4. A 34-year-old lady received a kidney transplant 3 months ago with stable kidney function. She is complaining of frequency of micturition (10 times/day). Routine USS showed multi-loculated collection above the bladder (see below).
- Describe the image above
- What is your diagnosis?
- What is your management?
Thank you
This is the typical picture of symptomatic lymphocele. It compresses the bladder. Needs confirmation by aspiration and analysis of the aspirate to make sure it is not a urine leak or infection. To exclude UTI as a cause of frequency. Treatment either by drainage (either laparoscopically into the peritoneal cavity or percutaneously). Sclerosant material could be an option but is much inferior to the other options as the lymphocele is symptomatic and multiloculated.
Thank you All for your reply
What is the difference in the clinical
picture and the radiological picture between infected and non-infected
lymphocele?
Dear, professor
Infected lymphocele:
*Systemic symptoms
*high inflammatory markers
*drain fluid (high Wbcs)
*gram stain and culure
*USS: hyper-echoic with septations
*Treatment: urgent drainage in most cases/antibiotics
Uncomplicated lymphocele:
*Mostly asymptomatic. Symptomatic when cause compression of the ureter, renal vessels, or lymphatic outflow of lowe limb or external genitalia
*drain/aspirated fluid fluid: K and creatinine similar to blood/high protein
*gram stain/culure (negative)
*USS: hypoechoic or anechoic. CT Also
differentiate/scintigraphy (rim)
*Treatment: small and asymptomatic no intrvention. Intrvention if symptomatic (laparoscopic marsupializatin is the preferred procedure)
Yes Dr Abdallah, I appreciate your approach
Thank you Professor Sharma
CLINICAL PICTURE (Infected lymphocele)
RADIOLOGY – USG (Infected lymphocele)
Hi Dr Saini,
That is a very abbreviated approach. I expect references.
Lymphocele can happen after a couple of weeks (generally in the 2-3rd month); the most common cause is inappropriate ligation of iliac lymphatics. generrally thin-walled (radiologically has thin wall enhancement) and contains fluid content of urea, cr similar to serum. perinephric lymphocele has the effect of compression. may cause hydronephrosis and even leg edema
If infected septation is present. This may be reflected clinically with pain and septic features.
https://radiopaedia.org/articles/perirenal-lymphocele?lang=us
Description of the image:
Homogenous ,hypodense and septated collection .
DD
Lymphocele
Urinoma
Hematoma
Lymphocele occurs in 6% to 22% as a complications post Renal transplant
It may be asymptotic if small or can causes urine obestruction,frequency , unilateral lower limb edema or DVT
diagnosis
Us or ct guided aspiration with cytology , cr and k content , fluid cs
Treatment
Asymptomatic : just follow up
Symptomatic lymphoceles:
Aspiration: by us or ct guided but high risk of recurrence
Prolonged drain placement : effective but high risk of infection
If failed or recurrence surgical removal
Reference
Ali Bourgi, Sleiman Merhej, Flavio Ordones, Elias Ayoub. Lymphocele after Renal Transplantation: A Contemporary Review and a Modern Approach for Prevention and Treatment. J Urol Neph St 3(1)- 2021
Hi Dr Wasef,
I like your abbreviated approach.When you type headings or subheadings, please type in bold or underline.
Hi Dr Islam,
I like your abbreviated approach.
Hi Dr Ben
That is a very abbreviated approach. I expect references.
Hi Dr Yusuf,
That is a very abbreviated approach. I expect references.
infected collection the patients will have signs of infection like:
fever, pain, in severe sepsis hemodynamic instability (low Bpr), and graft dysfunction
investigations will show high inflammatory markers CRP, ESR, and WBCs. Aspirated fluid C/S reveals the organism
U/S will show a hyper-echogenic collection with fibrin trails and thick wall
Non-infected ones have no sign of infection,
U/S will show clear fluid, hypodense with a thin wall
Hi Dr Jamila,
That is a very abbreviated approach. I expect references.
J Renal Transplant Sci, 2(1): 73-77 Gunawansa N, Sharma A & Halawa A
Hi Dr WAdi,
I like your abbreviated approach.
1. A complex echo pattern with internal debris within the collection is more indicative of complicated infected lymphocele
2. Hyper-echoic form of collection in infected lymphocele compared to hypoechoic or anechoic image for non-infected lymphocele
so in this scenario is a complex septate collection with an internal echoes pattern due to internal debris and also big enough pressure symptom needs US guided drainage and send drain fluid for culture and gram stain in addition to creatinine and electrolytes just as DDX from urinoma
Hi Dr Saja,
I like your abbreviated approach.
_ Non infected lymphocele is mostly asymptomatic except if large and causing pressure symptoms as presented in the current case with urinary bladder compression causing frequency and urgency.
_ Infected lymphocele causes fever, abdominal pain and graft tenderness, and can cause sepsis.
_ The diagnosis is confirmed by US guided aspiration and analysis of the fluid:
_ similar craetinine and K levels to that of the serum levels to exclude urinoma.
_ lymphocele has similar creatinine mad K levels, with high protein content.
_gram stain and culture to exclude infected lymphocele.
_ the radiological differentiation by US is that non infected lymphocele has anechoic apperacnce while infected has hyperechoic appearance. Also, CT abdomen and pelvis can well differentiate between them.
Hi Dr Shawky,
I like your abbreviated approach.
Clinically fever, abdominal pain, elevated WBC count and high CRP are indicators of infection but in immunocompromised patient these features my be absent and radiologically presence of air fluid level within a collection indicate infection.
Hi Dr Ben,
I like your abbreviated approach.
What is the difference in the clinical picture and the radiological picture between infected and non-infected lymphocele?
Clinical: by presence of fever, malaise, and pain with unclear fluids aspirated and a positive gram stain and culture.
Radilogical: ultrasound Complex echo pattern with internal debris within the collection is more indicative of complicated infected lymphocele. An uncomplicated lymphocele appears hypoechoic or anechoic compared to the hyper-echoic appearance of an infected lymphocele.
Reference:
Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem!
Hi Dr Alshaikh,
I like your abbreviated approach.
Infected lymphocele is associated with systemic symptoms such as fever, pain and tenderness, and leukocytosis, and by US it is hyperechoic, non-homogenous, with septation, while non-infected is more benign with no systemic symptoms, and by US it is homogenous without septation.
different clinical pictures of infected lymphocele are
fever, tenderness, or pain in the site of the graft, and leucocytosis. Drain fluid is turbid and gram stain positive.
radiological the collection is more echoic and may there is debris
non-infected absence feature of infection and only compressive symptom
drain is clear and sent for analysis
Infected lymphoceles are lobulated with septate and hyperechoic but non-infectious are hypoechoic.
