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. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: J Vasc Interv Radiol. 2021 Aug 5;32(11):1529–1535. doi: 10.1016/j.jvir.2021.07.022

Percutaneous Lymphatic Embolization as Primary Management of Pelvic and Retroperitoneal Iatrogenic Lymphoceles

Amgad M Moussa 1, Juan C Camacho 1, Majid Maybody 1, Adrian J Gonzalez-Aguirre 1, Fourat Ridouani 1, DaeHee Kim 1, Vincent P Laudone 1, Ernesto Santos 1
PMCID: PMC9150443  NIHMSID: NIHMS1730737  PMID: 34363941

Abstract

Purpose:

To evaluate the efficacy of lymphatic embolization (LE) in decreasing catheter output and dwell time in iatrogenic lymphoceles after percutaneous catheter drainage.

Materials and Methods:

Retrospective review of patients who underwent intranodal lymphangiography (INL) with or without LE for management of iatrogenic lymphoceles between January 2017 and November 2020 was performed. Twenty consecutive patients (16 men and 4 women; median age, 60.5 years) underwent a total of 22 INLs and 18 LEs for 15 pelvic and 5 retroperitoneal lymphoceles. Lymphatic leaks were identified in 19/22 (86.4%) of the INLs. Three patients underwent INL only because a leak was not identified or was identified into an asymptomatic lymphocele. One patient underwent repeat INL and LE after persistent high catheter output, and 1 patient underwent repeat INL with LE after the initial INL did not identify a leak. Catheter output was assessed until catheter removal, and changes in output before and after the procedure were reported. The patients were followed up for 2–30 months, and procedural complications were reported.

Results:

The median catheter output before the procedure was 210 mL/day (50–1,200 mL/day), which decreased to a median of 20 mL/day (0–520 mL/day) 3 days after the procedure, with a median output decrease of 160 mL (0–900 mL). The median time between INL with LE and catheter removal was 6 days, with no recurrence requiring redrainage. Four patients experienced minor complications of low-grade fever (n = 2) and lower limb edema (n = 2).

Conclusions:

Lymphangiogram and LE are safe and effective methods for the management of lymphoceles.

Lymphoceles are fluid collections secondary to leakage of lymph from afferent lymphatic channels. Most frequently, lymphoceles occur as a result of surgical trauma following oncologic lymph node dissection (LND) (1,2). The reported incidence ranges from 9% to 61%, and 2.5%–10% of patients require treatment (3–5). The current mainstay of treatment of symptomatic lymphoceles is percutaneous drainage catheter placement to relieve symptoms, which are often related to super-infection or compression of surrounding structures (6). Often, drainage is followed by sclerotherapy through the catheter using 1 or more sclerosants in 1 or multiple sessions. Sclerosis allows a steady decrease in catheter output by sealing the cavity, allowing removal of the indwelling catheter (1,7,8).

However, sclerotherapy has varying reported outcomes, often requiring multiple sessions and long catheter dwell times (1,7,9–11). This is likely because sclerotherapy does not address the full length of the leaking lymphatic vessel responsible for the lymphocele, only the distal leaking point. Therefore, lymphatic embolization (LE) of the inflow lymphatic vessel located upstream to the leak could potentially allow shorter catheter dwell times (12,13).

MATERIALS AND METHODS

Patient Population and Lymphocele Characteristics

This retrospective study was approved by the institutional review board of Memorial Sloan Kettering Cancer Center (approval number: 16–402). Review of medical records identified 20 consecutive patients (16 men and 4 women) with a median age of 60.5 years (39–73 years) who underwent a total of 22 intranodal lymphangiography (INL) procedures and 18 LE procedures for the management of 15 pelvic and 5 retroperitoneal iatrogenic lymphoceles following percutaneous drainage catheter placement from January 2017 to November 2020. The indications for percutaneous drainage catheter placement were infection (determined based on rim enhancement on contrast-enhanced computed tomography and elevated white blood cell count), pain, or compression of surrounding structures. The indication for INL was lymphatic fluid drainage exceeding 50 mL/day from the drainage catheter within the lymphocele. Asymptomatic lymphoceles identified using cross-sectional imaging were not percutaneously drained and were not embolized if a leak was identified using INL. The demographics and information regarding the original surgery, patient presentation, and time between surgery and lymphatic intervention are presented in Table 1.

