Japanese Journal of Clinical Oncology 30:397-400 (2000)
© 2000 Foundation for Promotion of Cancer Research
Prevention of Lymphocyst Formation Following Systematic Lymphadenectomy
+Department of Obstetrics and Gynecology, Hokkaido University School of Medicine, Sapporo, Japan
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ABSTRACT |
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Background: The occurrence of pelvic lymphocysts is an important complication following systematic lymphadenectomy for gynecological malignancies. We employed a procedure to prevent vaginal shortening following radical hysterectomy and we examined whether this procedure could be effective in preventing pelvic lymphocyst formation.
Methods: We studied the incidence of lymphocysts in 190 patients with 84 cervical cancers, 74 endometrial cancers and 32 ovarian cancers, using computed tomographic examination at 3 and 6 months subsequent to the surgery. The surgery included radical hysterectomy and a procedure to prevent vaginal shortening (101), modified radical hysterectomy (79) and simple hysterectomy (7), with systematic lymphadenectomy.
Results: There was a significant difference in the incidence of pelvic lymphocysts between cervical cancer (4.8%) and ovarian cancer (18.8%). The postoperative incidence of lymphocyst formation in patients undergoing radical hysterectomy with the procedure to prevent vaginal shortening (5.9%) was significantly lower than in those who underwent modified radical hysterectomy (15.2%).
Conclusion: Our procedure to prevent vaginal shortening could be effective in preventing not only the shortening of the vagina but also the occurrence of pelvic lymphocysts in patients undergoing radical hysterectomy with systematic lymphadenectomy for gynecological malignancies.
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INTRODUCTION |
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The occurrence of pelvic lymphocysts, which cause leg edema, subocclusion, deep venous thrombosis, pulmonary embolism and pain, is an important complication following systematic lymphadenectomy for gynecological malignancies (1–3). Normally, pelvic lymphocysts appear within 3–8 weeks after surgery (2,4–6). Although the exact mechanism of the formation of pelvic lymphocysts is not known, it has recently been reported that the long-lasting presence of a foreign body within the pelvis may possibly be linked to pelvic lymphocyst formation (1,7,8). To reduce the incidence of pelvic lymphocyst formation, various surgical procedures have been examined (1,7–10).
Radical hysterectomy for gynecological malignancies requires extensive resectioning of the vagina, which reduces the vaginal length and causes pain and discomfort during sexual intercourse. In order to solve this problem, we have employed a procedure to prevent vaginal shortening following radical hysterectomy (11); the procedure involves leaving the vaginal vault open and performing a postoperative treatment to prevent early closure of the vaginal stump.
In this study we examined whether the procedure to prevent vaginal shortening could be effective in preventing pelvic lymphocyst formation.
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METHODS |
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Procedure to Prevent Vaginal Shortening Following Radical Hysterectomy
We did not occlude the vaginal vault during the radical hysterectomy. Hemostasis of the vaginal stump was completed, followed by suturing of only the peritoneum, leaving the vaginal vault open to the retroperitoneal space. To prevent early closure of the vaginal vault, on the seventh day following the operation the stitches applied to ensure hemostasis of the vaginal stump were selectively removed and the vaginal vault was kept open thereafter by mechanical means. Normally, between the second and the fourth month, the length of the vagina was restored to a value within the normal physiological range, as reported previously (11).
We studied the incidence of lymphocysts in 190 patients with 84 cervical cancers (age range 28–63 years, median age 48.5 years), 74 endometrial cancers (31–70, 56.0 years) and 32 ovarian cancers (17–78, 52.5 years) using computed tomographic (CT) examination following various surgeries from 1987 to 1998 at our hospital. Postoperative CT examinations were performed at 3 and 6 months subsequent to the surgery, regardless of symptoms. The surgery included radical hysterectomy [Class III; Rutledge classification (12)] and a procedure to prevent vaginal shortening with systematic lymphadenectomy, modified radical hysterectomy (Class II) with systematic lymphadenectomy or simple hysterectomy (Class I) with systematic lymphadenectomy. For modified radical hysterectomy and simple hysterectomy, the procedure to prevent vaginal shortening was not performed. We performed paraaortic node dissection including the area both superior and inferior to the inferior mesenteric artery (IMA) for endometrial cancer and ovarian cancer. The area superior to IMA was not dissected for cervical cancer. Further, we employed omentectomy for all patients with ovarian cancer and for patients with endometrial cancer if the peritoneal cytology gave a positive result. However, omentectomy was not performed for patients with cervical cancer.
