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Postoperative Pelvic Lymphocysts
Vol. 108, October Printed in U.S.A.
THE JouRNAL OF UROLOGY
Copyright
© 1972 by The Williams & Wilkins Co.
POSTOPERATIVE PELVIC LYMPHOCYSTS JAMES R. GEYER
AND
JAMES A. MERRILL
From the Departments of Urology and Gynecology and Obstetrics, The University of Oklahoma Medical Center, Oklahoma City, Oklahoma
A lymphocyst, sometimes called a lymphocele, is a complication of radical pelvic operation which may cause hydronephrosis. It was first described by Kobayashi1 in 1950 but escaped attention in theurologic literature until the report by Griffith and Carlton2 in 1970. All known cases except one have been subsequent to radical hysterectomy and pelvic lymphadenectomy, or pelvic lymphadenectomy in conjunction with radiation therapy, for carcinoma of the cervix or endometrium. It is important to differentiate this complication from a pelvic abscess or ureteral injury, because even a large lymphocyst is likely to regress spontaneously if given enough time, while an attempt at surgical drainage may add to the morbidity. The case reported herein illustrates the non-operative management of bilateral pelvic lymphocysts during an 8-month period. CASE REPORT
E. C., UH 41-93-44, a 47-year-old Para 9, gravida 6 black woman, had received radium and x-ray therapy for stage II B carcinoma of the cervix in July 1967. She was referred to this hospital in July 1969 for treatment of a recurrence proved by cervical biopsy. Physical examination revealed a tall, slender woman in no distress. The only abnormal finding was an irregular crater of the cervix extending into the right fornix of the vagina. The corpus of the uterus was small, anterior and mobile; there was minimal induration of the right parametrium. The blood count, urinalysis and blood urea nitrogen (BUN) were normal. Culture of the urine was sterile. The roentgenogram of the chest and the excretory urogram (IVP) appeared normal. Cystoscopy and sigmoidoscopy were normal except that the bladder and the rectum appeared pale as a result of the irradiation. Radical hysterectomy with bilateral pelvic lymphadenectomy was performed under general anesthesia. Blood loss was estimated to be 600 ml. The abdomen and vagina were closed without drainage. The pathological diagnosis was squamous cell carcinoma of the cervix and the margins of the specimen and 9 lymph nodes were free of tumor. The patient had a fever for the first 3 days postoperatively and again during the entire second week Accepted for publication January 7, 1972. Kobayashi, T. and Inoue, S.: Lymphatic cyst seen after radical hysterectomy for cancer of the uterine cervix and its clinical significance. Clin. Gynec. Obst. Tokyo, 4: 91, 1950. 2 Griffith, D. P. and Carlton, C. E.: Lymphocyst: an unusual cause of ureteral obstruction. J. Urol., 1
103; 43, 1970.
with daily elevations of temperature from 38.5C to 39.9C. Then a pelvic abscess started to drain through the vagina. Culture of the vaginal drainage and the blood cultures yielded Bacteroides species, sensitive to tetracycline and ampicillin, which had been given throughout the febrile period. The patient's fever and general condition improved rapidly. When she was discharged from the hospital 23 days postoperatively the Foley urethral catheter remained indwelling. Complaints of pain in the lower abdomen, slight swelling of the left thigh and leg, chills and fever prompted rehospitalization in September. Pelvic examination revealed tender, firm, rather discrete indurated areas on both sides of the pelvis. Urinalysis was normal, culture of the urine from the urethral catheter yielded Klebsiella and the BUN was 11 mg. per cent. IVP demonstrated right hydronephrosis and absence of function of the left kidney (fig. 1, A). Cystoscopy revealed edema of the posterior wall and floor of the bladder. Number 5F catheters were passed in both ureters, obtaining a hydronephrotic drip from each kidney. Cultures of these urine specimens were sterile. After 3 days the right ureteral catheter was removed and a pull-out pyelogram showed constriction of the distal ureter (fig. 1, B). The left ureteral catheter was removed 4 days later; again a pull-out pyelogram demonstrated constriction of the distal ureter. Kanamycin was administered on the basis of sensitivity testing of the Klebsiella. The patient was discharged from the hospital without the urethral catheter after her temperature had been normal for a week and the swelling of the left lower extremity had diminished. The patient was admitted to the hospital again in October with painless swelling of the left thigh and leg of a moderate degree. There was also edema of the right labium majus, and a 5 by 5 cm. cyst was palpated in the left iliac fossa. A lymphocyst could not be palpated on the right side. Right hydronephrosis, absence of function in the left kidney and an hourglass configuration of the bladder were noted on the IVP (fig. 2, A). The swelling of the left lower extremity improved with elastic stockings and bed rest. An IVP in the outpatient clinic in December disclosed return of function to the left kidney. However, it was necessary to admit the patient to the hospital again in January 1970 because of pain in the left renal area and low grade fever. Pelvic examination revealed considerable reduction in the size of the left lymphocyst and the left thigh was not as swollen as it had been. Although the urinalysis was normal and urine culture was sterile, ampicillin was given. The fever disappeared after 5 days. BUN was 9 mg per 0
623
624
GEYER AND MERRILL
Frn. 1. A, IVP in September 1969, 5 weeks after radical hysterectomy and pelvic lymphadenectomy. B, right pyeloureterogram as catheter was withdrawn and left retrograde pyelogram in September 1969.
