Treatment of a high-volume retroperitoneal lymphocele with obstructive hydronephrosis following lymph node dissection via combined intra-lymphocele retrograde lymphangiography with glue embolization and sclerotherapy

Abstract

Management of symptomatic lymphoceles typically involves sclerotherapy and lymphangiography with embolization. When many afferent lymphatic channels are supplying a large-volume lymphocele, sclerotherapy is associated with high recurrence rate. This case presents a patient who underwent retroperitoneal lymph node dissection and developed a high-volume lymphocele that was compressing the ipsilateral ureter, causing hydronephrosis. He was treated with retrograde lymphangiography, whereby contrast dye was injected through the existing lymphocele drain and afferent lymphatics were visualized upon contrast reflux. These afferent channels were embolized and the lymphocele cavity was sclerosed, leading to reduction in lymphocele output, drain removal, and normalization of kidney function.

1 Introduction

The development of a lymphocele is an uncommon, although likely underreported, complication of retroperitoneal lymph node dissections (RPLND). Symptomatic lymphoceles have been reported in up to 2% of cases following RPLND ^, ; meanwhile, radical pelvic lymphadenectomies (PLND) carry significantly greater risks, with the most recent data showing that 5% of patients who undergo robotic PLND operations develop a symptomatic lymphocele. Most post-operative lymphoceles are asymptomatic and will reabsorb on their own within 1–2 months. Symptomatic cases are associated with compression of adjacent structures, including ureter(s) and vein(s), and commonly reported symptoms include renal colic, lower extremity swelling/edema, nausea, and emesis.

When symptoms manifest, treatment options include percutaneous aspiration, drainage, intracavitary sclerotherapy, antegrade lymphangiography with lymphatic embolization or surgical removal. The standard procedure for intracavitary sclerotherapy involves placement of a drain with aspiration of the fluid and then injecting the lymphocele with sclerosants such as doxycycline. ^, Intracavitary sclerotherapy of high-volume lymphoceles is associated with a high recurrence rate, owing to the presence of many small leaking channels that can be difficult to sclerose. ^,

Antegrade lymphangiography with intranodal lymphatic embolization involves injecting oil-based contrast dye into inguinal lymph nodes to visualize the afferent lymphatic channels that are supplying the lymphocele, followed by intranodal glue embolization. Prior studies have shown that intranodal lymphatic glue embolization results in faster resolution of the lymphocele than serial intracavity sclerotherapy.

This case report describes the outcome of a patient who developed a large retroperitoneal lymphocele following RPLND resulting in obstructive hydronephrosis and high-volume daily output (>500 cc) after drain placement. Patient underwent retrograde lymphocele lymphangiography and embolization, whereby contrast dye was injected directly into the lymphocele via a drain that had already been placed, allowing for opacification of the afferent lymphatic channels entering the lymphocele. Subsequent selective glue embolization of the afferent lymphatic channels and sclerotherapy of the lymphocele cavity led to resolution of the lymphocele.

2 Case presentation

This patient is a 36-year-old male with a history of non-seminomatous germ cell tumor of the left testicle who underwent left radical inguinal orchiectomy in November 2023 without complications. Three months later, he opted to undergo a nerve-sparing retroperitoneal lymph node dissection (RPLND) to prevent/remove potential metastases. A full bilateral template RPLND was performed to remove nodal tissue in the left and right para- and retro-aortic spaces in addition to the precaval, paracaval, retrocaval, and inter-aortocaval lymph node packets. The left spermatic cord, lumbar vessels and large lymphatic channels were ligated. He was discharged without complications on postoperative day 4.

At 3-month follow-up, the patient underwent oncologic surveillance computed tomography (CT) of the abdomen and pelvis which showed a large right retroperitoneal lymphocele ( Fig. 1 a) that was compressing the right ureter and causing upstream hydronephrosis ( Fig. 1 b) with concomitant increase in creatinine from 0.94 to 1.30 mg/dL. Patient underwent CT-guided 12-F drain placement into the lymphocele ( Fig. 1 c).

Lymphatic Interventional Radiology was consulted, and the patient presented for intracavity sclerotherapy and possible intranodal lymphangiography and glue embolization. At that time, patient reported approximately 500 cc of clear, serous output from the drain per 24 hours.

A diagnostic sinogram was performed through the existing drain with injection of water-soluble iodinated contrast. There was reflux of contrast from the lymphocele into the injured afferent lymphatics entering the lymphocele near surgical clips ( Fig. 2 a). These afferent channels, which were supplying the lymphocele, were selectively catheterized in a retrograde fashion with a 2.4F microcatheter and subsequently embolized with cyanoacrylate glue mixed with lipiodol from the surgical clips back to the lymphocele ( Fig. 2 b). The 12F drain was then repositioned into the dominant residual lymphocele cavity (∼50 mL capacity) and sclerotherapy was performed with doxycycline ( Fig. 2 c and d).