Other differences:
Infected lymphocele may be symptomatic, but non-infectious are asymptomatic.
Abnormal lab tests like leukocytosis, elevated inflammatory markers, high WBC and positive gram stain and culture in aspirate are another characteristics of infected lymphocele while non-infectious is the opposite.
What is the difference in the clinical picture and the radiological picture
between infected and non-infected lymphocele?
clinically the lymphocele is usually asymptomatic discovered by routine imaging mostly ultrasonograghy, but if large enough may produce compression symptoms as in this case .
once the lymphocele become infected there will be systemic symptoms of fever , local pain, raised inflamatory marker, leukocytosis.
RADIOLOGICALLY:
The presence of septation (non clear fluid) may suggest infection.
The figure demonstrates a hypoechoic collection, septate, but with its homogeneous content in close relationship with the bladder, possibly causing compression, justifying the symptom of urinary urgency.
My main hypothesis is lymphocele. This is because there was plenty of time for the development of the collection (3 months) and there are no associated infectious symptoms.
I would do a CT scan of the abdomen with contrast to confirm the lymphocele hypothesis. Subsequently, a percutaneous drainage guided by USG or tomography would be performed.
1)multi septated hypoechoic cystic lesion with debrid formation near the urinary bladder.
2) Infected lymphocele. urinary leak.
3)IV anitbiotic., Refer surgeon for drainage.
Ø multiloculated fluid collection /with septation = lymphocele.
DD. urine leak , hematoma
Ø lymphocele
Ø Drainage fluid analysis, biochemistry*Cr, K and cell count compared with serum for diagnosis and therapeutic to improve compression symptoms.
Ø Workup for UTI
Describe the image above
Multiple septated hypoechoic fluid collection above the urinary bladder
What is your diagnosis?
Lymphocele with bladder compression effect is the likely diagnosis but other possible differential should be ruled out like urinoma, hemorrhage and abscess by doing fluid analysis for creatinine and potassium and serum creatinine at the same time .CT scan and ultrasound features also may help Also points in the history regarding the time line of presentation and clinical presentation will help.
TREATMENT: small lymphoceles resolve spontaneously but the above case needs drainage with catheters or Laparoscopic deroofing and Marsupialization into peritoneal cavity.Sometimes sclerosing agent may be used
REFERENCE:
Gunawansa N, Sharma A, Halawa A. Lymphocele after renal transplantation: A new look at an age-old problem! J Renal Transplant Sci. 2019;2(1): 73-77
anechoic fluid collection suggestive of urinoma\urine leak
symptomatic lymphocele
aspiration with fluid analysis, renogram to exclude urine leak, as it is symptomatic treatment is surgical with laparoscopic or open drainage depending on the site
Describe the image above :
Multiloculated hypoechoic collection above the urinary bladder with septation.
What is your diagnosis?
Lymphocele
What is your management?
First confirm the diagnosis by biochemical analysis of the drained fluid for creatinine and k and compare it with the serum .
Second by US ,CT, and MRI for the exact location.
Treatment by aspiration either per cutaneous or through laproscopy.
This is a symptomatic multi-loculated lymphocele pressing on the bladder, causing symptoms of lower urinary tract.
Aspiration and sending a sample for potassium, creatinine, aerobic culture, WBCs, and serum procalcitonin will distinguish between urine, infected and non-infected lymphocele.
Treatment is laparoscopic deroofing into peritoneal cavity. Percutaneous aspiration and sclerosant have high failure rate in view of multiloculated collection with remote chance of introducing infection
1.Mutilocular hypoehoic collection with septation compressing the urinary bladder.
2.Diagnosis
lymphocele
need aspiration to exclude urine leak or infection
the levels of creatine and k within the lymphocele,the same as serum levels
but urine leak has increased levels of cr and k compared to serum levels
cytology and culture and sensitivity to exclude the infection.
3.Management of lymphocele
****A lymphocele with no infection or pressure symptoms can be safely left alone with periodic imaging surveilliance.
***** A lymphocele with infection or pressure symptoms
Percutaneous aspiration and sclerotherapy
Laparoscopic fenestration for recurrent and large lymphocele
Gunawansa N, Sharma A & Halawa A. (2019) Lymphocele after renal transplantation: A new look at an age-old problem! J Renal Transplant Sci, 2(1): 73-77.
non infected lymphocele : A symptomatic or pressure symptoms
sonar : non echoic fluid collection without septa
Infected lymphocele
fever, tender graft
sonar:hyper-echoic with septa and internal debris
oval, multilocular lesion with anechoic content and septations .
Lymphocele
Start with biochemical and microbiological analysis of the fluid aspirated from the lymphocele using an ultrasound-guided fine-needle percutaneous aspiration must be performed. Biochemical analysis of the creatinine, electrolytes (sodium and potassium), total protein and albumin are need to differentiate lymphatic complications from leak or accumulation of urine (urinoma) or sera (seroma). Once established that the fluid from the drain or from lymphocele is lymph, investigate whether the lymph derived from the renal graft or from the lymphatic of the recipient. Pacovsky et al. demonstrated significant differences in creatine kinase CK enzyme activity depending on the source of the lymph .
Treatment of lymphocele should start with minimally invasive measures. Generally, lymphatic disorders resolve spontaneously and do not require treatment but rather only a close follow-up. If the lymphocele is clinically symptomatic or the volume exceeds 140 mL, treatment is often required. Apercutaneous drainage alone or in association with sclerotherapy has been proven to be effective therapy. The effectiveness of aspiration varies between 25 and 41% compared with percutaneous drain placement between 50 and 55%.Sclerosing agents include fibrin glue, 95% ethanol instillation with addition of factor XIII and fibrinogen in cases of failure, sodium tetradecyl sulphate, tetracycline and povidone-iodine. The recurrence rate varies from 31 to 37.5% after the first and 18.7% after the second treatment. However, these procedures may impact the patient’s quality of life and increase the risk of infection. Moreover, Krol et al. demonstrated that puncture, drainage and sclerotherapy were not effective in patients with a lymphocele volume exceed 500 mL. Since 1992, the treatment of symptomatic lymphocele with laparoscopic fenestration of the lymphocele into the peritoneal cavity has been a safe and efficient method. The rate of recurrence is between 4 and 8%, compared with 16 and 51% for surgical treatment and aspiration, respectively. Laparoscopic surgery represents a valid therapeutic option compared with open surgery and to aspiration on the basis of the low rate of complication. In addition, the laparoscopic surgery is associated with a shorter time of hospitalization compared with open surgery. Capocasale et al. reported on the effect of octreotide (0.1 mg three time a day subcutaneously) compared with povidone-iodine instillation on patients with lymphorrhea. They found that with octreotide the mean length of lymphorrhea and the hospital stay were lower with minor patient discomfort than with povidone-iodine. The rationale for the use of octreotide was the expression of somatostatin receptors on the lymphatic vessels.
