Ask the Experts - Lymphocele Following Renal Transplantation?
I understand that management of small and noncompressive lymphoceles is conservative. However, large or compressive lymphoceles require either laparoscopic or open marsupialization into the peritoneum or aspiration and sclerosis with iodinated povidone. I will appreciate your comments, especially in relation to aspiration and sclerosis, and particularly in settings where experience with laparoscopy is limited.

Ricardo Silvestre Arze, MD

The estimated incidence of significant posttransplant perirenal fluid collections ranges from 1% to 10%. Etiologies of fluid collections after renal transplantation include lymphoceles, hematomas, and urinomas. Lymphoceles are the most common. Extensive iliac dissection may increase the risk of lymphoceles, although the source of the lymphatic leak may be the kidney allograft itself (either transected lymphatic vessels or transudation from decapsulation). Hematomas may arise due to surgical bleeding or after biopsy. Initial management of fluid collections associated with graft dysfunction should include placement of a urinary catheter in order to decompress the bladder. Small urinary leaks can be controlled in some instances with bladder drainage alone. Confirmation of a urinoma can be accomplished with fluid aspiration and biochemical assessment, followed by imaging studies. Usually, a percutaneous nephrostogram is required if a urinoma is suspected.

Asymptomatic lymphoceles are best left alone in the presence of normal graft function. If the graft is dysfunctional the lymphocele should be aspirated in order to assess the fluid, facilitate biopsy, and treat any ureteropelvic compression. Moderate-size lymphoceles can be managed with simple aspiration as the initial step. If the lymphocele recurs, then a pigtail catheter can be placed percutaneously. Large lymphoceles should be drained with a pigtail catheter. In addition to biochemistry, fluid should be sent for culture and gram stain. At subsequent visits, the lymphocele cavity can be eradicated with iodine or ethanol sclerosis accomplished over a few weeks. Superinfection of the lymphocele may ultimately require open drainage and packing of the lymphocele cavity.

Alternatively, large or symptomatic lymphoceles can be treated with internal surgical drainage (marsupialization into the peritoneum). We generally reserve surgical drainage for collections that are recurrent or refractory to percutaneous management, but there are advocates of an initial surgical management approach. The advantage of immediate surgical drainage is a shorter and more definitive treatment compared with percutaneous drainage and sclerotherapy. The disadvantage is a requirement for general anesthesia and the risk (albeit small) of ureteral injury during the marsupialization. Marsupialization can be performed either via a laparoscopic or open approach and is generally quite effective in decompression, provided the lymphocele is not loculated.