|Year : 2017 | Volume
| Issue : 2 | Page : 79-81
Postrenal transplant lymphocele causing anuria due to ureteric compression
Harsh Sutariya, Kajal Patel, Shruti Gandhi
Department of Radiology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre (IKDRC), Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), Ahmedabad, Gujarat, India
|Date of Web Publication||12-Sep-2017|
Department of Radio Diagnosis and Imaging, G. R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre, Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
Lymphocele is one of the most common complications following renal transplantation and can lead to an increase in morbidity. Its incidence has been reported to vary from 0.6% to 20%. The use of ultrasonography has increased the index of detection of lymphocele though the majority of them have small size and resolved spontaneously. We describe a case of a postrenal transplant patient who developed anuria due to transplanted ureteric compression by lymphocele in deceased donor dual-renal transplantation in the right renal fossa. When a transplanted patient comes with a history of sudden anuria, one should consider ureteric compression resulting from lymphocele as a possible cause.
Keywords: Anuria, lymphocele, renal transplant, ureteric compression
|How to cite this article:|
Sutariya H, Patel K, Gandhi S. Postrenal transplant lymphocele causing anuria due to ureteric compression. Indian J Transplant 2017;11:79-81
|How to cite this URL:|
Sutariya H, Patel K, Gandhi S. Postrenal transplant lymphocele causing anuria due to ureteric compression. Indian J Transplant [serial online] 2017 [cited 2020 Jan 25];11:79-81. Available from: http://www.ijtonline.in/text.asp?2017/11/2/79/214378
| Introduction|| |
Most lymphoceles occurring after renal transplantation are small, asymptomatic, and resolved spontaneously. With larger dimensions, however, they can cause deterioration of renal function due to obstructive changes in transplanted kidney by ureteric compression. Ultrasound is a key to diagnosis, but other radiological procedures such as isotopes scanning, computed tomography (CT), and magnetic resonance imaging (MRI) might be necessary in complicated cases. We describe clinical and imaging findings of a deceased donor dual-renal transplant recipient presenting with anuria due to ureteric compression caused by lymphocele.
| Case Report|| |
A 44-year-old postrenal transplant male patient presented with a complaint of fullness in the lower abdomen with decreased urine output of 15-day duration to our institute after 3 months of dual deceased donor renal transplantation. Deceased donor was 70-year-old aged, so according to the standard expanded criteria of donor, dual kidney transplantation was done. His postoperative course was uneventful. His native kidney disease was chronic glomerulonephritis and was hypertensive for 7 years. He was on maintenance dialysis twice a week since 2 years. He had a history of non-Hodgkin lymphoma 13 years ago, for which he underwent chemotherapy. Rabbit antithymocyte globulin 1.5 mg/kg body weight was given as an induction therapy. The patient was on triple immunosuppressant regime that comprises tacrolimus, prednisolone, and mycophenolate mofetil.
Investigation revealed serum creatinine of 4 mg/dl, ultrasonography (USG), and color Doppler study showed septated anechoic collection of 100 cc near lower pole of lower graft kidney [Figure 1]. Both transplanted kidneys showed mild hydronephrosis. Two small calculi of size 3–4 mm were seen in lower graft kidney. To know the exact size and location of lymphocele and its anatomic relation to the surrounding structures, contrast-enhanced CT (CECT) scan of abdomen was performed which showed dual-renal transplantation in the right renal fossa with about 8.8 cm × 5.5 cm × 5.2 cm sized well-defined nonenhancing collection at lower pole of lower graft kidney extending into inguinal canal. Upper transplanted kidney showed normal excretion of contrast with mild hydronephrosis. Proximal ureter of upper transplanted kidney coursed along lateral surface of lower kidney and distal ureter coursed posterior to collection, no evidence of hydroureter was seen [Figure 2]. Lower transplanted kidney showed increasingly dense nephrogram and delayed excretion of contrast. Two small calculi of size 3–4 mm and moderate hydronephrosis were seen. Ureter of lower transplanted kidney coursed along the medial surface of collection and appeared normal in caliber [Figure 3]. Based on imaging, an obstructive change in lower graft kidney due to compression of the ureter by lymphocele was made. Laparoscopic deroofing of lymphocele was attempted and ultimately subcutaneous drainage of lymphocele was done and drain was kept. Every alternate day betadine instillation was done. Gradually, over a period of 1 month, his lymphocele was decreased and serum creatinine level became normal (1 mg/dl) within 15 days. His fluid drain creatinine was 1.38 mg/dl. Subsequently, percutaneous nephrostomy tube was also removed. Follow-up examination during 1 year showed no infectious complications or recurrence or hydronephrosis in either of graft kidneys. The graft function was stable with serum creatinine of 1.1 mg/dl.
|Figure 1: (a and b) Ultrasound images: (a) Image showing moderate hydronephrosis in lower transplanted kidney, (b) image showing septated lymphocele (arrow) causing compression over transplanted ureter.|
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|Figure 2: Coronal contrast-enhanced computer tomography scan of excretory phase showing lymphocele (arrow) medial to transplanted ureter (open arrow) of upper transplanted kidney.|
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|Figure 3: Coronal contrast-enhanced computer tomography scan of excretory phase showing delayed excretion of contrast, two small calculi, and compression of lower ureter (arrow) of lower transplanted kidney by lymphocele (open arrow).|
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| Discussion|| |
The term “lymphocele” (lymphatic collection without an epithelial lining) originated from the Japanese literature. Lymphocele is fluid collection most frequently found following renal transplantation. Its incidence has been reported to vary between 0.6% and 20%., The incidence of lymphocele was not influenced by the recipient gender and age. The occurrence of lymphocele is caused primary by extravasation of lymph from the lymphatic vessels injured at the time of preparation of the iliac vessels of the recipient and unligated lymphatics from renal hilum of donor. The majority of significant postrenal transplant lymphoceles occurs within the first 3 months.
