:1133, 1971. 7. Koehler, P. R.: Injuries and Complications of the Lymphatic System Following Renal Transplantation. Lymphology, 5:61, 1972. 8. Koehler, P. R. and Kyaw, M. M.: Lymphatic Complications
Following Renal Transplantation. Radiology, 102:539, 1972. 9. Madura, J. A., Dunbar, J. D. and Cerilli, G. J.: Perirenal Lymphocele as a Complication of Renal Homotransplantation. Surgery, 68:310, 1970. 10. Meyers, A., Salant, D., Rabkin, R., et al.: Lymphoceles in Renal Homograft Recipients. Kidney Internat., 8:129, 1975. 11. Najarian, J. S. and Simmons, R. L.: Transplantation. Lea and Febiger, Philadelphia, 1972; p. 460. 12. Pederson, N. C. and Morris, B.: The Rule of the Lymphatic System in the Rejection of Homografts: A Study of Lymph From Renal Transplants. J. Exp. Med., 131:936, 1970. 13. Rashid, A., Posen, G., Couture, R., et al.: Accumulation of Lymph Around the Transplanted Kidney (Lymphocele) Mimmicking Renal Allograft Rejection. J. Urol., 111:145, 1974. 14. Rutledge, F., Dodd, G. D., Jr., and Kasilag, F. B., Jr.: Lymphocysts: A Complication of Radical Pelvic Surgery. Am. J. Obstet. Gynecol., 77:1165, 1959. 15. Schmidt, P., Zazgoynik, J., Piza, F., et al.: Diagnostic and Therapie eines alles mit Lymphozele nach Nierentransplantation. Schweiz. Med. Wschr., 103:1887, 1973. 16. Schweizer, R. T., Cho, S., Kountz, S. L. and Belzer, F. O.: Lymphoceles Following Renal Transplantation. Arch. Surg., 104:42, 1972. 17. Starzl, T. E., Growth, C. G., Putman, C. W., et al.: Urological Complications in 216 Human Recipients of Renal Transplants. Ann. Surg., 172:1, 1970. 18. Zincke, H., Woods, J. E., Aquilo, J. J., et al.: Experience with Lymphoceles After Renal Transplantation. Surgery, 77:444, 1975.
From the Department of Surgery, University of Minnesota, Minneapolis, Minnesota
Lymphoceles occur following 1.2 to 18.1% of renal transplants. Of 543 kidney transplants performed at the University of Minnesota, lymphoceles occurred in three (an incidence of 0.6%). These three patients are described. We believe lymphoceles can be prevented by ligation of all lymphatic channels around the iliac artery and vein as these structures are dissected. Also the lymphatics of the donor kidney should be ligated before division. Lymphoceles are best treated by drainage into the peritoneal cavity after excision of as much of the cyst wall as possible.
three patients who developed lymphoceles after receiving renal allografts.
L YMPHOCELES have been reported to occur after 1.2 to
Case Reports
18. 1% of renal transplants (Table 1). 12,6,7,l10l6,l8 They may lead to deterioration of renal function2'8'13'16'18 and the patient with a lymphocele may be inappropriately treated for allograft rejection. Other clinical findings associated with lymphoceles in renal allograft recipients include lower abdominal swelling or mass,2 5'7'8'10'13'15'18 edema over the allograft or of the ipsilateral leg,1 2'5'15'18 hypertension,2 8 drainage from the incision,2'5'7 enlarged allograft,2 fever without an obvious source of infections,2'7'8 urinary frequency,2 ipsilateral ileofemoral thrombophlebitis,2 and weight gain.16'18 While many small lymphoceles undoubtedly go undetected, treatment of large lymphoceles in transplant recipients is important because ofpossible compromise of allograft function due to compression of the graft ureter and blood vessels, and danger of infection. We have seen three lymphoceles in 543 consecutive renal transplants. We believe lymphoceles can be prevented by ligation of all donor renal and recipient lymphatics before they are divided. We describe here the Submitted for publication November 17, 1975. This work was supported by Grant #AM 13083 from the United States Public Health Service. Reprint requests: Dr. Simmons, Department of Surgery, Box # 185, Mayo Memorial Bldg., University of Minnesota Hospitals, Minneapolis, MN 55455.