Incidence. The first 3 reports in the American literature listing the incidence of lymphocyts after pelvic lymphadenectomy presented somewhat varying figures: Gray found the incidence to be 16.4 per cent in 55 cases, Rutledge reported 24 per cent in 281 cases and Ferguson reported 12.6 per cent in 95 cases. 0- 5 Etiology. The division of afferent lymphatic vessels initiates the formation of lymphocysts. Nelson found contrast material pooled in the pelvis on a lymph-
angiogram 2 weeks postoperatively. 6 Griffith and Carlton2 used lymphangiography to demonstrate a lymphocyte at 6 weeks and Weingold and associates7 similarly diagnosed lymphocysts at 9 months and 5 years. Earlier evidence of the dynamic state of the lymphocyst fluid included the re-accumulation of cyst fluid after aspiration, recovery from the cyst of indigo carmine originally injectei into the lower extremity, urinary excretion of indigo carmine which had been injected into the cyst and disappearance of radiopaque material from the cyst. 8 Mori found that the average number of lymph nodes removed was greater in patients in whom a lymphocyst developed than in others and that the lymphocyst occurred more often on the side with the greater number of lymph nodes. 8 Since the left side was involved more frequently, he considered a possible relationship to the increased incidence of iliofemoral vein thrombosis on the left. No correlation with preJperative irradiation, operative hemorrhage or postoperative infection was apparent.
' Gray, M. J., Plentl, A. A. and Taylor, H. C., Jr.: The lymphocyst: a complication of pelvic lymph node dissections. Amer. J. Obst. Gynec., 75: 1059,
6 Nelson, J. H., Jr., Roberson, J. 0. and Masterson, J. G.: Regeneration of pelvic lymph nodes after pelvic lymphadenectomy. Amer. J. Obst. Gynec., 93: 102,
cent and the creatinine clearance was 62 ml. per minute. The IVP was comparable to the one in early December 1969. Subsequently, the patient was followed in the outpatient clinic. By March 1970 the left lymphocyst had disappeared completely. The IVP revealed corresponding improvement in the function and drainage of the 2 kidneys (fig. 2, B). The length of the left kidney was only 11.5 cm., compared to its length of 13.7 cm. preoperatively, indicating some atrophy. DISCUSSION
1958.
1965.
Rutledge, F., Dodd, G. D., Jr. and Kasilag, F. B,, Jr.: Lymphocysts: a complication of radical pelvic surgery. Amer. J. Obst. Gynec., 77: 1165, 1959. 6 Ferguson, J. H. and Maclure, J. G.: Lymphocele following lymphadenectomy. Amer. J. Obst. Gynec.,
95: 304, 1967.
82: 783, 1961.
2: 178, 1955.