Ranghino A, Segoloni GP, Lasaponara F, Biancone L. Lymphatic disorders after renal transplantation: new insights for an old complication. Clin Kidney J. 2015 Oct;8(5):615-22. doi: 10.1093/ckj/sfv064. Epub 2015 Jul 16. PMID: 26413290; PMCID: PMC4581383.
Q1- Describe the image above
Multiple hypoechoic fluid collection around urinary bladder .
Q2- What is your diagnosis?
The most probable diagnosis is lymphocele with bladder compression effect.
Q3- What is your management?
At first we have to keep in our mind the differential diagnosis of afluid collection post transplantation:
1) Urinoma – urine leak.
2) Hemorrhage.
3) Abscess.
The important step is to differentiate between these possible cause of collection.
Fluid aspiration is vital as purulent aspirate indicate infection (abscess). Bloody aspirate indicate hematoma. Biochemical tests of aspirate is important to differentiate between urine leak and lymphocelle , the fluid creatinine and potassium level are very high (incompatible with life ) in urine leak but it is comparable to that of plasma in case of lymphocele.
In most cases, lymphocele disappear spontaneously without any need for a treatment.
But as this patient has bladder compression symptom which make intervention is necessary.
Available options are:
1) Percutaneous needle aspiration.
2) Continuous drainage over a period of time via various kinds of catheters.
3) Sclerotherapy with various agents.
4) Laparoscopic or open marsupialization.
references;
1) Ali Bourgi et al , Lymphocele after Renal Transplantation: A Contemporary
Review and a Modern Approach for Prevention and Treatment,journal of urology & nephrology studies,2021, volume 3- issue 1.
Describe the image above
Multi-loculated hypoechoic collection above the urinary bladder for DD.
What is your diagnosis?
Symptomatic lymphocele compressing the urinary bladder.
What is your management?
Aspirate the fluid from the collection and check creatinine and K (to exclude urine leak) and send t for culture (to exclude infection).
Send urine for dip stick, microscopy and culture.
Treatment of lymphocele by drainage either laparoscopic or open drainage and very rarely effective to use sclerosing agent.
A septated (multi-loculated) collection above the urinary bladder is seen, which is hypoechoic
A Lymphocele is one of the most common surgical complication post renal transplantation which may present as early as 1-2 weeks or several months to years post transplantation with incidence ranging from 0.6% to 34%
lymphocele is an abnormal fluid collection around the transplanted kidney due to surgical and medical risk factors .
Risk factors :
Clinical presentation:
The majority are asymptomatic. Symptoms may occur depending on the size , site and extent to the surrounding tissues.
Pressure effect on the hilar vessels may lead to impaired graft function or even venous or arterial thrombosis , pressure effect on ureter lead to hydro ureter and HN .
Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
Diagnosis :
The diagnosis is realized with imaging. The simplest method is the USS, determining the collection and its dimensions, location, relationship with the graft and compression effects on the vessels and ureter. Allows guided aspiration and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
Treatment :
Most of the asymptomatic lymphoceles require no specific treatment but they need to be assessed and followed for any pressure effects on the vasculature or ureter. Avoidance is through placement of retroperitoneal drains adjacent to the graft at the time of transplantation.
For symptomatic ones, treatment modalities include percutaneous aspiration, sclerotherapy and laparoscopic fenestration.
The picture of complex echo pattern with internal debris within the collection is more suggestive of complicated infected lymphocele
Hyper-echoic form of collection is found in infected lymphocele compared to hypoechoic /anechoic image for non-infected lymphocele
so it is a complex septate collection with an internal echoes picture due to internal debris and it is big enough to produce pressure symptom and needs US guided drainage and testing drain fluid for culture and gram stain in addition to creatinine and electrolytes as work up for DDX from urinoma
This is a multiloculated lymphocele with septate.
A complicated lymphocele.
Lab tests include: CBC diff, ESR, CRP , U/A, U/C .
The aspirated fluid should be tested for gram stain, culture, potassium and creatinine (compared to blood to differentiate from urinoma).
Treatment includes:
1. Simple aspiration
2. Sclerotherapy
3. Drain placement
4. Laparoscopic surgery (the preferred method)
5. Open surgery
multi-locular hypoechoic collection above the urinary bladder most probably lymphocele.
lymphocele causing compressing urinary bladder .
Lymphoceles is a complications of renal transplant that can compress and reduce graft function it may also cause deep vein thromboses by the same mechanism.
– Early presentation after transplantation consist of persistent drain output or wound leakage, while late presentation is a loculated collection which may be either asymptomatic or present with local symptoms caused by compression such as urinary frequency, pain, or lower extremity edema.
-Small collections can safely be observed,
– larger symptomatic lymphoceles will require intervention through aspiration and percutaneous drain placement to alleviate extrinsic compression.
-analysis of the fluid must be done to detect if its urine leak or lymphocele by testing the fluid for K and creatinine if the same as serum levels so it is lymphocele ,if higher so it is urine leak, fluid also should be send for culture.
-For persistent collections, intervention through laparoscopic or open fenestration can be performed, as well as percutaneous injection of sclerosing agents or fibrin glue, as these have also been reported to have high success rates
Hannah RChoate Laura A. Mihalko,Bevan T.Urologic complications in renal transplants.Transl Androl Urol. 2019 Apr; 8(2): 141–147
lymphocele is most likely the diagnosis and this is supported by the time of presentation after 3 months, and the radiological finding but needs to confirm by aspiration of the fluid and analysis for creatinine and k and should test the serum at the same time
the other differential diagnosis are urinoma but occur early postrenal transplant, hematoma also early post renal transplant and radiological finding is different and aspiration bloody
the perinephric abscess is another differential but the patient has fever tenderness and us there is thick wall and drain is pus
treatment by drainage laparoscopically into the peritoneal cavity or percutaneously and sometimes sclerosant agent can be done
If infected the acute phase reactants will be raised like CRP, ESR, procalcitonin, also WBC count, with other constitutional symptoms. Scan will show complex echoes and debris in it.
Aspiration and fluid creatinine and potassium comparison to serum to confirm.
according to timing, clinical presentation, and radiological finding(hypoechoic collection septated with the thin wall). it’s a classic case of noninfected lymphocele but still, a percutaneous .sample is needed to confirm the diagnosis and to exclude urine leak and infection.
management of such cases is by internal drainage into the peritoneal cavity or external drainage percutaneous
infected lymphocele usually presents with clinical symptoms and signs of infection like fever, leucocytosis and loin pain
radiologically the wall thick and fluid will be turbid with hyperechoic collection
its look like lympocyele ,shoulud be drain by intervtion radiolgist and to be sent for anlysis and acording to the anylsis to be mange.