Table 1.

Patient Demographics, Surgical Details and Clinical Presentation

Patient number Age (y) Sex Diagnosis Original surgery Time between surgery and lymphatic intervention (d) Presentation Presentation symptom Presentation side
1 59 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 46 Pelvic lymphocele Fever Right
2 63 M Prostate cancer Prostatectomy performed at another hospital, no surgical details available 180 Pelvic lymphocele Pain Left
3 39 M Testicular cancer Complete retroperitoneal lymph node dissection 168 Retroperitoneal lymphocele Pain Right
4 52 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 40 Pelvic lymphocele Pain Right
5 54 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 25 Pelvic lymphocele Compression Left
6 52 F Atrophic kidney Laparoscopic left radical nephrectomy 18 Retroperitoneal lymphocele Pain Left
7 44 F Ovarian cancer Total abdominal hysterectomy and bilateral salpingooophorectomy and partial colectomy, with pelvic and para-aortic lymph node dissection 23 Retroperitoneal lymphocele Fever Left
8 59 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 14 Pelvic lymphocele Compression Right
9 72 M Bladder cancer Cystectomy with bilateral total pelvic lymphadenectomy 44 Pelvic lymphocele Compression Left
10 68 M Bladder cancer Cystectomy with bilateral total pelvic lymphadenectomy 36 Pelvic lymphocele Compression Left
11 64 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 49 Pelvic lymphocele Compression Right
12 71 F Melanoma Pelvic lymphadenectomy with external iliac, hypogastric, and obturator nodes 75 Pelvic lymphocele Compression Left
13 59 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 36 Pelvic lymphocele Pain Left
14 60 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 34 Pelvic lymphocele Fever Right
15 68 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 29 Pelvic lymphocele Pain Left
16 63 M Bladder cancer Cystectomy with bilateral total pelvic lymphadenectomy 27 Pelvic lymphocele Pain Left
17 71 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 94 Pelvic lymphocele Fever Right
18 73 M Prostate cancer Laparoscopic prostatectomy with bilateral total pelvic lymphadenectomy 70 Pelvic lymphocele Fever Right
19 61 F Ovarian cancer Total abdominal hysterectomy and bilateral salpingooophorectomy with pelvic, para-aortic, and portahepatis lymph node dissection 27 Retroperitoneal lymphocele Pain Left
20 43 M Testicular cancer Pelvic, para-aortic, and pararenal lymphadenectomy 30 Retroperitoneal lymphocele Pain Left
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Lymphangiogram and LE Technique

The procedures were performed in an outpatient setting under moderate sedation. The skin overlying inguinal regions was surgically prepared and draped, and under ultrasound guidance, a 25-gauge needle was advanced into the corticomedullary junction of 1 of the visualized inguinal lymph nodes. In pelvic lymphoceles, access was obtained ipsilateral to the lymphocele (Fig 1). Bilateral access was obtained for retroperitoneal lymphoceles. Subsequently, Lipiodol (Guerbet, Villepinte, France) was slowly injected by hand under fluoroscopic guidance. A classical beaded appearance of the lymphatic vessels confirmed an intralymphatic location. Lipiodol extravasation into the lymphocele cavity was considered a lymphatic leak (Fig 2). LE was performed by targeting the closest upstream lymph node or lymphatic vessel feeding the leak as identified using fluoroscopic images. If there were any intervening lymph nodes between the groin lymph node and the leak, fluoroscopy-guided puncture of the lipiodol-stained lymph node or lymphatic vessel feeding the leak was performed using a 22- or 25-gauge needle at the discretion of the interventional radiologist.

Figure 1.

Figure 1.

Figure 1.

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(a) An axial image of contrast-enhanced computed tomography of the pelvis showed a large left pelvic lymphocele (asterisk) compressing surrounding structures, including the left external iliac vein. (b) A fluoroscopic scout film of the pelvis was taken after the placement of a drainage catheter in the left pelvic lymphocele and after the placement of a 25-gauge needle (arrowheads) in 1 of the inguinal lymph nodes under ultrasound guidance (not shown).

Figure 2.

Figure 2.

Figure 2.