4
7 Weingold, A. B., Olivo, E. and Marino, J.: Pelvic lymphocyst: diagnosis and management. Arch. Surg., 8 Mori, N.: Clinical and experimental studies on the so-called lymphocyst. J. Jap. Obst. Gynec. Soc.,
POSTOPERATIVE PELVIC LYMPHOCYSTS
625
Fm. 2. A, IVP in October 1969 shows hourglass configuration of the bladder. B, IVP in March 1970 Prevention. Several investigators have advocated careful ligation of lymphatics at the inguinal ligament and in the obturator fossa during the pelvic lymphadenectomy to prevent the pooling of lymph which leads to cyst formation. 5 , 8 , 9 The effectiveness of this technique is obscured by the high incidence of lymphocysts reported from several centers. It should be just as important to avoid unnecessary extension of the dissection with prolonged operating time. According to Rutledge, leaving the pelvic peritoneum open with a free connection between the dissection site and the abdominal cavity or placing drains down to the dissection site did not prevent lymphocyst formation. 4 He also stated that intramuscular trypsin did not lower their incidence but their average size seemed to be reduced. Symmonds and Pratt cautioned against vaginal drainage after radical hysterectomy and pelvic lymphadenectomy because of the possibility of infection resulting in vesicovaginal or ureterovaginal fistulas. 10 They recommended extraperitoneal suction catheters in both iliac fossas but did not give the incidence of lymphocysts. At the University of Okla9 Byron, R. L., Jr., Yonemoto, R. H., Davajan, V., Townsend, D., Bashore, R. and Morton, D. G.: Lymphocysts: surgical correction and prevention. Amer. J. Obst. Gynec., 94: 203, 1966. 10 Symmonds, R. E. and Pratt, J. H.: Prevention of fistulas and lymphocysts in radical hysterectomy. Preliminary report of a new technic. Obst. Gynec., 17: 57, 1961.
homa Medical Center the abdomen and vagina are closed without drainage unless an unsuspected adnexal abscess or another source of infection is discovered during the operation. Symptoms and findings. Depending on its size and location a lymphocyst may compress the ureter, bladder, sigmoid colon and iliac blood vessels. Small lymphocysts are asymptomatic while the larger ones may cause local pain of a minor degree, urinary frequency, constipation, edema of the mons pubis and labia, and pain and edema in the lower extremity. In Ferguson's series of 12 patients, 7 had pyelonephritis and 4 had edema of a lower extremity. 5 Eighty to 90 per cent of lymphocysts arc apparent by 3 weeks postoperatively. 4 , 8 There may be a visible prominence of the lower abdomen above the inguinal ligament and the lymphocyst can be palpated in the iliac fossa by abdominal or pelvic examination. Sometimes it bulges into the vagina. One may get an exaggerated impression of its true size from the edema in the surrounding tissues. The larger cysts sometimes feel fluctuant and extension of the leg may be painful. In Mori's cases, 44.5 per cent of the lymphocysts were the size of a hen's egg and only 2 per cent were the size of a fist. 8 Ferguson found larger cysts containing an average of 300 ml. of fluid and he once aspirated 700 ml. of fluid. 5 Aspiration reveals clear, yellowish or sometimes colorless fluid-like urine or serum in which a network of fibrin may form.
626
GEYER AND MERRILL
Lymphocysts are usually unilocular and the cyst wall varies from 1 to 3 mm. in thickness. Radiologic examination. The IVP commonly shows anterior or medial displacement of the ureter and ureteral obstruction. The cystogram shows indentation of the bladder with an hourglass configuration if lymphocysts are present bilaterally. Cyst puncture to instill radiopaque material is not recommended because of the danger of introducing infection. Venography should not be necessary. As mentioned earlier, Weingold and associates7 and Griffith and Carlton2 have employed lymphangiography to verify the diagnosis. Treatment. Spontaneous regression of lymphocysts is well documented in the literature. In Mori's series of 71 cases, 70 per cent of the lymphocysts were absorbed by 50 days postoperatively; another 3 per cent persisted more than 6 months and 4 per cent were present for more than a year. 8 Rutledge found that observation was usually adequate for the smaller lymphocysts even though absorption occurred slowly over a period of several months. 4 Ferguson reported that 5 lymphocysts disappeared between 4 and 78 weeks postoperatively with an average time of 25 weeks. 5 Non-operative management consists of bed rest for pain and edema of the leg, antibiotic therapy of pelvic and urinary infections, serial IVPs in cases of ureteral obstruction and ureteral catheterization of an infected hydronephrotic kidney. Fitted elastic stockings help to control leg edema and hasten ambulation. When cystoscopy is performed in the early postoperative period, the bladder should not be overdistended because the surgical dissection may have compromised the vesical wall. Retrograde ureteropyelograms with a cone-tip or Braasch bulb catheter in the ureteral orifice afford the best demonstration of the distal ureter to rule out a urinary fistula or extravasation. If a ureteral catheter is left indwelling thorough perinea! care must be rendered daily. The catheter may be irrigated with diluted polymyxin solution if it becomes plugged. A large fraction of the
