Complications post surgery can include the development of pelvic lymphoceles which patients may present infection or external leaks. Daniel Eun, MD, Fox Chase-Temple Urologic Institute Provider, discusses how to avoid and manage lymphoceles post robotic surgery.
I'm going to talk on political in fossils and what I've learned over the years as far as as trying to avoid them and manage them. So I hope that you'll find this topic compelling. Alright so here is my financial disclosures. So you know over the years I think many of us who do more and more robotic surgery understand that we can do a really good node dissection robotically. This is a cyst ectomy operation. You can see how well you can literally clean out the lymph nodes, I would argue you know just as good um as you could the open surgery but we also know that there are potential complications and risks that come from uh no dissection. The more you take, the more there is a risk vascular nerve um injury, lymphedema in fossils, external leaks, abscesses, infections and then compressive complications that can cause what we fear. Probably one of the worst theory complications which is a DVT and PE. And so I think that the the fundamental difference between the cyst ectomy, no dissection and a prostatectomy and lymph node dissection and the complications that come from it. The fact that the bladder reattach is quickly interior early and the extra perennial space lymphatic spaces now sequestered and from there can come a host of problems. And so the compression of the space can cause a lot of compression on the iliac vessels and cause D. V. T. S. Um And I think it's it's well understood that the more lymphatic channels are disrupted the greater chance for creating volumes Olympus Hills and lymphatic output. And so you know if you look through the literature I just quoted in the I'm sorry VIP Patel's paper but there's a lot out there Lynn facil formation uh If you study them can reach up to 60% but symptomatically facility where people actually complained and you end up in the er can be 16 up to 16% and some papers up to 18 to 20%. So the manifestations of Olympus seals and you know these are things that I used to see a lot in my practice external leaks where patients say they got urine like output. You know straw colored urine like fluid output coming from one of their incisions. Sometimes it's profound and they say drips sometimes I put it in Ostuni bags over the incisions. Um They typically run its course and then it stops on its own and I always kind of wondered what the heck was going on to cause that that that problem because it always kind of seemed to self resolve right? Um And then you get these infected lymph seals or abscesses that show up and it's never right after surgery it's always 4 to 68 to 12 weeks afterwards and you know you'd have to put in an ir drain you have to treat with antibiotics. I would always start off with M. R. I say coverage with you know um with Van Gogh as well as broad spectrum and uh it can cause a you know a lot of distress to the patient. Um And then every once in a while you'd have somebody with a DVT or PE I had one patient years ago who went home, we had studied them on a readmission and they said that they definitively could not rule out a DVt. They recommended that I don't send the patient home on anti coagulation. The guy dropped at right and that haunted me forever. And so um and so ah several years ago at the AU A. I saw the lady group present. Um they're they're abstract and they basically talked about this perennial flap that they would would That they would do. And if you look at this paper, you know, you would see that um 155 consecutive patients with greater than when your follow up group. A was patients that just had standard lymph node dissection and group B that had perennial interposition flap And you can see the results are profound, right? 11%? Um Facil vs 0%. And the meantime deliver cell detection, which is kind of what we always knew as anecdote, you know, around 30 days. That's what they saw as well. And I would, you know, I remember staying up at night trying to think of ways to stop these lymphocytes complications because I would get a readmission every 4-6 weeks on this and it was just a thorn in my side. I remember at some point I started backing off on doing lymph nodes and taking lesser lymph nodes because of the fear of this complication. And you know what I realized a lot of us have realized is that sealants him a static agents, you know using vessel sealers. None of it really helps. And so uh this is the lady paper where they essentially they turn in the lateral flaps of the bladder wings and when they peck see that down, what it does is create a channel Along here that stays open right and they do that on the left and they do that on the right and we've modified it since then. Um but we repeated the study just to validate it in our group. And so we did consecutive patients 1st 200 did not undergo peroneal in their position flap. And this is really because we had a leahy resident that came and did my fellowship and on day one he goes Dan what are you doing this? I said I'm intrigued. I saw the paper, I saw their abstract, I want to do it but I don't know how to do it. So he showed me Kevin showed me how to do this and and this is probably what 3-4 years ago. I have not yet. I have not had an emphasis on readmission since it is astounding right. And so we did this study. We also found similar results of them. 0% symptomatically facil readmission after um afterwards. And you can see we did a very similar thing where we would rotate in the picture on the left here shows what happens when the bladder seals up. It n traps a lymphatic collection that can grow quite sizable. And there's been multiple, you know, validation studies out there. There is actually a multi institutional pelican study that I saw found online where they do something a little bit differently. They cut out like a b flat next to the bladder and they lay that down. And and so it's it's a similar concept of leaving a channel laterally. And you can see that in these validation studies, you know, you know that ours was 6% vs 0% in the in the in the position flap. Um Stoltenberg had a paper 8% vs 2%, and tomorrow's group had 4% versus zero, essentially close to 0%. And so I'll show you a video kind of the way that we do it. We don't put in as many stitches. We just use we just use a Vlach and you're you're not going down to the Crotch, you're moving about 5,6cm away, right? And they were using a 6" block. And then essentially we see those clips, that's where my pedestal clips are. I just go a little bit more media or anterior to that. So I don't bag the ureter right. And then we take another stitch on the perennial side. And you know I'm lazy I don't want to tie those knots. And so I just use a clip but you could certainly tie that down. And so what does is it keeps that channel open right? And so on the other side You know nowadays I think I just future it in instead of you know tying a knot and putting a clip on. But essentially you move about 5,6 cm away from the Crotch. You throw a stitch there, find your clip where your medical clips are come a little bit medial to it and then finish that off it really it takes like a minute to do right. It's very quick, it's very efficient. And um and I told David canes that like to me, you know although we've had a lot of iterations and variations of a prostatectomy operation over the years. To me this represents the single biggest advancement in this operation. All the limb fossils. The readmissions, the D. V. T. S. The ps. That you could stop by simply adopting such a simple technique I think is a profound and probably underappreciated. So this is a lady video showing two years later a patient that needed a lap coli and they show how the bladder has sealed. You can see that those channels still remain open right. And so it's a proof of concept two years later showing how that looks and how the bladder re seals And so in our paper, the other thing we looked at because some people will say when you rotate the bladders like that, you know, it doesn't affect the bladder volume. You know, R. I. P. S. S. Scores stayed the same. We did not have any, you know, more increase in urinary complaints or urinary, um you know, capacity issues and so the bladder pretty much goes back into place. But those lateral wings still stay pinned down, that's really what I want to share with you. Hopefully you guys, some of you guys will take this and apply this into your practice. It's very easy to do and it's just a very simple way to get rid of a very unfortunate complication.