We had an unusual case of infected tuberculous lymphocele in the post operative period and had published it
Kirushnan BB, Akhil MS, Arumugam K, Ravichandran R. Esophageal tuberculosis and infected tuberculous lymphocele: Unusual case presentations of tuberculosis in postrenal transplantation. Indian J Transplant 2017;11:168-70
Describe the image above
This image is showing a multiloculated collection around bladder.
It can be lymphocele
Urinoma
seroma
Abcess
What is your diagnosis?
As there are no obvious signs of infection the most likely it is lymphocele. However it will require further test to confirm.
What is your management?
It is important to rule out UTI- So urine RE and culture
Fluid from collection to check creatinine and electrolytes. If its urine then creatinine level will be at least two times the serum level. In case of lymph creatinine level will be similar to serum or even low.
As regards definite management the option include-
Aspiration alone
Aspiration with injection of sclerosant
Laparoscopic deroofing and Marsupialization into peritoneal cavity.
Aspiration alone and aspiration with sclerosant are inferior to Laparoscopic deroofing and Marsupialization into peritoneal cavity.
Perinepheric fluid collection
Lymphocele
Fluid aspiration + urology consultation
Describe the image above
The image showed cystic collection with septation(multiloculated) with hypoechoic pattern.
The differentials are:
· Urinoma.
· Lymphocele and Seroma.
· Haematoma.
· Perinephric abscess.
What is your diagnosis?
Lymphocele with pressure effect on the bladder is the most likely diagnosis;
· No systemic symptoms going with infective process.
· Lymphocele may occur from as early as 2 weeks to as late as 5 years post-transplant.
· Normally maintained UOP and stable KFT.
What is your management?
1. Investigations:
· Fluid biochemistry: If drain fluid creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher.
· Ultrasonography, CT scan, or MRI may help identifying the location and the source of collection and then after the appropriate way of intervention.
2. Treatment1;
· Aspiration (nearly 100% chances of recurrence).
· Percutaneous drainage (50% success rate).
· Drainage by laparoscopic method, or open marsupialisation. Open drainage is preferred over laparoscopic technique in patients with a small lymphocele adjacent to vital renal structures.
· Continuous drainage may be used together with the application of sclerosants like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin(Periureteral fibrosis is a risk if sclerosing agents are used).
References
1. Identifying Early Extraperitoneal High-Volume Urine Leak Post Kidney TransplantationBrian Mark Churchill,Ajay Sharma,Davis Aziz,Ahmed Halawa
multi-loculated hypo-echoic collection with septation above the bladder
Lymphoceles on US are anechoic and may contain septations. They may have a more complex appearance if they become infected.
Lymphocele
Lymphocele is the most commonly encountered perinephric fluid collection, typically occurring 2 weeks to 6 months after surgery, and is the most common collection resulting in allograft hydronephrosis .
These fluid collections, which lack a true epithelial lining at histologic analysis, occur along the lymphatic drainage pathways in the postoperative patient and are often asymptomatic .
At US, these collections are characteristically well marginated and anechoic, occasionally containing thin internal septa
Lymphoceles are characterized by a barely perceptible wall and internal simple fluid attenuation at CT and high T2 signal intensity at MRI.
Infrequently, these lymph-filled collections cause mass effect on the transplant kidney, ureter, vasculature, or urinary bladder, in which case US-guided percutaneous drainage or laparoscopic peritoneal fenestration may be performed .
Percutaneous catheter drainage results in high rates of reaccumulation (approaching 90%); thus, sclerosing agents such as ethanol, povidone-iodine, or fibrin glue have been used as alternatives with varying degrees of success .
Although nonspecific, lymphoceles can be associated with allograft rejection and are thought to be the result of increased regional lymph flow in the setting of inflammation .
Treatment
Lymphoceles are usually asymptomatic and diagnosed incidentally by ultrasound. In most cases, lymphocele disappear spontaneously without any need for a treatment. Several important factors can guide our choice of treatment: severity of the symptoms, clinical condition of the patient. For the conservative treatment of posttransplant lymphoceles, percutaneous needle aspiration, continuous drainage over a period of time via various kinds of catheters, and sclerotherapy with various agents have been proposed .
Aspiration
Ultrasound-guided aspiration can be used as a diagnostic tool or treatment. to both diagnose and treat a lymphocele. It can be used as the initial treatment modality to relieve urinary obstruction, recover kidney function, and prevent emergency situations. Although simple, safe, and economical, a repeated treatment may be necessary with a low a low risk of infection in each aspiration. A systematic review by Lucewicz et al. looking at over 20 studies, reported that simple aspiration alone has a recurrence rate ranging between between 10% and 95% .
Externaldrain placement
A lymphocele can also be treated by external drainage by placing a drain. However, this procedure takes a long time and can cause problems related to major fluid loss and secondary infection (particularly in immunosuppressed transplant recipients). External drainage has an efficacy of 50% and a recurrence rate of 20%–60%
Sclerotherapy
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum).
Imaging of Renal Transplant Complications throughout the Life of the Allograft: Comprehensive Multimodality Review
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Lymphocele after Renal Transplantation: A Contemporary Review and a Modern Approach for Prevention and treatment
Describe the image above
This is an US image showing an anechoic peri-nephric fluid collection with thin septations extending to the pelvis and compressing the bladder causing
What is your diagnosis?
· Lymphocele is the most likely diagnosis due to:
1) The timing of the collection after 3 months(usually develop between 2 weeks up to 6 Months)
2) The absence of echoic shadows or debris that may point to an abscess, besides, the patient is clinically stable.
· Lymphoceles may result from drainage of the lymphatics divided during surgery to expose the iliac vessels and from injured lymph channels in the donor kidney hilar vessels. To reduce that, minimization of the pelvic dissection with lymphatic ligation, avoidance of sirolimus based regimens in the early postoperative period as it increases the incidence of Lymphoceles.
· Lymphoceles may be asymptomatic or symptomatic like this index case who has frequency due to bladder compression(However, UTI need to be excluded with urine examination and cultures) . Additional symptoms are pain and LL swelling and increasing incidence of DVT.
· Differential diagnoses are: peri-nephric abscess, hematoma and urinoma (usually occurs at an earlier time)
· To confirm the diagnosis, US guided aspiration is done and the aspirated fluid is checked for appearance(clear, VS bloody or turbid), biochemistry (to check for creatinine and potassium in relation to the blood) and microbiology and culture.