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(a) A fluoroscopic image was taken during the injection of Lipiodol through the cannulated inguinal lymph node, with contrast medium flowing through the lymphatic vessels (arrow) toward the drainage catheter. (b) The injection of lipiodol through another cannulated inguinal lymph node (arrowheads) with contrast medium flowing through the lymphatic vessels (arrow) and accumulation of the contrast close to the drainage catheter (asterisk), identified the presence of a lymphatic leak. A mixture of n-butyl-2-cyanoacrylate and Lipiodol was then injected through the same access points into both of the lymph nodes to embolize the leak.

LE was performed using a mixture of lipiodol and n-butyl-2-cyanoacrylate (n-BCA) (Trufill; Codman Neuro, Raynham, Massachusetts). Prior to glue injection, 5% dextrose was injected under fluoroscopic guidance to confirm the intralymphatic location by identifying the washout of lipiodol in the lymphatic vessels. The ratio of n-BCA to Lipiodol ranged between 1:2 and 1:10 based on the distance between the site of injection and the site of leakage, with a higher dilution of n-BCA used for longer distances to allow the mixture to travel further before polymerization. Embolization was terminated when the mixture of n-BCA and Lipiodol was seen flowing into the lymphocele. If no lymphatic leak was identified, LE was not performed. Some patients required embolization of more than 1 lymph node when several areas of leakage were identified. The number of lymph nodes embolized was at the discretion of the interventional radiologist. Seven interventional radiologists with a range of 1–25 years of experience performed the procedures.

Outcome Variables

Technical success of INL was defined as the ability to inject Lipiodol into the lymphatic system. Technical success of LE was defined as successful embolization of the leaking lymphatic vessel. Clinical success of LE was defined as the cessation of drainage from the lymphocele catheter. Catheter output was assessed until the catheter was removed (when the daily output was at or below 10 mL for at least 1 day, with the catheter flushing appropriately), and changes in the output before and after the procedure were reported. The patients were followed up for 2–30 months (median, 3 months) for the recurrence of symptoms related to the previously drained lymphocele.

Cross-sectional imaging was performed only for the follow-up of the patients’ underlying malignancy (to assess residual or recurrent malignancy) as per the follow-up plan of the surgical and medical oncology teams, with no dedicated cross-sectional imaging performed to assess the resolution or recurrence of lymphoceles after catheter removal. Complications after the procedure were reported according to the Society of Interventional Radiology classification (14).

RESULTS

Lymphangiogram Findings and Initial Management

The median time between the original surgery and lymphatic intervention was 36 days (14–180 days). The median time between percutaneous drainage and lymphatic intervention was 9.5 days (0–38 days). Three patients underwent same-session percutaneous drainage and lymphatic intervention after a discussion with the referring urologist. The median catheter output before the procedure was 210 mL/day (50–1,200 mL/day). Two patients underwent only INL because a leak was not identified. One patient underwent repeat INL and LE because of persistent high catheter output, and 1 patient underwent repeat INL with LE after the initial INL because a leak was not identified. All INLs were technically successful, with lymphatic leaks identified in 19/22 (86.4%) of the INLs. In 1 patient, a lymphatic leak entering an undrained asymptomatic lymphocele was identified and was not embolized, as is the standard management for asymptomatic lymphoceles. The lymphatic leak going into the symptomatic lymphocele was not seen.

LE Outcomes

Eighteen LEs were attempted, all of which were technically and clinically successful. The median volume of the mixture of Lipiodol and n-BCA used was 1.0 mL (0.3–2.8 mL). Three days after the procedure, the median catheter output was 20 mL/day (0–520 mL/day), with a median output decrease of 160 mL (0–900 mL). The median time between INL with LE and catheter removal was 6 days (1–29 days). The procedural details and outcomes are presented in Table 2.

Table 2.