urine drains around the smaller caliber ureteral catheters to enter the bladder. Creatinine clearance determinations provide a means for assessing the effect of prolonged bilateral hydronephrosis. Some sacrifice of renal function can be tolerated in individualizing treatment for cases of recurrent carcinoma after irradiation, just as nephrectomy would be acceptable management for a ureterovaginal fistula under similar conditions if the contralateral kidney were normal. Several investigators have considered pyelonephritis, hydronephrosis and edema of the leg as indications for surgical intervention at least in cases of large lymphocysts. 2 • 4 • 5 Aspiration has been discouraged because of the rapid re-accumulation of fluid, the necessity for multiple taps and the possibility of introducing infection. In some instances, infection of the cyst contents has resulted in intractable pelvic wall abscesses because tissue damage from prior irradiation precluded healing. 11 Likewise, incision and external drainage may be complicated by prolonged drainage or infection. Internal drainage as described by Byron seems to be a safer approach: a transperitoneal window is made in the cyst, the fluid is evacuated and either the sigmoid colon or the cecum is anchored to the posterior wall of the cyst, depending on the side involved. 9 In our opinion surgical drainage should be avoided as long as possible to afford an opportunity for the spontaneous regression of the lymphocyst. SUMMARY
Hydronephrosis after radical pelvic operation may be caused by a lymphocyst. It is important to differentiate this complication from a pelvic abscess or ureteral injury because even a large lymphocyst is likely to regress spontaneously if given enough time and surgical intervention carries a high risk of morbidity. A case is presented in which non-operative management was successful. 11 Rutledge, F. N., Gletcher, G. H. and MacDonald, E. J.: Pelvic lymphadenectomy as an adjunct to radiation therapy in treatment for cancer of the cervix. Amer. J. Roentgen., 93: 607, 1965.
THE JouRNAL OF UROLOGY
Copyright
© 1972 by The Williams & Wilkins Co.
POSTOPERATIVE PELVIC LYMPHOCYSTS JAMES R. GEYER
AND
JAMES A. MERRILL
From the Departments of Urology and Gynecology and Obstetrics, The University of Oklahoma Medical Center, Oklahoma City, Oklahoma
A lymphocyst, sometimes called a lymphocele, is a complication of radical pelvic operation which may cause hydronephrosis. It was first described by Kobayashi1 in 1950 but escaped attention in theurologic literature until the report by Griffith and Carlton2 in 1970. All known cases except one have been subsequent to radical hysterectomy and pelvic lymphadenectomy, or pelvic lymphadenectomy in conjunction with radiation therapy, for carcinoma of the cervix or endometrium. It is important to differentiate this complication from a pelvic abscess or ureteral injury, because even a large lymphocyst is likely to regress spontaneously if given enough time, while an attempt at surgical drainage may add to the morbidity. The case reported herein illustrates the non-operative management of bilateral pelvic lymphocysts during an 8-month period. CASE REPORT
E. C., UH 41-93-44, a 47-year-old Para 9, gravida 6 black woman, had received radium and x-ray therapy for stage II B carcinoma of the cervix in July 1967. She was referred to this hospital in July 1969 for treatment of a recurrence proved by cervical biopsy. Physical examination revealed a tall, slender woman in no distress. The only abnormal finding was an irregular crater of the cervix extending into the right fornix of the vagina. The corpus of the uterus was small, anterior and mobile; there was minimal induration of the right parametrium. The blood count, urinalysis and blood urea nitrogen (BUN) were normal. Culture of the urine was sterile. The roentgenogram of the chest and the excretory urogram (IVP) appeared normal. Cystoscopy and sigmoidoscopy were normal except that the bladder and the rectum appeared pale as a result of the irradiation. Radical hysterectomy with bilateral pelvic lymphadenectomy was performed under general anesthesia. Blood loss was estimated to be 600 ml. The abdomen and vagina were closed without drainage. The pathological diagnosis was squamous cell carcinoma of the cervix and the margins of the specimen and 9 lymph nodes were free of tumor. The patient had a fever for the first 3 days postoperatively and again during the entire second week Accepted for publication January 7, 1972. Kobayashi, T. and Inoue, S.: Lymphatic cyst seen after radical hysterectomy for cancer of the uterine cervix and its clinical significance. Clin. Gynec. Obst. Tokyo, 4: 91, 1950. 2 Griffith, D. P. and Carlton, C. E.: Lymphocyst: an unusual cause of ureteral obstruction. J. Urol., 1
103; 43, 1970.
