Khauli Rb

Post-Transplant Lymphoceles: A Critical Look into the Risk Factors, Pathophysiology and Management

To define better the prevalence and pathophysiology of lymphoceles following renal transplantation, we prospectively evaluated 118 consecutive renal transplants performed in 115 patients (96 cadaveric, 22 living-related, 7 secondary and 111 primary). Ultrasonography was performed post-operatively and during rehospitalizations or whenever complications occurred. Perirenal fluid collections were identified in 43 patients (36%). Lymphoceles with a diameter of 5 cm. or greater were identified in 26 of 118 cases (22%). Eight patients (6.8%) had symptomatic lymphoceles requiring therapy. The interval for development of symptomatic lymphoceles was 1 week to 3.7 years (median 10 months). Risk factors for the development of lymphoceles were examined by univariate and multivariate analysis, and included patient age, sex, source of transplants (cadaver versus living-related donor), retransplantation, tissue match (HLA-B/DR), type of preservation, arterial anastomosis, occurrence of acute tubular necrosis-delayed graft function, occurrence of rejection, and use of high dose corticosteroids. Univariate analysis showed a significant risk for the development of lymphoceles in transplants with acute tubular necrosis-delayed graft function (odds ratio 4.5, p = 0.004), rejection (odds ratio 25.1 p < 0.001) and high dose steroids (odds ratio 16.4, p < 0.001). When applying multivariate analyses using stepwise logistic regression, only rejection was associated with a significant risk for lymphoceles (symptomatic lymphoceles--odds ratio 25.08, p = 0.0003, all lymphoceles--odds ratio 75.24, p < 0.0001). When adjusting for rejection, no other risk factor came close to being significant (least p = 0.4). Therapy included laparoscopic peritoneal marsupialization and drainage in 1 patient, incisional peritoneal drainage in 4 and percutaneous external drainage in 3 (infected). All symptomatic lymphoceles were successfully treated without sequelae to grafts or patients. We conclude that allograft rejection is the most significant factor contributing to the development of lymphoceles. Therapy of symptomatic lymphoceles should be individualized according to the presence or absence of infection.

Treatment of Lymphocele and Lymphatic Fistula Following Renal Transplantation by Laparoscopic Peritoneal Window

Symptomatic lymphoceles that occur after renal transplantation are managed best by surgical marsupialization with drainage into the peritoneal cavity. We report a case of post-transplant lymphocele associated with a cutaneous lymphatic fistula, which was successfully treated using laparoscopic drainage without a major surgical incision. With this new technique we were able to remove an ellipse of peritoneal wall along with the adjacent lymphocele wall and to lyse all internal lymphocele loculations, allowing for the free flow of lymph into the peritoneal cavity and cessation of cutaneous leakage. We believe that, when technically possible, laparoscopic internal peritoneal drainage is an effective procedure for managing simple and complex symptomatic lymphoceles with or without associated lymphatic fistulas, provided there is no evidence of infection.

Defining the Role of Renal Angiography in the Diagnosis of Renal Artery Disease

The current goal of angiography in the diagnosis of renal artery disease is poorly defined, probably because of the diversity of patients presenting for management. The current application of angiography is better understood when put into perspective with the patient population that we are trying to screen. There are two distinct patient populations with renovascular disease: those with uncontrolled hypertension and those with azotemia or risk of progression to end-stage renal disease. The role of angiography in these two patient populations is quite different. In patients with hypertensive renovascular disease, angiography should be applied rather late and should be preceded by other noninvasive testing to screen patients from those with essential hypertension, since the prevalence of this disease is low and the cost implications of applying angiography primarily are immense. The two promising tests in this setting are captropril renography and duplex ultrasound scanning. In contradistinction, patients with azotemic renovascular disease, suffering from bilateral renal artery stenoses, or suffering from stenosis of the renal artery in a solitary kidney may be better studied by early application of renal angiography, especially those at risk of progression and for whom intervention is indicated.

Nonoperative Management of Post-Transplantation Bladder Leak: Serendipitous Salutary Effect of Temporary Cyclosporine Nephrotoxicity and Oligoanuria

Post-transplantation bladder leak, a potentially serious complication, is traditionally managed by reexploration and closure, and may require percutaneous placement of a nephrostomy tube. We report intractable bladder leakage that persisted following reclosure in a patient who also had cyclosporine nephrotoxicity. The attendant oligoanuria obviated the need for nephrostomy drainage and allowed healing of the bladder leak. The patient subsequently recovered from cyclosporine injury and regained renal function.