Between August 1, 1967, and July 1, 1975, 543 kidney transplants were performed in 501 patients at the University of Minnesota Health Sciences Center. Four hundred fifty-nine were first transplants. Three lymphoceles developed, an incidence of 0.6%. All occurred in patients receiving their first transplant. Case 1. A 53-year-old woman had renal failure because of polycystic kidney disease. She received a cadaveric kidney transplant January 25, 1972. Standard immunosuppression and antilymphocyte globulin (ALG) were given.1" She left the hospital 13 days after transplantation. The BUN and creatinine continued to decrease after discharge to 33 mg/100 ml and 1.5 mg/100 ml respectively. Treatment was begun February 25, 1972, with methylprednisolone and prednisone for rejection. She was again treated for rejection July 3, 1972. Rejection was confirmed by kidney biopsy. On August 16, 1972, she entered the hospital because of urinary frequency and stress incontinence. Cystoscopy was performed and the bladder was seen to be distorted by a mass. The BUN was 81 mg/100 ml and the creatinine was 2.3 mg/100 ml. A few days later a lower abdominal mass could be palpated. On September 14, 1972, the lymphocele was drained and part of the cyst wall was excised. The contents of the lymphocele were sterile. The BUN decreased to 63 mg/100 ml and the creatinine fell to 2.0 mg/100 ml. Comment: Although biopsy showed rejection, some of the renal malfunction may have been due to the lymphocele. In fact, the creatinine did decrease from 2.3 mg/100 ml to 2.0 mg/100 ml. Case 2: Polycystic kidney disease led to renal failure in a 42-year-old woman. On February 7, 1972, she received a kidney allograft from her sister. Standard immunosuppression and ALG were used posttransplant."1 She was discharged 15 days after transplantation when the BUN was 24 mg/100 ml and the creatinine was 1.1 mg/100 ml. She entered the hospital again on February 28, 1972, because the BUN had increased to 83 mg/100 ml and the creatinine had risen to 3.2 mg/100
166
Vol. 184 * No. 2
167
PREVENTION OF LYMPHOCELES
ml. Kidney biopsy showed changes compatible with acute tubular necrosis but no signs of rejection were seen. On April 3, 1972, she was admitted for weight gain. An open kidney biopsy was performed and an unsuspected lymphocele was encountered. Drainage catheters were left in for 6 days and then removed. Contents of the lymphocele were sterile. The kidney biopsy revealed rejection. The BUN was 102 mg/100 ml and the creatinine was 5.8 mg/100 ml. She was treated for rejection and the BUN decreased to 57 mg/100 ml and the creatinine fell to 3.2 mg/100 ml. A midline mass became apparent May 5, 1972. Because of a persistent urinary tract infection and autogenous right ureteral reflux, she underwent resection of her own right ureter on May 17. Two lymphoceles were incised and part of the cyst wall was resected. The BUN again increased to 76 mg/100 ml and the creatinine rose to 5.4 mg/100 ml. Despite antirejection therapy the BUN and creatinine remained elevated, and hemodialysis was required. On August 31, 1972, she received a second kidney transplant from her son. She has maintained normal renal function. Case 3: A 35-year-old woman received a renal allograft on July 20, 1972, because of renal failure due to diabetes mellitus. She was discharged 14 days after transplantation. The blood urea nitrogen (BUN) was 19 mg/100 ml and the creatinine was 1.0 mg/100 ml. She remained well until March, 1974, when she entered the hospital with a fever of 39.60. An intravenous pyelogram and barium enema demonstrated a right pelvis mass compressing the ureter and bladder and elevated the cecum. On needle aspiration of the mass 1400 ml straw-colored fluid was withdrawn. Gastrografin was instilled into the cavity and an x-ray showed the large cyst. On March 21, 1974, open drainage was carried out and penrose drains were left in place. The fluid removed from the cavity was sterile. The drains were removed after four days and the patient was discharged. A right lower quadrant mass was again detected in July, 1974. Seventeen hundred ml of dark fluid was drained from the cyst. The fluid was sterile. On July 22, 1974, catheters were placed into the cyst for drainage and triamcinolone hexacetamide was injected daily for three days. Drainage stopped after three days and the catheters were removed. The cyst recurred again and on August 6, 1974, it was incised and part of the cyst wall was removed. Culture of the cyst fluid revealed coagulase negative Staphylococcus. The lymphocele recurred once more. On September 19, 1974, more of the cyst wall was removed and the cyst was marsupialized into the peritoneal cavity. It did not recur again. On June 22, 1975, the BUN was 21 mg/100 ml and the creatinine was 1.3 mg/100 ml. Comment: This lymphocele recurred despite incision and drainage and removal of the cyst wall. Marsupialization into the peritoneal cavity pennitted reabsorption of the cavity fluid by the peritoneum and the lymphocele did not recur again.