with daily elevations of temperature from 38.5C to 39.9C. Then a pelvic abscess started to drain through the vagina. Culture of the vaginal drainage and the blood cultures yielded Bacteroides species, sensitive to tetracycline and ampicillin, which had been given throughout the febrile period. The patient's fever and general condition improved rapidly. When she was discharged from the hospital 23 days postoperatively the Foley urethral catheter remained indwelling. Complaints of pain in the lower abdomen, slight swelling of the left thigh and leg, chills and fever prompted rehospitalization in September. Pelvic examination revealed tender, firm, rather discrete indurated areas on both sides of the pelvis. Urinalysis was normal, culture of the urine from the urethral catheter yielded Klebsiella and the BUN was 11 mg. per cent. IVP demonstrated right hydronephrosis and absence of function of the left kidney (fig. 1, A). Cystoscopy revealed edema of the posterior wall and floor of the bladder. Number 5F catheters were passed in both ureters, obtaining a hydronephrotic drip from each kidney. Cultures of these urine specimens were sterile. After 3 days the right ureteral catheter was removed and a pull-out pyelogram showed constriction of the distal ureter (fig. 1, B). The left ureteral catheter was removed 4 days later; again a pull-out pyelogram demonstrated constriction of the distal ureter. Kanamycin was administered on the basis of sensitivity testing of the Klebsiella. The patient was discharged from the hospital without the urethral catheter after her temperature had been normal for a week and the swelling of the left lower extremity had diminished. The patient was admitted to the hospital again in October with painless swelling of the left thigh and leg of a moderate degree. There was also edema of the right labium majus, and a 5 by 5 cm. cyst was palpated in the left iliac fossa. A lymphocyst could not be palpated on the right side. Right hydronephrosis, absence of function in the left kidney and an hourglass configuration of the bladder were noted on the IVP (fig. 2, A). The swelling of the left lower extremity improved with elastic stockings and bed rest. An IVP in the outpatient clinic in December disclosed return of function to the left kidney. However, it was necessary to admit the patient to the hospital again in January 1970 because of pain in the left renal area and low grade fever. Pelvic examination revealed considerable reduction in the size of the left lymphocyst and the left thigh was not as swollen as it had been. Although the urinalysis was normal and urine culture was sterile, ampicillin was given. The fever disappeared after 5 days. BUN was 9 mg per 0
623
624
GEYER AND MERRILL
Frn. 1. A, IVP in September 1969, 5 weeks after radical hysterectomy and pelvic lymphadenectomy. B, right pyeloureterogram as catheter was withdrawn and left retrograde pyelogram in September 1969.
Incidence. The first 3 reports in the American literature listing the incidence of lymphocyts after pelvic lymphadenectomy presented somewhat varying figures: Gray found the incidence to be 16.4 per cent in 55 cases, Rutledge reported 24 per cent in 281 cases and Ferguson reported 12.6 per cent in 95 cases. 0- 5 Etiology. The division of afferent lymphatic vessels initiates the formation of lymphocysts. Nelson found contrast material pooled in the pelvis on a lymph-
angiogram 2 weeks postoperatively. 6 Griffith and Carlton2 used lymphangiography to demonstrate a lymphocyte at 6 weeks and Weingold and associates7 similarly diagnosed lymphocysts at 9 months and 5 years. Earlier evidence of the dynamic state of the lymphocyst fluid included the re-accumulation of cyst fluid after aspiration, recovery from the cyst of indigo carmine originally injectei into the lower extremity, urinary excretion of indigo carmine which had been injected into the cyst and disappearance of radiopaque material from the cyst. 8 Mori found that the average number of lymph nodes removed was greater in patients in whom a lymphocyst developed than in others and that the lymphocyst occurred more often on the side with the greater number of lymph nodes. 8 Since the left side was involved more frequently, he considered a possible relationship to the increased incidence of iliofemoral vein thrombosis on the left. No correlation with preJperative irradiation, operative hemorrhage or postoperative infection was apparent.
