Complications and their management following retroperitoneal lymph node dissection in conjunction with retroperitoneal laparoscopic radical nephroureterectomy

Abstract

Objectives To describe the detailed perioperative complications and their management after retroperitoneal lymph node dissection with retroperitoneal laparoscopic radical nephroureterectomy for patients with upper tract urothelial carcinoma at three institutions. Methods Retroperitoneal lymph node dissection was performed on patients with upper tract urothelial carcinoma located at the pelvis and/or upper or middle ureter, and its template included the renal hilar and para‐aortic lymph nodes (left side) and the renal hilar, paracaval, retrocaval, and intra‐aortocaval lymph nodes (right side). The lymph nodes and kidneys were removed en bloc. The primary endpoint was postoperative complication rates, and the secondary endpoints were intraoperative findings and chylous leakage management. The associations of retroperitoneal lymph node dissection with postoperative complications were examined using logistic regression with propensity score techniques. Results Eighty‐eight (31%) and 195 (69%) patients underwent and did not undergo retroperitoneal lymph node dissection, respectively. There was no significant difference in postoperative complications and other perioperative findings in the entire cohort, except for prolonged operation time. Retroperitoneal lymph node dissection was not statistically significantly associated with total and serious complications in propensity score analyses. Postoperative chylous leakage could be conservatively managed even though it is common in patients with retroperitoneal lymph node dissection (14/88 (16%)). The incidence of chylous leakage was significantly lower in patients whose lymphatic vessels were meticulously clipped completely during retroperitoneal lymph node dissection (5.3% vs 24%; P = 0.017). Conclusion There was no association between retroperitoneal lymph node dissection with laparoscopic radical nephroureterectomy and postoperative complications. However, chylous leakage is often observed after retroperitoneal lymph node dissection and careful management is highly required. The use of clips during retroperitoneal lymph node dissection is recommended to minimize chylous leakage risk.

Prevention, incidence, and risk factors of chyle leak after radical nephrectomy and thrombectomy

“…Firstly, for patients with tumors located on the left side, grade 3 or 4 TT, more caution should be exercised in handling the tissue around the cisterna chyli and lymphatic vessels, as these patients have a higher risk of developing CL. Careful ligation of non‐vascular strip‐like tissues reduces the risk of chyle leakage from 24% to 5.3% in patients with completely clamped lymphatic vessels during surgery 18 . When ligating non vascular ducts, bundle by bundle ligation could be used.…”

“…Careful ligation of non‐vascular strip‐like tissues reduces the risk of chyle leakage from 24% to 5.3% in patients with completely clamped lymphatic vessels during surgery. 18 When ligating non vascular ducts, bundle by bundle ligation could be used. When the surgical scope reaches the high position of the main chyle cistern, titanium clips or Hem‐o‐lok are used to close the main and branches.…”

Need for and extent of lymph node dissection for upper tract urothelial carcinoma: an updated review in 2023

“…Another prospective study by Huang et al [61] assessed the safety of extended LND during laparoscopic extraperitoneal RNU in 39 patients, reporting no severe complications. A recent published retrospective study led by Kanno et al [62 ▪ ] assessed the perioperative complication and its management after template-based LND during laparoscopic extraperitoneal RNU. The authors reported a high rate of postoperative chylous leakage (14/88), which was conservatively managed and prevented by meticulously clipping each lymphatic vessel [62 ▪ ].…”

Initial satisfying experience of total retroperitoneal laparoscopic radical nephroureterectomy: a retrospective comparative research

“…The current recommendation for low-risk upper urinary tract urothelial carcinoma (UTUC) is kidney-sparing surgery, and for patients with high-risk UTUC, radical nephroureterectomy (RNU), retroperitoneal lymph node dissection (RPLND), and/or perioperative platinum-based combination chemotherapy is recommended (1)(2)(3). For RNU, since bowel function recovers much faster and the urinary implantation is more limited, the retroperitoneal approach is commonly considered during open surgery.…”