Endolymphatic Ethiodized Oil Intranodal Lymphangiography and Cyanoacrylate Glue Embolization for the Treatment of Postoperative Lymphatic Leak After Robot-Assisted Laparoscopic Pelvic Resection

Abstract

Purpose: To report the approach, technical success, clinical outcomes, complications, and follow-up of ethiodized oil intranodal lymphangiography with cyanoacrylate glue embolization for the treatment of lymphatic leak after robot-assisted laparoscopic pelvic resection. Materials and Methods: Four men with mean age 68.7 ± 14.3 years were treated with ethiodized oil intranodal lymphangiography with cyanoacrylate embolization for postoperative lymphatic leak. Patients underwent either (1) cystoprostatectomy with ileal conduit and bilateral extensive pelvic lymph node dissection for muscle-invasive urothelial carcinoma and presented with postoperative lymphatic ascites (n = 2) or (2) prostatectomy with bilateral standard pelvic lymph node dissection for prostate carcinoma and presented with postoperative pelvic lymphoceles (n = 2). Intranodal lymphangiography and embolization procedural details, technical success, clinical outcomes, and follow-up were recorded. Results: In four patients, a total of six ethiodized oil intranodal lymphangiograms were performed, two procedures being repeated interventions. Inguinal lymph node catheterization and ethiodized oil lymphangiography was technically effective in all procedures. A mean of 5.2 ± 2.0 mL of ethiodized oil was used for lymphatic opacification. Cyanoacrylate was diluted to 24.2% with ethiodized oil and 0.44 mL of cyanoacrylate was instilled during first time interventions. On repeat procedures, cyanoacrylate was diluted to 51.7%, and 0.52 mL was instilled. The primary clinical success rate was 50% (n = 2/4). Clinical success was achieved in all patients after two interventions (n = 4; 100%). No complications were reported at mean follow-up of 134.7 ± 79.2 days (range: 59-248 days). Conclusion: Ethiodized oil intranodal lymphangiography with direct cyanoacrylate glue embolization is a minimally invasive treatment option for lymphatic leak after pelvic resection.

Keywords: chylous ascites; cyanoacrylate glue; endolymphatics; ethiodized oil intranodal lymphangiography; lymphoceles; urologic surgery.

FIG. 1.

Eighty-four-year-old male with a history of muscle-invasive bladder cancer status post-cystoprostatectomy with ileal conduit. The patient presented with recurrent abdominal distension and lymphatic ascites. (A) Coronal computed tomography image of the abdomen demonstrated large volume ascites (arrow). (B) Nuclear medicine SPECT/CT Tc99m sulfur colloid lymphoscintigraphy demonstrated progressive pooling of radiotracer within the pelvis (arrows), compatible with a lymphatic leak. (C) A 25-gauge spinal needle was inserted into a right inguinal lymph node (arrow) and pelvic lymphangiography was performed. (D) With continued injection of contrast, extravasation was seen emanating from a right pelvic lymphatic vessel with pooling in the right hemipelvis (arrow). (E) The needle was subsequently primed with 5% dextrose. n-BCA glue was mixed with ethiodized oil (1 mL cyanoacrylate: 4 mL ethiodized oil) and was injected, thereby embolizing the leak (arrow). The patient's ascites subsequently resolved. CT, computed tomography; SPECT, single-photon emission computed tomography. n-BCA, n-butyl cyanoacrylate.

FIG. 2.

Seventy-five-year-old male with muscle-invasive bladder cancer status post-cystoprostatectomy with ileal conduit. The patient presented with large volume ascites. (A) A 25-gauge spinal needle was inserted into a right inguinal lymph node (arrow) and lymphangiography was performed using ethiodized oil. There was extravasation secondary to disrupted lymphatics in the right hemipelvis (arrowhead). (B) Bilateral intranodal pelvic lymphangiography demonstrated multifocal bilateral lymphatic disruptions (arrowheads). (C) Both needles were subsequently primed with 5% dextrose and cyanoacrylate glue embolization was performed (arrowheads) using n-BCA mixed with ethiodized oil (2 mL cyanoacrylate: 5 mL ethiodized oil). (D) Progressively more dense embolic agent was seen extending into the areas of lymphatic disruption (arrowheads) bilaterally thereby embolizing the leaks. The patient's ascites subsequently resolved.