' Gray, M. J., Plentl, A. A. and Taylor, H. C., Jr.: The lymphocyst: a complication of pelvic lymph node dissections. Amer. J. Obst. Gynec., 75: 1059,
6 Nelson, J. H., Jr., Roberson, J. 0. and Masterson, J. G.: Regeneration of pelvic lymph nodes after pelvic lymphadenectomy. Amer. J. Obst. Gynec., 93: 102,
cent and the creatinine clearance was 62 ml. per minute. The IVP was comparable to the one in early December 1969. Subsequently, the patient was followed in the outpatient clinic. By March 1970 the left lymphocyst had disappeared completely. The IVP revealed corresponding improvement in the function and drainage of the 2 kidneys (fig. 2, B). The length of the left kidney was only 11.5 cm., compared to its length of 13.7 cm. preoperatively, indicating some atrophy. DISCUSSION
1958.
1965.
Rutledge, F., Dodd, G. D., Jr. and Kasilag, F. B,, Jr.: Lymphocysts: a complication of radical pelvic surgery. Amer. J. Obst. Gynec., 77: 1165, 1959. 6 Ferguson, J. H. and Maclure, J. G.: Lymphocele following lymphadenectomy. Amer. J. Obst. Gynec.,
95: 304, 1967.
82: 783, 1961.
2: 178, 1955.
4
7 Weingold, A. B., Olivo, E. and Marino, J.: Pelvic lymphocyst: diagnosis and management. Arch. Surg., 8 Mori, N.: Clinical and experimental studies on the so-called lymphocyst. J. Jap. Obst. Gynec. Soc.,
POSTOPERATIVE PELVIC LYMPHOCYSTS
625
Fm. 2. A, IVP in October 1969 shows hourglass configuration of the bladder. B, IVP in March 1970 Prevention. Several investigators have advocated careful ligation of lymphatics at the inguinal ligament and in the obturator fossa during the pelvic lymphadenectomy to prevent the pooling of lymph which leads to cyst formation. 5 , 8 , 9 The effectiveness of this technique is obscured by the high incidence of lymphocysts reported from several centers. It should be just as important to avoid unnecessary extension of the dissection with prolonged operating time. According to Rutledge, leaving the pelvic peritoneum open with a free connection between the dissection site and the abdominal cavity or placing drains down to the dissection site did not prevent lymphocyst formation. 4 He also stated that intramuscular trypsin did not lower their incidence but their average size seemed to be reduced. Symmonds and Pratt cautioned against vaginal drainage after radical hysterectomy and pelvic lymphadenectomy because of the possibility of infection resulting in vesicovaginal or ureterovaginal fistulas. 10 They recommended extraperitoneal suction catheters in both iliac fossas but did not give the incidence of lymphocysts. At the University of Okla9 Byron, R. L., Jr., Yonemoto, R. H., Davajan, V., Townsend, D., Bashore, R. and Morton, D. G.: Lymphocysts: surgical correction and prevention. Amer. J. Obst. Gynec., 94: 203, 1966. 10 Symmonds, R. E. and Pratt, J. H.: Prevention of fistulas and lymphocysts in radical hysterectomy. Preliminary report of a new technic. Obst. Gynec., 17: 57, 1961.
homa Medical Center the abdomen and vagina are closed without drainage unless an unsuspected adnexal abscess or another source of infection is discovered during the operation. Symptoms and findings. Depending on its size and location a lymphocyst may compress the ureter, bladder, sigmoid colon and iliac blood vessels. Small lymphocysts are asymptomatic while the larger ones may cause local pain of a minor degree, urinary frequency, constipation, edema of the mons pubis and labia, and pain and edema in the lower extremity. In Ferguson's series of 12 patients, 7 had pyelonephritis and 4 had edema of a lower extremity. 5 Eighty to 90 per cent of lymphocysts arc apparent by 3 weeks postoperatively. 4 , 8 There may be a visible prominence of the lower abdomen above the inguinal ligament and the lymphocyst can be palpated in the iliac fossa by abdominal or pelvic examination. Sometimes it bulges into the vagina. One may get an exaggerated impression of its true size from the edema in the surrounding tissues. The larger cysts sometimes feel fluctuant and extension of the leg may be painful. In Mori's cases, 44.5 per cent of the lymphocysts were the size of a hen's egg and only 2 per cent were the size of a fist. 8 Ferguson found larger cysts containing an average of 300 ml. of fluid and he once aspirated 700 ml. of fluid. 5 Aspiration reveals clear, yellowish or sometimes colorless fluid-like urine or serum in which a network of fibrin may form.