· A non-infected lymphocele fluid is typically clear with creatinine and k levels similar to the blood and has a negative microbiology. On the other side, infected lymphocele fluid may be turbid with high WCC and the microbiology will be positive and this requires urgent drainage with antibiotics.
What is your management?
· This case requires a good Collaborative work with the transplant surgeon
· The procedure of choice is laparoscopic marsupialization (drained internally into the peritoneal cavity, where the fluid is resorbed).
· Alternatives:
– Percutaneous drainage with frequent injections of sclerosants like alcohol, povidone-iodine or fibrin glue may be unsuccessful with this symptomatic multi-loculated lymphocele.
– Simple aspiration results in re-accumulation in 90% of cases and is therefore not commonly employed.
– Catheter drainage results in successful treatment of the lymphocele in 50–87% of cases.
References
1 Howard M. Richard. Peri-renal Transplant Fluid Collections. Semin Interven Radiol. 2004, December: 21(4): 235- 237.
2. Hannah R. Choate et al. Urologic complications in renal transplants. Review Article. Transl Androl Urol 2019;8(2):141-147
3. Samuel Palli, Tariq Zayan, Ajay Sharma, and Ahmed Halawa. Approach to Increased Drain Output Post-Kidney Transplantation. Journal of Renal Transplantation Science JRTS, 1(1): 14-19
– Multiloculated collection related to transplanted kidney
– Mostly a case of lymphocele , DD >>urine leak & hematoma.
– Aspiration guided by US & analysis for creatinine, electrolytes, protein content, gram stain and culture with Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes to differentiate between lymphocele & urinoma.
– Ttt of lymphocele : considering pressure symptoms & increase frequency of micturition , it needs intervention , options are : Percutaneous aspiration and sclerotherapy , laparoscopic fenestration or open surgery .
( Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem! Nalaka Gunawansa , Ajay Sharma and Ahmed Halawa)
Image
Multilocular lymphocele with less defined edges and nonhomogenous hypoechoic content partially with separations/debris.
Diagnosis
Likely diagnosis is symptomatic lymphocele. Lymphocele is a cystic mass that can form in the pelvic retroperitoneum or in the paraaortic region after pelvic or paraaortic lymphadenectomy or transplantation. It is a collection of lymphatic fluid bordered by a thick fibrous wall without vascular supply and epithelial lining, expanding from the retroperitoneum into the pelvis or the abdominal cavity.
Lymphoceles generally develop in the post op period within one year of transplant. Most are asymptomatic, without the need for therapeutic intervention. However, this patient is complaining of increased frequency of micturition, making her diagnosis symptomatic lymphocele.
Symptomatic lymphocele is a serious complication and can cause severe post op morbidity. Abdominal pain, swelling of lower limbs, DVT and hydronephrosis are other possible symptoms she can have.
This condition does not become malignant, but can cause elevation in the tumor marker level CA 125. The basis for this is peritoneal irritation caused by the lymphocele or development of secondary infection within the lymphocele.
Differentials for lymphocele include UTI, relapsing malignant tumor, hematoma, urinoma, seroma, or abscess. Ultrasound helps in making the diagnosis with more clarity.
Management
References :
Multiloculated cystic lesion compressing urinary bladder.
Lymphocele
D/D:
Urinoma
Hematoma
Small lymphoceles do not cause any symptoms and thus, do not require any form of treatment. However, large ones can cause pain and swelling. Certain therapies are performed in such cases to provide symptoms relief.
The standard treatment for the condition is lymphocele drainage under CT or ultrasound guidance.
The above image :
Multi-loculated collection above the bladder related to transplanted kidney with acontent of hypo echoic fluids with presence of many septae
For DD
Mostly multiloculated Lymphocele
Hematoma
Urinoma
Abcess
Diagnosis :
Mostly symptomatic lymphocele
But we need to do some investigation to exclude other DD :
*USS guided aspiration and biochemical analysis of the fluid
High creatinine and K levels in Urinoma and urine leak
CS of aspirated fluid if suspected abcess or infected Lymphocele
At the same time samples taken from serum and urine for creatinine and electrolytes
urine analysis
CBC , CRP
**USS appearance may also point to a potential infection in the complicated infected lymphocele: Prescence of a complex echo pattern with internal debris inside the collection.
*** CT : usually can differentiate non infected Lymphocele from infected one
and help in diagnosis of Hematoma and abscess
Treatment:
1- Asymptomatic lymphoceles are self-limiting and don’t need any particular therapy ( after excluding any pressure or infections effects )
2- Percutaneous aspiration :
Remain the most safest means of assistance when required. In order to determine the collection’s true nature and rule out infection, it also permits sampling of the collection
Installation of a percutaneous drain to reduce re-accumulationr external drainage is mostly associated with infection.
3- Sclerotherapy :
percutaneous drainage + sclerotherapy to sclerose open lymphatics
4- Laparoscopic fenestration :
After exclusion of infection >> Making fenestrations in the lymphocele capsule allows for the opening of large lymphoceles into the peritoneal cavity. This enables internal lymphatic drainage to the peritoneal cavity.
5- Open surgical drainage:
In cases of infection or when laparoscopic fenestration is not possible, open surgical drainage of lymphocele is necessary.
References:
Lucewicz A, Wong G, Lam VWT, Hawthorne WJ,Allen R, et al. (2011) Management of primarysymptomatic lymphocele after kidney transplantation: Asystematic review. Transplantation 92: 663-673.
Minetti EE (2011) Lymphocele after renaltransplantation, a medical complication. J Nephrol 24:707-716.
Multiloculated fluid collection in suprapubic area ((lymphocele ))
A lymphocele is a common finding after renal transplantation. The majority of patients are asymptomatic. However, once a lymphocele has become symptomatic, this condition has to be treated. Lymphoceles may originate either from the lymphatic system of the recipient or the transplanted kidney. The most sensible measures to prevent their occurrence therefore seems to be to restrict the transplant bed to the smallest permissible level with careful ligature of the lymphatic vessels in the area of the kidney hilum.
Therapy of a lymphocele after renal transplantation should commence with minimally invasive measures and continue with invasive procedures only if these are unsuccessful, namely, puncture and drainage then sclerotization, and then laparoscopic or open marsupialization.
Lymphoceles are usually asymptomatic and diagnosed incidentally by ultrasound. In most cases, lymphocele disappear spontaneously without any need for a treatment. Several important factors can guide our choice of treatment:
severity of the symptoms
lesion size
potential post-therapeutic complications
the clinical condition of the patient.
For the conservative treatment of posttransplant lymphoceles, percutaneous needle aspiration, continuous drainage over a period of time via various kinds of catheters, and sclerotherapy with various agents have been proposed
1- Aspiration
Ultrasound-guided aspiration can be used as a diagnostic tool or treatment. to both diagnose and treat a lymphocele. It can be used as the initial treatment modality to relieve urinary obstruction, recover kidney function, and prevent emergency situations.