Discussion
Lymphoceles are complications of the transplant operation that we believe can be avoided. The lymphoceles led to compromise of allograft function in two of the three patients and to an otherwise unneeded operation in all three. Decreased graft function due to a lymphocele has also been reported by others.1'2'5'10'13'16 While lymphoceles are known to occur following pelvic lymphadenectomy in radical pelvic surgery,3 4'14 they have been reported infrequently in association with renal transplantation.1'2,6,7,10,16-18 Lymphoceles are most likely due to leakage of lymph from recipient lymphatic channels. Madura et al. 9 Koehler and Kyaw,8 and Braun et al.2 have demonstrated by lymphangiography that host lymphatics communicated with the lymphocele. Some
TABLE 1. Incidence ofLymphoceles Following Renal Transplantation Author
Boglin et al.1 Braun et al.2 Kiser et al.6 Meyers et al.10 Schweizer et al.16 Starzl et al.17 Zincke et al.18 University of Minnesota
No. Lymphoceles
No. Patients
%
6 15 3 7 6 3 6 3
42 83 250 176 280 216 215 543
14.3 18.1
1.2 4.0 2.1 1.4 2.6 0.6
lymphoceles may well be due to divided lymphatics from the donor kidney.13'18 Pederson and Morris12 showed that lymphatic flow increases 19 times in sheep kidneys undergoing rejection compared to autografted kidneys. Diuretics and ureteral absorption are known to increase the flow of lymph in the kidney and may also contribute to the formation of a lymphocele. Rejection was confirmed by biopsy in two of our three patients with lymphoceles around the time the lymphoceles became evident. Radiation16 and hematomas13 have also been thought to play a role in the formation of lymphoceles. We believe ligation of all lymphatic channels around the recipient iliac vessels and on the donor kidney will prevent lymphoceles. Iliac lymph nodes are usually found in close proximity to the iliac artery and vein. In the absence of pathology, these nodes are small and are frequently not identified. However, usually large lymphatic channels can be identified passing over the iliac vein. When the abdominal wall muscles are divided and the peritoneum is reflected superiorly and to the left (for allografts placed in the right iliac fossa), the iliac vein and artery come into veiw. To clean the vein, ligatures are passed under the lymphatic channels and investing fascia with a right angle clamp. The ligatures are tied and the lymphatic channels and investing fascia are divided exposing the vein. Generally only two or three sets of ligatures are required to completely expose the iliac vessels. The lymphatic vessels of the donor kidney pass around the renal artery to lumbar lymph nodes. After the renal artery and vein have been identified the lymphatics around the renal artery are ligated and divided. These ligatures also encompass nerve fibers in proximity to the artery. It is important to keep these ligatures as far from the hilus of the kidney as possible in order not to ligate early branches of the renal artery. Care must also be taken to avoid catching the adventitia of the artery, because it may lead to torsion of the artery after it is placed in the recipient with compromise of flow. Generally, two or three ligatures are required for the renal lymphatics. Braun et al.2 reported a single surgical drainage can resolve a lymphocele in 75% of patients and remain free of infection in 80%. Others5'6'8'13'16'17 have also used incision and drainage. Drainage was tried initially in all three of our
168
HOWARD, SIMMONS AND NAJARIAN
patients but was effective in only one. Furthermore, there is a danger of peri-renal infection associated with open drainage especially in diabetic patients that may lead to loss of life or loss of the kidney.5'8 Multiple aspirations of lymphoceles have been tried, but this technique has led to recurrence and infection.1018 We now favor marsupialization of the lymphocele into the peritoneal cavity with resection of as much of the cyst wall as possible, as advocated by Byron et al.3 Marsupialization maintains constant drainage into the peritoneal cavity should the lymphatic leak persist. It also eliminates an opening to the outside thus greatly reducing the likelihood of infection. Removing the wall of the lymphocele prevents it from reforming and ensures adequate drainage into the peritoneal cavity.