Procedural Details and Outcomes

Patient number Laterality Leak Embolization Glue dilution Output before the procedure (mL/day) Output 3 d after the procedure (mL/day) Time from percutaneous drainage to INL (d) Time from the first treatment to removal (d) Change in output Complication
1 Right Superficial inguinal lymph node Leaking lymph node 1:10 500 15 26 14 485 Fever
2 Left Not identified (venolymphatic communications) Not attempted - - - - - - Pain
3 Bilateral Right common iliac lymph node One leaking lymph nodes 1:6 1,000 100 24 20 900 None
4 Right External iliac lymph node Leaking lymph node 1:3 210 10 19 3 200 Fever
5 Left External iliac lymph node Leaking lymph node 1:10 300 200 11 6 100 None
6 Bilateral Left para-aortic lymph node Leaking lymph node 1:4 400 20 7 19 380 None
7 Bilateral Right external iliac lymph node (asymptomatic lymphocele) Not attempted - 400 40 10 6 360 None
8 Right Inguinal lymph node Leaking lymph node 1:8 600 500 0 (same session) 19 100 None
8 (second procedure) Right Inguinal lymph node Three leaking lymph nodes 1:7 200 50 150 Unilateral lower limb edema
9 Left Inguinal lymph node Leaking lymph node 1:8 160 10 0 (same session) 2 150 Pain
10 Left Inguinal lymph node Three leaking lymph nodes 1:6 1,200 520 8 28 680 Unilateral lower limb edema
11 Right Inguinal lymph node Two leaking lymph nodes 1:9 180 20 18 4 160 None
12 Left Not identified Not attempted - 500 200 38 29 300 None
12 (second procedure) Left Inguinal lymph node Leaking lymph node 1:8 125 95 30 None
13 Left Inguinal lymph node Leaking lymph node 1:5 120 25 14 4 95 None
14 Right Inguinal lymph node Lymphatic vessel 1:2 120 0 16 1 120 None
15 Left Inguinal lymph node Lymphatic vessel 1:2 50 25 0 (same session) 8 25 None
16 Left Not identified Not attempted - 100 0 9 4 100 None
17 Right Inguinal lymph node Leaking lymph node 1:6 120 15 10 3 105 None
18 Right Inguinal lymph node Leaking lymph node 1:7 200 0 9 1 200 None
19 Bilateral Left common iliac lymph node Leaking lymph node 1:4 750 15 14 6 735 None
20 Bilateral Left common iliac and external iliac lymph nodes Leaking lymph node and lymphatic vessel 1:5 270 20 10 6 250 None
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INL = intranodal lymphangiography.

Complications

Overall, 4 patients experienced complications following the procedure, all of which were minor. Two patients had low-grade fever 1–3 days following the procedure, with 1 patient requiring overnight admission for fever workup (grade B). Two patients experienced ipsilateral nonpitting lower limb edema for several months following the procedure. In 1 patient, edema was present prior to the procedure but worsened after the procedure. In both the patients, the edema responded to the use of compression stockings (grade B).

DISCUSSION

LND is an important part of surgical treatment for several malignancies (15,16). With its proven superiority in staging compared with imaging, along with a potential survival benefit incurred with an extended LND compared with the standard LND, LND is an integral part of surgical oncology (15,17). Since an increasing number of patients are undergoing LND and since the extent of LND is expected to increase, more patients are expected to experience symptomatic lymphoceles (18,19).

Sclerotherapy is the mainstay of treatment for lymphoceles following percutaneous drainage to relieve symptoms. However, it often requires several sessions and relatively long catheter dwell times (6–8). In addition, multiple sclerosants are used and are used in varying quantities and dwell times based on operator preference, with no consensus on the best regimen (1,8,10,11). Sclerotherapy is also believed to have a lower rate of success in patients with a higher daily catheter output and larger initial volume (8).

LE has proven its efficacy in lymphatic leaks elsewhere in the body and has shown promising results in the management of lymphoceles (13,20–22). Baek et al (13) reported their experience with 5 patients who underwent LE for lymphoceles following gynecologic surgery, in 4 of whom, sclerotherapy had previously failed. Lymphatic leaks were identified in all the patients, and single-session LE was successful in 3 patients who had shown a single site of lymphatic leakage. In the 2 remaining patients who showed multiple sites of lymphatic leakage, repeat INL and LE were successful in decreasing the catheter output and allowing catheter removal. No significant complications were reported apart from pain after the procedure, which resolved in 1 day.