2- Externaldrain placement
A lymphocele can also be treated by external drainage by placing a drain. However, this procedure takes a long time and can cause problems related to major fluid loss and secondary infection (particularly in immunosuppressed transplant recipients). External drainage has an efficacy of 50% and a recurrence rate of 20%–60%
3- Sclerotherapy The instillation of a sclerosing agent is another treatment approach. These include povidone iodine, fibrin glue, 95% ethanol,
fibrinogen, bovine protease inhibitor, human thrombin, calcium chloride, gentamy sodium tetradecyl sulphate and tetracycline]. The sclerosing agent has been instilled and kept in situ for varying periods ranging from 5 min to 24 h
Post-transplant lymphoceles have also been treated with a combination of percutaneous aspiration and sclerotherapy. Although this reduced the recurrence rate, recurrences were still reported in 20% of cases
4-Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum).
The open procedure is safe and 100% effective because the lymphocele can be localized accurately. However, the recurrence rate is still 15%. This may be attributed to the high rate of lymph vessel injuries incurred during the open method.
The recurrence rate of the laparoscopic method is lower (0%–10%) because the rate of lymph vessel injuries is lower. Also, the hospitalization period is shorter in this method
Reference
Lymphocele after Renal Transplantation: A Contemporary Review and a Modern Approach for Prevention and Treatment
Ali Bourgi*1, Sleiman Merhej2, Flavio Ordones3 and Elias Ayoub4
Journal of urology and nephrology studies . DOI: 10.32474/JUNS.2021.03.000155
-A collection superior to the bladder with variable sized hypoechoic locules
-Mostly a lymphocele occurring post transplanation
-Treatment need to be started since the patient is symptomatizing he complains of polyuria with minimally invasive measures and if failed invasive procedures can be used as percutaneous needle ultrasound guided aspiration
puncture and drainage then sclerotization using povidone iodine, fibrin glue, 95% ethanol,
fibrinogen, bovine protease inhibitor, human thrombin, calcium chloride, gentamy sodium tetradecyl sulphate and tetracycline kept in situ for 5min to 24 h.
laparoscopic fenestration (internal drainage to the peritoneum) in non infected lymphoceles
,open surgical internal drainage required in the
presence of infection (external drainage) or where laparoscopic fenestration is not possible
Reference
Ali Bourgi, Sleiman Merhej, Flavio Ordones, Elias Ayoub. Lymphocele after Renal Transplantation: A Contemporary Review anda Modern Approach for Prevention and Treatment. J Urol Neph St 3(1)- 2021.
A septated (multi-loculated) collection above the urinary bladder is seen, which is hypoechoic.
Symptomatic lymphocele (multiseptated), compressing urinary bladder.
The patient should undergo tests including complete blood counts, urine routine microscopy and urine culture (to rule out any associated UTI, although no history of fever or dysuria is present).
The fluid from the collection should be aspirated and tested for gram stain, culture (to rule out infection), creatinine and potassium (to rule out urinoma)
Laparoscopic surgery to fenestrate the lymphocele into the peritoneal cavity is the treatment of choice for this symptomatic lymphocele (1,2). This approach has very low recurrence rate as compared to other approaches like aspiration alone, or sclerotherapy.
References:
1) Lucewicz A, Wong G, Lam VW, Hawthorne WJ, Allen R, Craig JC, Pleass HC. Management of primary symptomatic lymphocele after kidney transplantation: a systematic review. Transplantation. 2011 Sep 27;92(6):663-73. doi: 10.1097/TP.0b013e31822a40ef. PMID: 21849931.
2) Gunawansa N, Sharma A, Halawa A. Lymphocele after renal transplantation: A new look at an age-old problem! J Renal Transplant Sci. 2019;2(1): 73-77.
I like your well structured reply.
Describe the image above
USG showed anechoic collection with septa within the collection at inferior to the region between kidney and bladder
What is your diagnosis?
Post transplantation Lymphocele ( symptomatic)
What is your management?
References
I like your well structured reply. But, there are no references! Please type headings as bold or underline. It would make it easier to read.
Multi-loculated, hypoechoic fluid collection above the urinary bladder with debri in collection.
Diagnosis is post-transplant lymphocele
Management by percuteneous aspirated under USS guidance or laparoscopic fenestration
Appropriate antibiotic if infected
Hi Dr Ansary
I like your abbreviated approach.
this image is showing multi loculated cyst above the bladder and causing frequency .
This is most probably lymphocyte,and need to aspirate the fluid for confirmation and it is usually having high urea with normal k and creat similar to the serum .
this complication is seen in the first 3 month post renal transplant
It can cause hydronephrosis and leg edema
Hi Dr Rihab,
I like your abbreviated approach.
1.Describe the image above
Multi-loculated, hypoechoic fluid collection above the urinary bladder.
What is your diagnosis?
Post-transplant lymphocele
What is your management?
-It is symptomatic, so it needs intervention, either:
Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed.
Laparoscopic fenestration
It can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained to the peritoneal cavity whereby the peritoneal lymphatics would drain it into the thoracic duct. It is associated with a lower overall rate of recurrence of 8%, compared with 16% and 51% for open surgery and aspiration therapy, respectively.
Reference:
–Lucewicz et al .Management of Primary Symptomatic Lymphocele After Kidney Transplantation: A Systematic Review Transplantation: September 27, 2011 – Volume 92 – Issue 6 – p 663-673.doi: 10.1097/TP.0b013e31822a40ef
Yes Dr Reem
1. The image above shows a septated fluid collection suggestive of lymphocele, it has clear anechoic appearance that goes with none infected lymphocele. However, it is large enough and cause bladder compressive symptoms as frequency.
2. Diagnosis is none infected lymphocele, however confirmation of the diagnosis includes 2 important steps;
_ US guided aspiration and fluid biochemical analysis for creatinine and K, if higher level than the serum values it is urinoma (urine leakage) if high protein and similar creatinine and K levels to the serum , diagnosis of lymphocele is confirmed
_ in addition, biological analysis for Gran stain and culture to exclude 2 ry infected lymphocele is essential.
_ other parameters to exclude infections as CBC, CRP , procalcitonin are helpful in treatment decision.
_ urine analysis and culture to exclude UTI as a cause of frequency is needed. However presence of such mass can explain frequency in the index case
3. Management :
_ being symptomatic lymphocele so treatment is required by fenestration and peritoneal drainage after Exclusion of infection.
Or laparoscopic drainage and antibiotics for infected ones.
Yes Dr Shawky
A 34-year-old lady with a 3 month ago kidney transplant with normal kidney function but frequently micturition with Ultrasound showed multi-lobulated collection.