There were no significant differences in the node status or body mass index of the patients. All surgeries were performed by the authors in a uniform manner. The pelvic peritoneum and paracolic gutters were sutured after node dissection and a closed-suction drain was then placed through the abdominal wall into each paravesical space for all 190 patients. We did not conduct any defibrotide antithrombotic prophylaxis and no patients received radiotherapy before surgery.
The results in the two groups were compared by the 
2 test.
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RESULTS |
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With regard to the incidence of pelvic lymphocysts, 20 patients were identified as having developed pelvic lymphocysts out of the total 190 patients on whom surgery for gynecological malignancies with systematic lymphadenectomy was performed (10.5%). The difference in the incidence of pelvic lymphocysts between the groups based on age range was not statistically significant (Table 1). Pelvic lymphocysts were recognized in four out of the 84 patients with cervical cancer (4.8%), 10 out of the 74 with endometrial cancer (13.1%) and six out of the 32 with ovarian cancer (18.8%). Significant differences in incidence were recognized between those with cervical cancer and ovarian cancer (p < 0.05). Further, the incidence of pelvic lymphocysts in patients with cervical cancer was trending higher (p = 0.053) than in patients with endometrial cancer (Table 2). However, the difference in the incidence of pelvic lymphocysts between the groups based on FIGO (International Federation of Gynecology and Obstetrics) stage was not statistically significant (Table 3).
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In patients with cervical cancer, 29 out of 84 patients received and 55 out of 84 patients did not receive postoperative radiation therapy. Pelvic lymphocysts were recognized in two out of the 29 patients (6.9%) and two out of the 55 patients (3.6%), respectively. There was no statistical significance between the two groups.
In patients with endometrial cancer, radical hysterectomy with the procedure to prevent vaginal shortening or modified radical hysterectomy was performed according to the presence or absence of preoperative documentation of cervical invasion, respectively. Pelvic lymphocysts were recognized in one out of the 17 patients (5.9%) and nine out of the 57 patients (15.8%) who underwent radical hysterectomy with the procedure to prevent vaginal shortening and modified radical hysterectomy, respectively.
The incidence of pelvic lymphocysts in relation to the type of surgery was as follows: pelvic lymphocysts occurred in six of the 101 patients who underwent radical hysterectomy with the procedure to prevent vaginal shortening (5.9%), 12 of the 79 patients who underwent modified radical hysterectomy (15.2%), one of the seven patients who underwent simple hysterectomy (14.3%) and one of the three patients who had already had their uterus removed. Compared with the modified radical hysterectomy, the radical hysterectomy with the procedure to prevent vaginal shortening was associated with a significantly lower incidence of lymphocyst formation (p < 0.05) (Table 4).
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There was a statistical difference (p = 0.021) in the incidence of pelvic lymphocysts between patients who underwent paraaortic node dissection including the area superior to IMA and not including the area superior to IMA. However, performing omentectomy did not affect the pelvic lymphocyst formation.