626
GEYER AND MERRILL
Lymphocysts are usually unilocular and the cyst wall varies from 1 to 3 mm. in thickness. Radiologic examination. The IVP commonly shows anterior or medial displacement of the ureter and ureteral obstruction. The cystogram shows indentation of the bladder with an hourglass configuration if lymphocysts are present bilaterally. Cyst puncture to instill radiopaque material is not recommended because of the danger of introducing infection. Venography should not be necessary. As mentioned earlier, Weingold and associates7 and Griffith and Carlton2 have employed lymphangiography to verify the diagnosis. Treatment. Spontaneous regression of lymphocysts is well documented in the literature. In Mori's series of 71 cases, 70 per cent of the lymphocysts were absorbed by 50 days postoperatively; another 3 per cent persisted more than 6 months and 4 per cent were present for more than a year. 8 Rutledge found that observation was usually adequate for the smaller lymphocysts even though absorption occurred slowly over a period of several months. 4 Ferguson reported that 5 lymphocysts disappeared between 4 and 78 weeks postoperatively with an average time of 25 weeks. 5 Non-operative management consists of bed rest for pain and edema of the leg, antibiotic therapy of pelvic and urinary infections, serial IVPs in cases of ureteral obstruction and ureteral catheterization of an infected hydronephrotic kidney. Fitted elastic stockings help to control leg edema and hasten ambulation. When cystoscopy is performed in the early postoperative period, the bladder should not be overdistended because the surgical dissection may have compromised the vesical wall. Retrograde ureteropyelograms with a cone-tip or Braasch bulb catheter in the ureteral orifice afford the best demonstration of the distal ureter to rule out a urinary fistula or extravasation. If a ureteral catheter is left indwelling thorough perinea! care must be rendered daily. The catheter may be irrigated with diluted polymyxin solution if it becomes plugged. A large fraction of the
urine drains around the smaller caliber ureteral catheters to enter the bladder. Creatinine clearance determinations provide a means for assessing the effect of prolonged bilateral hydronephrosis. Some sacrifice of renal function can be tolerated in individualizing treatment for cases of recurrent carcinoma after irradiation, just as nephrectomy would be acceptable management for a ureterovaginal fistula under similar conditions if the contralateral kidney were normal. Several investigators have considered pyelonephritis, hydronephrosis and edema of the leg as indications for surgical intervention at least in cases of large lymphocysts. 2 • 4 • 5 Aspiration has been discouraged because of the rapid re-accumulation of fluid, the necessity for multiple taps and the possibility of introducing infection. In some instances, infection of the cyst contents has resulted in intractable pelvic wall abscesses because tissue damage from prior irradiation precluded healing. 11 Likewise, incision and external drainage may be complicated by prolonged drainage or infection. Internal drainage as described by Byron seems to be a safer approach: a transperitoneal window is made in the cyst, the fluid is evacuated and either the sigmoid colon or the cecum is anchored to the posterior wall of the cyst, depending on the side involved. 9 In our opinion surgical drainage should be avoided as long as possible to afford an opportunity for the spontaneous regression of the lymphocyst. SUMMARY
Hydronephrosis after radical pelvic operation may be caused by a lymphocyst. It is important to differentiate this complication from a pelvic abscess or ureteral injury because even a large lymphocyst is likely to regress spontaneously if given enough time and surgical intervention carries a high risk of morbidity. A case is presented in which non-operative management was successful. 11 Rutledge, F. N., Gletcher, G. H. and MacDonald, E. J.: Pelvic lymphadenectomy as an adjunct to radiation therapy in treatment for cancer of the cervix. Amer. J. Roentgen., 93: 607, 1965.