Reference:
Incidence:
Yee et al.
0%
Katz et al.
0%
Modi et al.
0.13%
Kumar et al.
0.13%
Liss et al.
0.4%
Yip et al.
0.4%
Babaian et al.
0.5%
Ghazi et al.
0.6%
Lallas et al.
0.6%
Cooperberg et al.
1.1%
Ploussard et al.
1.1%
Hashimoto et al.
1.5%
Sejima et al.
2%
Stololzenburg et al.
2%
Zorn et al.
2%
Sagalovich et al.
2.4%
Galfano et al.
1–3%
Polcari et al.
3%
Silberstein et al.
3%
Waggenhoffer et al.
3%
Yuh et al.
3%
Davis et al.
4%
DiPierro et al.
4%
Feicke et al.
4%
Koo et al.
4%
Orvieto et al.
7.9%
Froehner et al.
30.9%
Since most lymphoceles are subclinical, the diagnosis is based on clinical suspicion and symptoms. Patients with pelvic pain localized to one side, irritative urinary symptoms, or unilateral leg swelling should prompt radiologic evaluation. CT scan or ultrasound can be used to evaluate a patient for lymphocele formation. The true rate of subclinical lymphoceles is difficult to define as they often are asymptomatic. Keskin et al. reported on 521 patients after robotic-assisted radical prostatectomy who were prospectively imaged at 1 and 3 months postoperatively with abdominal and pelvic ultrasound. They found an overall lymphocele rate of 9%, of which, 2.5% became symptomatic. Interestingly, 76% of lymphoceles discovered at 1 month postsurgery resolved by the 3-month study. If patients continued to have lymphoceles on the 3-month ultrasound, 64% of those patients went on to have symptoms related to the lymphocele [5].
Risk factors for lymphocele formation include the number of lymph nodes removed [6], presence of nodal metastases, tumor volume in the prostate, and extracapsular extension [7]. The extent of PLND has been clearly shown to correlate with the lymphocele formation. Davis reviewed his experience with limited and extended PLND performed robotically for patients with intermediate and high-risk prostate cancer. He noted a higher rate of lymphoceles with the extended PLND and noticed that there were fewer lymphoceles if care was taken to clip as many open lymphatic channels as possible. He also noted a higher rate of symptomatic lymphoceles in patients undergoing the extraperitoneal approach for PLND (3/16 or 19%) as compared to the transperitoneal approach (0/47) [8]. This has led to the practice of creation of a peritoneal fenestration in those patients undergoing extraperitoneal prostatectomy with PLND in an effort to allow the lymphatic fluid to escape into the transperitoneal space and be reabsorbed [9].
The majority of lymphoceles that occur after transperitoneal PLND are asymptomatic and resolve without complications. If an asymptomatic lymphocele is discovered, it can be observed with serial imaging to confirm resolution. Some lymphoceles may become clinically apparent by causing compression of the bladder, leading to bladder symptoms such as urgency and frequency. These symptoms are common after prostatectomy so an index of suspicion is needed to prompt radiographic investigation for the lymphocele. Lymphoceles that are clinically silent may become apparent if the lymphocele becomes infected. Davis noted cases of infected lymphoceles occurring greater than 6 months after PLND and speculated that an asymptomatic lymphocele could persist after PLND and later become seeded with an infection from another source [8]. In the series by Keskin, symptomatic lymphoceles developed, on average, 11.2 months after PLND with lymphoceles becoming clinically significant as long as 22 months after surgery [5]. Therefore, the surgeon needs to maintain an index of suspicion for this complication not only in the early postoperative period but also in the long-term follow-up.
