Lymphocele: prevalence and management in gynecological malignancies

Abstract

A lymphocele is a cystic mass that may occur in the retroperitoneum following a systematic pelvic and/or para-aortic lymphadenectomy. Lymphoceles may be the cause of severe morbidity, or rarely mortality. Symptomatic lymphoceles manifest with pain, compression of adjacent structures, lymphoedema, deep vein thrombosis or inflammation. The morbidity associated with a symptomatic lymphocele may reduce the quality of life of a patient, as well as delay subsequent cancer treatment. The number and positivity of removed lymph nodes, surgical approach, type of tumor, radiotherapy and BMI rate are among the most discussed risk factors of lymphocele formation. The incidence of postoperative lymphocele is reported in the broad range of 1–58%; 5–18% of those who are symptomatic. Only symptomatic lymphoceles should be treated. Mini-invasive methods involving catheter drainage and sclerotization tend to prevail. Surgery either via laparoscopy or laparotomy remains an option in recurring, poorly accessible or inflammatory lymphoceles.

Keywords::

• complications of surgical treatment
• gynecological malignancy
• intervention radiology
• lymphadenectomy
• lymphocele

Financial & competing interests disclosure

This work was supported by the Ministry of Health of the Czech Republic projects No. NT13070, CZ-DRO VFN 64165 and CZ-DRO FNBr 65269705, and by Charles University projects UNCE 204024 and PRVOUK P27/LF1/1. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Lymphoceles occur in 1–58% of patients (usually one–third) after pelvic and/or para-aortic lymphadenectomy for gynecological malignancy.

• There is no need for systematic search to diagnose lymphocele in asymptomatic patient. In patient with symptoms of lower abdomen pain, compression of pelvic structures, acute lymphoedema of lower limb, deep vein thrombosis in pelvis or inflammation, a symptomatic lymphocyst should be consider as a source of these symptoms.

• Keeping the peritoneum open above the lymphadenectomy site represents the gold standard of preventing the development of lymphoceles. Prophylactic post-surgery drainage does not reduce lymph production.

• The technique of leaving the vaginal stump open, omentoplasty, new technologies as well as postoperative administration of octreotide represent promising methods of preventing the formation of lymphoceles. Further research is needed, however, particularly prospective controlled studies covering larger groups of patients with gynecological cancers.

• Most lymphoceles are asymptomatic, only 5–10% cause pain, compression of adjacent structures, acute lymphoedema or infection.

• Lymphocele should be treated only if symptomatic.

• Ultrasound- or computed tomography guided percutaneous drainage, possibly accompanied by sclerotization represents a valid treatment option.

• If mini-invasive therapy fails, surgery is required. Such procedures are technically very demanding, but may be facilitated by the use of peri-operative ultrasound and by ureteral catheterization.