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DISCUSSION |
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The incidence of lymphocysts after surgery for gynecological malignancy reportedly varies from a high of 25.3% (13) to a low of 1.5% (14), thus showing great differences depending on the reporter. We believe that these differences are due to the different degree of thoroughness of the lymphadenectomy or the different methods used for identification. Previous radiotherapy (15–17), positive nodes (15,18) and prophylactic heparin (19,20) have all been implicated as possible risk factors. Accordingly, we excluded from our study patients who had received previous radiotherapy or prophylactic heparin. However, we did not conduct any analysis of the relationship between nodal status and pelvic lymphocyst formation. In our study, there was a significant difference in incidence between cervical cancer and ovarian cancer and the incidence of pelvic lymphocysts in patients with cervical cancer was higher than that in patients with endometrial cancer. However, we did not identify any differences in the incidence of pelvic lymphocysts that were dependent on the clinical stage of cervical cancer, endometrial cancer or ovarian cancer. The reason for the lower incidence of pelvic lymphocysts in cervical cancer in comparison with that in endometrial and ovarian cancer was considered to be differences in the primary diseases or surgical procedures. We performed paraaortic node dissection including the area both superior and inferior to IMA for endometrial and ovarian cancer. The area superior to IMA was not dissected for cervical cancer. There was a statistical difference in the incidence of pelvic lymphocysts between patients with cervical cancer and in patients with endometrial or ovarian cancer. However, we thought that paraaortic node dissection including the area superior to IMA did not increase the incidence of pelvic lymphocysts and this statistical difference was due to other factors. We employed omentectomy for all patients with ovarian cancer and for patients with endometrial cancer if the peritoneal cytology gave a positive result. However, omentectomy was not performed for patients with cervical cancer. Because of the retroperitoneum suture for all patients in this study, we believe that performing omentectomy did not affect the pelvic lymphocyst formation directly. In fact, there was no statistical difference in pelvic lymphocyst formation in these groups.
Concerning endometrial cancer, it was observed that the more positive nodes, the higher was the incidence of pelvic lymphocysts in patients who underwent radical hysterectomy after signs of cervical invasion were identified (15,18). However, because the pelvic lymphocyst incidence in these patients was lower than that in patients with no cervical invasion, we believe that the incidence of pelvic lymphocysts was affected by the differences in hysterectomy procedures, not by differences in the primary diseases. Considering this hypothesis, we studied the pelvic lymphocyst incidence on a surgical procedure basis among gynecological malignancies that included cervical, endometrial and ovarian cancer. To determine whether the procedure to prevent vaginal shortening made any difference in the incidence of lymphocysts, we should have compared the patients who underwent radical hysterectomy either with or without the procedure to prevent vaginal shortening. Unfortunately, very few patients who had undergone radical hysterectomy without the procedure to prevent vaginal shortening were examined by postoperative CT. To our knowledge, there is no literature to demonstrate the difference in the incidence of pelvic lymphocyst formation between radical hysterectomy and modified radical hysterectomy. The results obtained in this study showed that the postoperative incidence of pelvic lymphocyst formation in patients undergoing radical hysterectomy with the procedure to prevent vaginal shortening was significantly lower than that in those who underwent modified radical hysterectomy.
It has been generally considered that after systematic lymphadenectomy, drainage is necessary to prevent the formation of pelvic lymphocysts (21,22). However, a recent study has shown that the damaged peritoneum normally heals without adhesions unless there is infection, ischemia or foreign bodies (23,24). It has been reported that a pelvic drain could, if left in situ for some days, impair the reparative and absorptive capacities of the peritoneum and so contribute to the very problems that its use was intended to prevent (25). Consequently, the pelvic peritoneum and the peritoneum along the paracolic gutters were left open (9) with no closed-suction drainage (1,7,8) or an omental J-flap (10) was used to reduce the incidence of lymphocyst formation. It is known that if the vaginal vault is left open, it will serve as a passive drain during the early postoperative period. However, leaving the vaginal vault open without performing a postoperative treatment to prevent early closure of the vaginal stump does not affect the incidence of pelvic lymphocysts (26). During the postoperative period when pelvic lymphocysts are most likely to occur, the subsequent procedure to prevent vaginal shortening works effectively as a means of continuous drainage that does not necessitate the presence of foreign bodies on the peritoneal surfaces.
We assume that this mechanism lowered the pelvic lymphocyst incidence and conclude that our procedure to prevent vaginal shortening could be effective in preventing not only the shortening of the vagina but also the occurrence of pelvic lymphocysts in patients undergoing radical hysterectomy with systematic lymphadenectomy for gynecological malignancies.
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FOOTNOTES |
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+ For reprints and all correspondence: Ritsu Yamamoto, Department of Obstetrics and Gynecology, Hokkaido University School of Medicine, Kita-15, Nishi-7, Kita-Ku, Sapporo, 060-8638, Japan. E-mail: tellme33@netfarm.ne.jp
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Received May 10, 2000; accepted July 7, 2000.
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