Lymphoceles leading to secondary complications including lower extremity edema, infection, deep venous thrombosis, or ileus require treatment. Treatment is also indicated for symptomatic lymphoceles resulting in patient discomfort such as pelvic pressure or urinary frequency. Initial management of lymphoceles involves placement of a percutaneous drain until the drain output is minimal which can take several days to weeks. It is recommended that lymphocele fluid be sent for culture to evaluate for infection as well as fluid creatinine to rule-out urine leak. If lymphocele recurs, secondary treatment options including repeat percutaneous drainage with instillation of a sclerosing agent. A variety of sclerosing agents have been used, either alone or in combination, with success including tetracycline , doxycycline, povidone iodine, and alcohol. The initial size of the lymphocele is a risk factor for failure of sclerotherapy with larger-sized lymphoceles leading to greater failures [10]. Larger lymphoceles may be better treated with marsupilization of the lymphocele which can be performed laparoscopically, robotically or by an open approach.
Vascular Injury
Vascular injury during pelvic lymphadenectomy is rare and reported in the literature as case reports. Hemal described a case of external iliac vein dissection injury sustained during laparoscopic PLND and radical cystectomy. The vein injury was successfully repaired with laparoscopic suturing and they noted that increasing the pneumoperitoneum pressure and keeping the patient in steep Trendelenburg position were key maneuvers to provide visualization of the injury [11]. Safi et al. reported a case of complete transection of the external iliac artery encountered during laparoscopic PLND and prostatectomy. The artery was very redundant, was below the external iliac vein, and was mistaken for the lymphatic packet. They reapproximated the artery end to end with a laparoscopic running double-armed suture after gaining proximal and distal control with laparoscopic graspers. Laparoscopic prostatectomy was completed and the artery remained patent on postoperative imaging [12]. Another case study presented by Castillo details thermal injury to the external iliac artery which occurred during laparoscopic PLND and cystectomy. The injury was due to heat from an electromechanical scalpel instrument used during dissection. Vascular bulldog clamps used for open surgery were introduced through a 10-mm laparoscopic port and were applied to gain proximal and distal control. The injury was debrided and sutured laparoscopically using 5–0 monofilament suture with a successful outcome [13].
The iliac and obturator lymphatics in the pelvis surround major vascular structures including the external iliac vein artery, the internal iliac vein and artery, and the obturator vessels. The pelvic vasculature are at risk from injury during dissection, application of clips and by inadvertent thermal injury from electrocautery. When dissecting around the pelvic vasculature, it is important to maintain adequate exposure and ensure that the bedside assistant has clear access to the area of dissection so that suction may be applied if bleeding is encountered. Another potential cause of vascular injury is the uncontrolled or blind passage of robotic instruments into the body by the bedside assistant. This is especially concerning during the introduction of sharp instruments such as the robotic scissors and can be avoided by pulling the robotic camera back to watch the instrument pass through the robotic port. Vascular injury is also possible when there is failure of insulation surrounding a monopolar instrument leading to inadvertent conduction of electrical current onto a vessel [14]. This can be prevented by ensuring the insulation on the instrument is intact and avoid resting the sheathed portion of a monopolar instrument on the vessels. Finally, when using both monopolar and bipolar instruments simultaneously around the pelvic vessels, great care must be taken to avoid pressing the wrong foot pedal during robotic dissection. This is because the instrument not applying energy is used to provide exposure and if the wrong pedal is inadvertently pressed, this could lead to serious injury. This is best prevented by conscious hesitation prior to applying any form of cautery and performing a mental check to ensure the proper pedal is being activated.
In the case studies describing laparoscopic repair of vascular injury, the common factor among all the reports was the vast experience of the laparoscopic surgeons performing the repair. Laparoscopic suturing is a complex skill and should only be attempted by experienced laparoscopic surgeons. Robotic surgery with the enhanced ease of suturing over pure laparoscopy makes repair of lacerations of the pelvic vasculature possible without the need to convert to open surgery. However, one must always be mindful that a significant vascular injury that cannot be controlled robotically necessitates conversion to open for appropriate control and repair. Consulting a vascular surgeon is also indicated if there is any question regarding the extent or management of the injury.
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