The image shows hypo-echoic, with multiple –septate cysts with a collection of fluid that is adjacent to the urinary bladder.
1) Urinoma
2) Seroma
3) An abscess
1) Do a urinalysis or urine dipstick?
2) With ultrasound guidance aspiration of the liquid can be done and compare the characteristic of the urine
3) So serum creatinine and glucose and potassium and compare with the aspiration of the liquid
4) Once it is definitely lymphocele the treatment is election is the aspiration of the fluid under ultrasound guidelines with or without sclerotherapy.
5) Other severe cases can be done with a more invasive procedure like laparoscopic or open surgery to fenestrate the lymphocele into the peritoneal cavity.
References:
Ania, L., et al. Transplantation (2011). Management of primary symptomatic lymphocele after kidney transplantation: A systematic review. September 27, 2011 – Volume 92 – Issue 6 – p 663-673
I like your approach, Dr Badal.
4. A 34-year-old lady received a kidney transplant 3 months ago with stable kidney function. She is complaining of frequency of micturition (10 times/day). Routine USS showed multi-loculated collection above the bladder (see below).
====================================================================
Describe the image above
===================================================================
What is your diagnosis?
Non-surgical risk factors:
-diabetes.
-PKD.
-Donor obesity (BMI>30)
-sirolimus.
-graft rejection.
-Increased recipient age, increased warm ischemia time, acute tubular necrosis and delayed graft function, extended pre-transplant dialysis, and retransplantation.
====================================================================
CLINICAL PRESENTATION:
====================================================================
DIAGNOSIS:
====================================================================
What is your management?
1-Patients who are asymptomatic merely need follow-up.
2-Intraoperative drain
During transplantation, many surgeons install retroperitoneal drains near the graft.
3-Sclerotherapy and aspiration
Aspirating symptomatic lymphoceles under USS supervision is the safest intervention.
4-Fenestration laparoscopic
Fenestrations in the lymphocele capsule may open large lymphoceles into the peritoneal cavity. This drains lymph into the peritoneum. low recurrence rate.
5– Open surgery
Infection (external drainage) or inability to do laparoscopic fenestration need open lymphocele drainage.
====================================================================
Reference
1. Heyman JH, Orron DE, Leiter E. Percutaneous management of postoperative lymphocele. Urology 1989; 34: 221–22.
2-Ebadzadeh MR, Tavakkoli M. Lymphocele after kidney transplantation. Where are we standing now? Urol J 2008; 5: 144–148
3-Braun WE, Banowsky LH, Straffon RA, et al. Lymphocytes associated with renal transplantation. Report of 15 cases and review of the literature. Am J Med 1974; 57: 714–729
4-Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem!
Article · January 2019
5-Lucewicz A, Wong G, Lam VWT, Hawthorne WJ,
Allen R, et al. (2011) Management of primary
symptomatic lymphocele after kidney transplantation: A
systematic review. Transplantation 92: 663-673
I like your summary, Dr WAdi
Hypodense multiloculated homogenous collection above urinary bladder
D/D
lymphocele/ urinoma, hematoma
U/s guided needle aspiration for analysis of the fluid, and culture
if it is not urine by analysis percutaneous drain under-USS- guide (risk of infection)
or if large recurrent laparoscopic fenestration into the peritoneal cavity
Short and sweet reply
There is septated clear fluid collection .
differential diagnoses:
urinoma, loculated ascitic fluid, abscess
ultrasound guided aspiration of fluid for investigation
CBC and ESR
CRP
T.B work up.
That is too brief
*Pelvic US : showed ; multi-loculated cystic lesion above bladder could be urinoma or lymphocele or hematoma.Needs for FNA aspiration and analysis of fluid doing : creatinine, K in fluid , protein content, Gm stain and culture).
is the preferred procedure)
*Lymphocele can be drained laparoscopic marsupialization which; is considered first line for pelvic lymphocele or may left with no intervention if not large nor symptomatic. *Percutaneous aspiration will be done if urinary leak, obstruction.
Hi Dr Omar,
I like your abbreviated approach.
It’s multinloculated cystic lesion above bladder , adjuscent to graft kidney
I will keep D/D of Urinoma and lymphocele.
Septations /loculations favour more towards lymphocele until there is history of long standing frequency with UTI which has led to development of infected urinoma.
Yes Dr Saini, I appreciate your approach but I am not sure if the symptom of longstanding UTI will be of diagnostic value in deciding whether it is infected urinoma or infected lymphocyte.
When infected: always external drainage, not just aspiration. We know that aspiration of that fluid is of immense diagnostic value.
Routine USS showed multi-loculated collection above the bladder Working diagnosis will be directed to types of peri-renal fluid collections, such as lymphocele hematoma or urine leak.
Lymphoceles are collections of lymph caused by leakage from severed lymphatics surrounding the iliac vessels or the renal hilum of the donor kidney.
Some are asymptomatic, the larger the lymphocele, the more likely
it is to cause pain, ureteral obstruction, or venous compression.
Diagnosis:
Simple needle aspiration of the fluid using sterile technique makes the diagnosis. The fluid obtained is clear and has high protein content, and the creatinine concentration approximates that of serum.
Treatment:
*asymptomatic lymphocele: No therapy is necessary
*Percutaneous aspiration should be performed if there is suspicion of a ureteral leak, obstruction, or infection.
*The most common indication for treatment is ureteral obstruction. If the cause of the obstruction is simple compression caused by the mass effect of the lymphocele, drainage alone will resolve the problem.
* treat the infection if present
*Lymphoceles can be drained laparoscopic or open
surgical approach.
Reference
Handbook of
Kidney
Transplantation
Edited by
Gabriel M. Danovitch, MD
Medical Director, Kidney and Pancreas Transplant Program
Ronald Reagan Medical Center at UCLA
John J. Kuiper Chair of Nephrology and Renal Transplantation
Distinguished Professor of Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California
Lymphocele drainage by open surgical technique is of historical importance.
Thank you, Mohamed
This is the typical picture of symptomatic lymphocele. It compresses the bladder. Needs confirmation by aspiration and analysis of the aspirate to make sure it is not a urine leak or infection. To exclude UTI as a cause of frequency. Treatment either by drainage (either laparoscopically into the peritoneal cavity or percutaneously). Sclerosant material could be an option but is much inferior to the other options as the lymphocele is symptomatic and multiloculated.
The US showed multiloculated hypoechoic collection adjacent to the graft and compressing upper the urinary bladder in keeping with the post-transplant collection.
Perinephric post-transplant collection:
-It can be a symptomatic
-May cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression
-Can cause pressure on the hilar vessels, can lead to impaired graft function and may even lead to a catastrophic renal artery or vein thrombosis. Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
The differential includes:
-Lymphoceles.
