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Editorial Comment to Risk factors for pelvic lymphoceles post‐radical prostatectomy

Pelvic lymph node dissection (PLND) might account for perioperative morbidity and complications, including lymphoceles and lymphorrhea. Lymphoceles can lead to infection, nerve injury, prolonged drain stay and, consequently, prolonged hospital stay. Furthermore, in some series, lymphoceles and lymphorrhea have been associated with increased risk of deep venous thrombosis and pulmonary embolism. Venous thromboembolism, for example, occurred in up to 1.5% of patients who underwent laparoscopic radical prostatectomy plus PLND relative to virtually no risk in patients treated with prostatectomy only. Although PLND has never been proven to be beneficial for the outcome of low-risk prostate cancer patients, an extended PLND (ePLND) should not be omitted in intermediateto high-risk prostate cancer patients. Even in the presence of such a recommendation, many urologists are reluctant to take such an extensive surgical approach in all patients with more aggressive cancer variants. This reticence is because of the lack of a proven prospective benefit of ePLND for cancer control, as well as to the potential exposure of patients to the risk of lymphoceles and their potentially related complications. This argument has been based on previous studies reporting higher rates of lymphoceles in patients treated with ePLND. Some points, however, need to be considered. First, reports from the literature are hardly comparable as a result of the heterogeneous definition of lymphocele, as well as to the different approaches used to determine the presence and extent of this complication. Second, several recent reports showed that PLND and its extent are only some of the potential risk factors for lymphocele development. Several other variables have been suggested to promote lymphoceles and lymphorrhea, such as locally advanced disease, clinical patient characteristics (i.e. old age and obesity) and prophylactic therapy with low molecular weight heparin. In addition, surgical aspects have been thought to correlate with the risk of harboring a lymphocele postoperatively. External iliac lymphadenectomy, for example, was associated with higher risk of lymphoceles and lymphorrhea relative to obturator node removal. For this reason, all lymphatics lateral to the external iliac artery should be saved. The type of surgical approach was also thought to represent a determinant of lymphocele formation. Theoretically, the use of a transperitoneal approach (i.e. laparoscopic and robot-assisted PLND) might reduce the rate of lymphocele formation. Unfortunately, it has been shown that up to 51% of patients treated with laparoscopic or robot-assisted prostatectomy also might develop a lymphocele. This finding is even more significant considering that the vast majority of patients treated with a minimally invasive approach are treated with a limited PLND; however, not all lymphoceles translate into a significant clinical condition. Indeed, <10% of lymphoceles are usually symptomatic, and only approximately 2% require intervention. That said , are lymphoceles and lymphorrhea something to worry about? In the current issue of the International Journal of Urology, Khoder et al. confirmed that lymphoceles after prostatectomy are more common than thought, although they rarely necessitated intervention. Given the relatively low prevalence of complications that are clinically significant, and that can affect patients’ quality of life and morbidity, the main effort should focus on preventing lymphocele development during surgery, especially in those patients at higher risk for lymphocele formation. In the first setting, many authors suggested technical tips that might decrease patients’ risk of harboring a symptomatic lymphocele: closed suction drain, sclerotherapy, talc poudrage, fibrin sealant, intramuscular injection of octeotride, pressure dressings, careful ligation of lymphatic vessels and avoidance of electrocautery. In a prospective randomized clinical trial, Simonato et al. showed that a surgical patch located after PLND reduces drainage volume and prevents lymphocele development after extraperitoneal radical retropubic prostatectomy with pelvic lymphadenectomy. Furthermore, Waldert et al. evaluated the efficacy and costeffectiveness of FloSeal hemostatic matrix in preventing lymphocele development after laparoscopic and robotassisted pelvic lymphadenectomy. Although not prospectively randomized, such matched cost analysis suggested that the use of FloSeal after lymphadenectomy might reduce the number of symptomatic lymphoceles in a cost-effective manner. In conclusion, lymphoceles and lymphorrhea are not negligible when patients undergo pelvic lymphadenectomy, even in the hands of the most experienced surgeons. Exposure of patients at risk of lymphocele formation should be balanced with the proven benefit of PLND of accurate nodal staging and improved cancer control in highly selected patients. Prevention of lymphoceles begins with a meticulous surgical approach in which surgeons should be extremely careful in ligating or clipping all of the distal ends WY KHODER ET AL.