German surgeons say a small, technical change to a surgery for prostate cancer can greatly reduce the common post-operative complication of lymphatic fluid collecting in the pelvis.
The technique allows the fluid to escape into the abdomen by creating a small flap in the peritoneum – the lining of the abdomen – and attaching this flap down into the pelvis. Then it can be more easily absorbed.
Researchers presented their findings recently at the 2023 European Association of Urology Annual Congress in Milan.
The research hasn’t been published yet in a peer-reviewed journal.
What to know about lymphocele
The scientists said in a statement that about 10% of people whose prostate cancer and lymph nodes are removed by robot-assisted keyhole surgery require treatment for symptoms caused by lymphatic fluid collecting in the pelvis, a condition known as lymphocele.
Lymphocele can also be found in nearly a third of subjects without them reporting symptoms, which include infection, pelvis pain, bladder pressure, and swollen legs due to vein compression.
If left untreated, symptomatic lymphocele can lead to serious infections or deep vein thrombosis.
Draining a lymphocele can take from three days to three weeks, with treatment complete only when the fluid is no longer accumulating. That means a hospital stay for some people.
“When they’ve only just returned home following a cancer operation, the last thing patients need is to return to hospital with this kind of complication, which unfortunately is fairly common,” said Manuel Neuberger, a urology specialist from University Medical Centre Mannheim and Heidelberg University in Germany, in a statement.
If drainage doesn’t cure the problem, then – in rare cases – doctors create an artificial opening in the peritoneum, providing an escape route for the lymph so it’s no longer stuck in the pelvis.
The German team says creating a flap beforehand can prevent the condition in the first place.
Details from the prostate cancer surgery study
Researchers looked at 550 subjects and four different surgeons working at University Medical Centre Mannheim, who were only told whether a subject was to have a peritoneal flap once the rest of the operation had been completed.
Study participants were randomized between the two groups – with flap or without – accounting for other factors that might increase the risk of lymphocele. Those factors included diabetes, the extent to which lymph nodes were removed, whether they took anti-coagulants and the surgeon doing the operation.
Researchers followed up for 6 months after the operation. Only 10 people in the peritoneal flap group developed a symptomatic lymphocele, compared to 25 in the control group.
When discharged, 20 people in the flap group had lymphocele with no symptoms, compared to 46 in the control group. During follow-up, this rose to 27 in the flap group and 74 in the control group.
“Using the peritoneal flap reduced the incidence of lymphocele from nine percent to less than four percent,” said Dr Philipp Nuhn, a team leader and a professor of urology at University Medical Centre Mannheim, in a statement. “We now use this as the new standard in Mannheim, and hope that – following these results – it will become common practice elsewhere as well.”
Experts react to prostate cancer surgery technique
Doctors interviewed by Healthline said the new procedure seems to make sense.
“Creation of a peritoneal window is actually a well-known treatment for patients with pelvic lymphoceles,” Dr. S. Adam Ramin, a urologist and medical director of Urology Cancer Specialists in Los Angeles, told Healthline.
“This article discusses a proactive approach to prevention of lymphocele formation,” Ramin added. “In other words, rather than waiting to see if lymphocytes form, and then do another second surgery, it may make sense to create the peritoneal window at the time of prostatectomy to proactively prevent lymphocele formation.”
Ramin added that the advantages of the procedure would depend on how the prostatectomy procedure is performed.
“If the prostatectomy procedure is a Retzius-sparing procedure, or an extra peritoneal procedure, in which case the peritoneum is not opened during the laparoscopic (keyhole) robotic prostatectomy, then it makes sense to create the peritoneal window,” Ramin said. “However, the more common technique of prostatectomy done robotically involves an intraperitoneal approach in which case a peritoneal window is automatically created. The benefit of additional peritoneal windows with this particular type of surgery is unknown.”
An uncommon but potentially dangerous condition
Dr. Michael Johnson, a urologist at Siteman Cancer Center at Washington University in St. Louis, told Healthline that lymphoceles aren’t common after prostate surgery, and symptomatic lymphoceles are less common.
However, he said, they’re problematic when they occur.
“It is a small technical change,” Johnson said. “As patients recover from prostate surgery, we hope that they do not develop a lymphatic leak and we have ways to minimize this risk.
“If they do, we hope that the fluid naturally drains into the peritoneal cavity,” he added. “This technical change helps maximize this. My takeaway from this is that surgeons need to look at their personal rates of lymphoceles and ensure that they continue (to) refine their technique – which may include this peritoneal window – to ensure optimal patient safety.”