Smolock et al (21) reported their experience with INL and LE in 10 patients with lymphoceles and lymphorrhea, with a clinical success rate of 80%. The reported median time to resolution of symptoms was 7 days (range, 1–17 days), and the reported median number of INL and LE procedures needed was 1 (range, 1–2). They reported 1 complication in which the extravasation of glue reached the saphenofemoral junction, resulting in leg edema, which was treated by anticoagulation. Chu et al (22) reported similar promising results in 9 patients, with a reported clinical success rate of 100%, a median time to resolution of symptoms of 7 days (range, 2–19 days), and a median number of INL and LE procedures of 1 (range, 1–3).

The results reported by this study are comparable with those of previous studies, further highlighting the value of INL or LE in the management of lymphoceles with a high daily output, exceeding 50 mL/day, which was the cutoff used in prior studies to initiate sclerotherapy (7). The emphasis placed in this study on the change in output from immediately prior to INL with LE to after the procedure highlights the effect of INL with LE in decreasing the catheter output and was not reported in the other studies. The technique of LE used in the majority of the patients in this study was the most similar to the technique used by Smolock et al (21) (intranodal embolization) because it was believed to be more technically feasible than the technique used by Baek et al (13), which entails the cannulation of the lymphatic vessels. Like prior studies, the reported complications were minor. Lower limb edema, which is a known complication of pelvic lymphadenectomy caused by the interruption of the lymphatic system, was seen in 2 patients in this study and may have been exacerbated by the intralymphatic Lipiodol and n-BCA (23–25). The ratio of Lipiodol to n-BCA used was at the discretion of the operator based on the distance between the site of injection and the site of leakage. The goal was to occlude the entire length of the lymphatic vessel, with the glue minimally extending into the lymphocele cavity, and, therefore, more dilute concentrations were often used.

In comparison with reported studies on sclerotherapy, INL and LE compare favorably in terms of time to the resolution of symptoms. This is likely because LE directly targets the cause of the lymphocele, the lymphatic leak, and occludes it in the seconds it takes the mixture of Lipiodol and n-BCA to polymerize. In addition, as reported previously and seen in 2 of the reported patients (numbers 7 and 16), lymphangiography alone can sometimes cause a decrease in or the cessation of the catheter output, even if no leak is identified, which is attributed to the irritant effect of Lipiodol (26). Sclerotherapy, on the other hand, acts indirectly through the irritation of the lymphocele wall, causing inflammation and fibrosis of the lymphatic vessels, which takes more time (8). Zuckerman and Yeager (11) reported a median duration of treatment of 14 catheter days (range, 2–77 days) in patients who underwent ethanol sclerotherapy. Alago et al (7) reported a median duration of sclerotherapy with povidone-iodine of 9 days and a mean of 13 days, with no reported range and with a lower daily catheter output (30–100 mL/day) compared with the INL with LE studies. A higher complication rate was also reported in both the studies, although all were minor.

The limitations of this study include its retrospective and descriptive nature. The other limitations include this study being a single-center study; the small number of patients; the lack of uniformity in the LE technique, particularly glue dilution; and limiting follow-up to the resolution of clinical symptoms, with no dedicated imaging follow-up.

In conclusion, INL and LE are promising, simple, safe techniques that may decrease percutaneous catheter dwell time in patients with iatrogenic lymphoceles. A prospective study comparing it with sclerotherapy is warranted to assess its value more accurately.

RESEARCH HIGHLIGHTS.

  • Symptomatic lymphoceles, which developed following oncologic pelvic and retroperitoneal surgery, were treated with a 2-step approach using ultrasound-guided direct nodal injection lymphangiography, followed by embolization using Lipiodol and n-butyl-2-cyanoacrylate.

  • Lymphangiography identified a leak in 19 of 20 patients (22 total procedures). The lymph node closest to the leak was accessed for embolization, which succeeded in all 18 attempts, with cessation of the leak and removal of the drainage catheter after a median of 6 days after embolization.

  • Four patients experienced minor complications of fever or limb edema, which resolved. No recurrences were observed.

STUDY DETAILS.

Study type:

Retrospective, observational, descriptive study

Level of evidence:

4 (SIR-D)

Acknowledgments

This research was funded in part by the NIH/NCI Cancer Center Support Grant P30 CA008748.

ABBREVIATIONS

INL

intranodal lymphangiography

LE

lymphatic embolization

LND

lymph node dissection

n-BCA

n-butyl-2-cyanoacrylate

Footnotes

None of the authors have identified a conflict of interest.

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