References 1. Boglin, A., Leroux-Robert, C., Redrossian, J., et al.: Compression Ureterale par un Lymphocele apres Transplantation Renal. A propos de deux cas. Nouv. Presse Medi., 1:1211, 1972. 2. Braun, W. E., Banowsky, L. H., Straffon, R. A., et al.: Lymphoceles Associated with Renal Transplantation. Report of 15 Cases and Review of the Literatures. Am. J. Med., 57:714, 1974. 3. Byron, R. L., Jr., Yonemoto, R. H., Dauajan, V., et al.: Lymphocysts: Surgical Correction and Prevention. Am. J. Obstet. Gynecol., 94:203, 1966. 4. Ferguson, J. H. and MaClure, J. G.: Lymphocele Following Lymphadenectomy. Am. J. Obstet. Gynecol., 82:783, 1961. 5. Inocencio, N. F., Pierce, J. M., Jr., Rosenberg, J. C., et al.: Renal
Ann. Surg.
*
August 1976
Allograft with Massive Perirenal Accumulation of Lymph. Br. Med. J., 3:452, 1969. 6. Kiser, W. S., Hewitt, C. B. and Montie, J. E.: The Surgical Complications of Renal Transplantation. Surg. Clin. North Am., 51:1133, 1971. 7. Koehler, P. R.: Injuries and Complications of the Lymphatic System Following Renal Transplantation. Lymphology, 5:61, 1972. 8. Koehler, P. R. and Kyaw, M. M.: Lymphatic Complications
Following Renal Transplantation. Radiology, 102:539, 1972. 9. Madura, J. A., Dunbar, J. D. and Cerilli, G. J.: Perirenal Lymphocele as a Complication of Renal Homotransplantation. Surgery, 68:310, 1970. 10. Meyers, A., Salant, D., Rabkin, R., et al.: Lymphoceles in Renal Homograft Recipients. Kidney Internat., 8:129, 1975. 11. Najarian, J. S. and Simmons, R. L.: Transplantation. Lea and Febiger, Philadelphia, 1972; p. 460. 12. Pederson, N. C. and Morris, B.: The Rule of the Lymphatic System in the Rejection of Homografts: A Study of Lymph From Renal Transplants. J. Exp. Med., 131:936, 1970. 13. Rashid, A., Posen, G., Couture, R., et al.: Accumulation of Lymph Around the Transplanted Kidney (Lymphocele) Mimmicking Renal Allograft Rejection. J. Urol., 111:145, 1974. 14. Rutledge, F., Dodd, G. D., Jr., and Kasilag, F. B., Jr.: Lymphocysts: A Complication of Radical Pelvic Surgery. Am. J. Obstet. Gynecol., 77:1165, 1959. 15. Schmidt, P., Zazgoynik, J., Piza, F., et al.: Diagnostic and Therapie eines alles mit Lymphozele nach Nierentransplantation. Schweiz. Med. Wschr., 103:1887, 1973. 16. Schweizer, R. T., Cho, S., Kountz, S. L. and Belzer, F. O.: Lymphoceles Following Renal Transplantation. Arch. Surg., 104:42, 1972. 17. Starzl, T. E., Growth, C. G., Putman, C. W., et al.: Urological Complications in 216 Human Recipients of Renal Transplants. Ann. Surg., 172:1, 1970. 18. Zincke, H., Woods, J. E., Aquilo, J. J., et al.: Experience with Lymphoceles After Renal Transplantation. Surgery, 77:444, 1975.