-Seroma.
-Urinary leaks (urinomas)
-Perinephric hematomas
In the index case, lymphocele is likely.
Lymphocele:
-Resulting from the disruption of lymphatics in the recipient or leaking lymph from the donor kidney that accumulates to form a cystic lesion composed mainly of lymphocytes
– the reported incidence shows a wide variation ranging from 0.6% to 34%
– Occurs as early as 1-2 weeks after transplant and may occur several months to years after transplantation.
Urinary leak (urinoma)
-Typically presents in the first few weeks post-transplantation
– Urinary extravasation may be a result of distal ureteric ischemia.
– Presented with increasing wound drainage, decreasing urine output and severe pain over the allograft.
Diagnosis:
– US as an initial screening.
– Sometimes, CT may be required to determine the collection and its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter.
– US-guided aspiration for diagnostic and therapeutic options.
– Send for biochemical analysis of fluid (creatinine, electrolytes(K), protein content, gram stain and culture) allows differentiation of seroma and lymphocele from the urinary leak.
– Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes.
Lymphocele: The fluid is clear and has high protein content, and the creatinine concentration approximates serum.
Urinoma: clear fluid with very high creatinine compared to the serum and high potassium.
If a leak is suspected:
– Ascending cystogram to detect the leak and its level
– Nuclear to confirm the leak.
– DJ stenting.
Management of post-transplant collection:
Depending on the size, extent and location in relation to the allograft and pressure effects:
The majority are asymptomatic, are self-limiting, and do not require specific treatment (conservative management with US monitoring).
Symptomatic collection with presser effect:
-Infected collection needs to be treated with an antibiotic.
– Urinary catheterization to relieve pressure symptoms.
– Percutaneous aspiration and placement of a drain to minimize re-accumulation; however, the risk of infection is high.
-Drainage followed by sclerotherapy to sclerose open lymphatics sclerotherapy is another option.
– Laparoscopic fenestration if large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained to the peritoneal cavity, whereby the peritoneal lymphatics would drain it into the thoracic duct.
– Open drainage carries a significantly higher risk of ureteric damage.
REFERENCES
– Samuel Palli, Tariq Zayan, Ajay Sharma, and Ahmed Halawa. Approach to Increased Drain Output Post-Kidney Transplantation. Journal of Renal Transplantation Science JRTS, 1(1): 14-19
– Sharma R., Patel S., Laftavi M. and Zachariah M. Urinary obstruction from lymphocele. Kidney International, 2015; 87: 2245.
– Lucewicz A., Wong G., Lam V., Hawthorne W., Allen R., et al. Management of primary symptomatic lymphocele after kidney transplantation: a systemic review. Transplantation, 2011: 92(6):663-673.
– Guanawansa N., Sharma A. and Halawa A. Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem. JRTS, 2019; 2(1): 73-77.
Thank you
This is the typical picture of symptomatic lymphocele. It compresses the bladder. Needs confirmation by aspiration and analysis of the aspirate to make sure it is not a urine leak or infection. To exclude UTI as a cause of frequency. Treatment either by drainage (either laparoscopically into the peritoneal cavity or percutaneously). Sclerosant material could be an option but is much inferior to the other options as the lymphocele is symptomatic and multiloculated.
What is your diagnosis? Mostly Lymphocele
Peritransplant fluid collections consist of blood, urine, lymph, or pus
1. Lymphoceles
· Are the most common peritransplant fluid collection
· Usually accumulate several weeks to months after surgery.
· Usually appear as septated hypoechoic fluid collections
2. Hematomas
· The most common peri transplant fluid collections in the immediate postoperative period
· It could be subcapsular or extra-renal in location
· It could be large enough to cause allograft collecting system obstruction
· In the acute phase, it appears echogenic on US and hyperdense on CT
· Progressively decreasing in echogenicity on US and density on CT as hemolysis occurs
3. Urinomas
· result from urine extravasation from the allograft pelvis, ureter, or ureteroneocystostomy due to:
a.incomplete bladder closure
b.ureterovesicular anastomotic leak,
c.collecting system ischemia,
d.collecting system rupture from pressure related to severe obstruction, or as a complication of biopsy
· Cystography can be performed to determine whether the bladder is the source of leak
· appear as simple hypoechoic fluid collections
· If urine leakage is active, a contrast-enhanced CT or MR may be acquired in the delayed phase to confirm presence of urine within the peri-transplant fluid collection
· ultrasound-guided fluid aspiration may be obtained for creatinine analysis
4. Abscesses
· generally, occur 4 to 5 weeks after transplantation
· appear as complicated fluid collections, usually cystic with a thick wall surrounding a central cystic area
· Both US and CT enable rapid diagnosis and provide imaging guidance for aspiration and drainage.
· the absence of imaging features characteristic of an abscess does not exclude the presence of infection
What is your management?
· A specimen gram stain, culture, and creatinine should always be sent to exclude infection and urine leak, respectively
· Symptomatic lymphoceles can be aspirated under USS guidance
· Some clinicians recommend placement of a percutaneous drain to prevent re-accumulation, but external drainage always get infected.
· Large lymphoceles can be opened into the peritoneal cavity by Laparoscopic fenestration
Handbook of Kidney Transplantation Edited by Gabriel M. Danovitch, MD
Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem! Nalaka Gunawansa1,2* , Ajay Sharma2,3 and Ahmed Halawa2,4
Thank you
This is the typical picture of symptomatic lymphocele. It compresses the bladder. Needs confirmation by aspiration and analysis of the aspirate to make sure it is not a urine leak or infection. To exclude UTI as a cause of frequency. Treatment either by drainage (either laparoscopically into the peritoneal cavity or percutaneously). Sclerosant material could be an option but is much inferior to the other options as the lymphocele is symptomatic and multiloculated.
The above image shows hypo-echoic, multiple-septated cysts with fluid collection adjacent to the urinary bladder
– lymphocele
– hematoma
– infection and abscess
– urine leak and urinoma
This mass compresses the bladder and causes an intermittent need for evacuation of the urinary bladder
We need to know I the frequency only increased or the amount also to r/o DI
US or CT guided aspiration of those cysts for cytology
Send sample creatinine along with serum creatinine to r/o urinoma
Monitor rft, inflammatory markers
Thank you
This is the typical picture of symptomatic lymphocele. It compresses the bladder. Needs confirmation by aspiration and analysis of the aspirate to make sure it is not a urine leak or infection. To exclude UTI as a cause of frequency. Treatment either by drainage (either laparoscopically into the peritoneal cavity or percutaneously). Sclerosant material could be an option but is much inferior to the other options as the lymphocele is symptomatic and multiloculated.