The most frequent symptoms associated with lymphocele are lower abdominal pain, azotemia, anuria, gross hydronephrosis, ipsilateral leg or scrotal swelling, deep vein thrombosis due to the compression of iliac veins, and urinary urgency or frequency due to extrinsic bladder compression and urinary retention. Our patient presented with anuria. The occurrence of lymphoceles after surgery of transplantation does not seem to be the result of any single factor. A number of etiological factors are described and a large variety of combinations are likely to be causal. Contributing factors that have been implicated in the development of lymphocele includes leakage of lymph from recipient lymphatic channels, use of diuretic, obesity, transplanted kidney biopsy, acute rejection, higher dose of corticosteroids, severed lymphatic vessels of donor kidney allograft, functional delay of deceased donor graft, presence of polycystic disease, sirolimus immunosuppression, repeat transplantation, and thromboembolic prophylaxis with low-dose heparin. The risk factor in our patient appears to be dual-renal transplantation and the deceased donor transplantation. Our patient did not have a history of polycystic kidney disease, previous biopsy, or sirolimus or heparin ingestion.
Lymphoceles may develop in the early postoperative period or months following surgery and detected with the routine application of posttransplant USG. On USG, lymphocele appears as hypoechoic to anechoic masses with through transmission, occasionally with septa and dependent scattered debris. Ultrasound offers the advantage of being noninvasive, safe, and unaffected by the degree of renal dysfunction. Other radiological procedures such as isotopes scanning, CT, and MRI might be necessary in complicated cases. CECT scan of pelvis shows nonenhancing hypodense collection around lower pole of graft kidney and causing compression over transplanted ureter. It demonstrates excretion of contrast, degree of obstruction in form of hydronephrosis and hydroureter, and its relation with adjacent ureter and vessels which can aid in needle aspiration when ultrasound guidance has failed. Although lymphocele collection is harmless and asymptomatic in many cases, it can seriously affect renal graft function and necessitates intervention. Because treatment of lymphocele and urinoma differs, it is important to clarify the cause of perigraft fluid collection. Creatinine level similar to serum confirms its lymphatic nature. Treatment of lymphocele has evolved over the years. Although lymphoceles can be initially managed by percutaneous aspiration with or without instillation of sclerosant agent such as povidone-iodine. Surgery is needed in the presence of local symptoms, graft dysfunction, or both. Surgery includes open surgical drainage, internal marsupialization, or laparoscopic peritoneal drainage. Laparoscopy is the procedure of the choice for surgical management. The most susceptible organ to injury during laparoscopy is the transplanted ureter. A significant recurrence rate has been reported following aspiration (33%), sclerotherapy (25%), and surgery (12%). As was the case in this study, laparoscopic deroofing of lymphocele was attempted in view of bilateral obstruction and allograft dysfunction, and ultimately subcutaneous drainage of lymphocele was done. Follow-up USG in postoperative period is extremely important for the diagnosis of lymphocele size.
| Conclusion|| |
Most of the lymphocele are small and remain subclinical and resolve spontaneously; however, symptomatic cases may lead to serious complication. Clinical significance depends on type, location, size, and growth of fluid collections. It is well diagnosed by USG and CT scan and subsequently treated by percutaneous drainage or laparoscopic deroofing can improve graft function. Routine postoperative sonography can detect lymphocele.
The authors extend their hearty gratitude to Dr. Vivek Kute; Professor in Nephrology, Institute of Kidney Diseases and Research Centre and Institute of Transplantation Sciences and Ms. Jyotsana Suthar for their valuable guidance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Samhan M, Al-Mousawi M. Lymphocele following renal transplantation. Saudi J Kidney Dis Transpl 2006;17:34-7.
] [Full text]
Dubeaux VT, Oliveiera RM, Moura VJ, Pereira JM, Henriques FP. Assessment of lymphocyte following 450 renal transplantation. Int Braz J Urol 2004;30:18-21.
Bailey SH, Mone MC, Holman JM, Nelson EW. Laparoscopic treatment of post renal transplant lymphocele. Surg Endosc 2003:17;1896-9.
Burgos FJ, Teruel JL, Mayayo T, Lovaco F, Berenguer A, Orte L, et al.
Diagnosis and management of lymphoceles after renal transplantation. Br J Urol 1988;61:289-93.
Metcalf KS, Peel KR. Lymphocele. Ann R Coll Surg Engl 1993;75:387-92.
Ebadzadeh MR, Tavakkoli M. Lymphocele after kidney transplantation: Where are we standing now? Urol J 2008;5:144-8.
Atray NK, Moore F, Zaman F, Caldito G, Abreo K, Maley W, et al
. Post renal transplant lymphocele: A siglecenter experience. Clin Transplant. 2004;18:46-49.
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