Lymphocele is defined as a lymph-filled collection without an epithelial lining that typically develops in the retroperitoneal space following renal transplantation¹. It arises due to disruption of lymphatic vessels during donor nephrectomy or recipient iliac vessel dissection. Although most lymphoceles are small and clinically silent, larger collections can result in significant morbidity, including infection, ureteric obstruction, and allograft dysfunction¹.

The incidence of lymphocele varies widely depending on detection modality and follow-up duration, with increased detection rates attributed to routine use of ultrasonography¹. Structural causes of graft dysfunction, such as lymphocele, are often under-recognized and may mimic immunological etiologies³.

Robotic-assisted kidney transplantation is increasingly adopted due to its minimally invasive approach and reduced complication rates. Meta-analyses have demonstrated a lower incidence of symptomatic lymphocele with robotic techniques². However, clinically significant lymphocele continues to occur, necessitating vigilance.

CASE PRESENTATION

A 27-year-old male with end stage renal disease (ESRD) underwent live-related renal transplantation, with his mother as the donor. Native kidney biopsy demonstrated chronic hypertensive changes along with features of thrombotic microangiopathy secondary to uncontrolled hypertension. Genetic evaluation for primary thrombotic microangiopathy was negative.

The patient underwent a robotic assisted kidney transplantation (RAKT) for ESRD. The early postoperative course was largely uneventful except for transient acute tubular injury on postoperative day one. Induction immunosuppression included anti-thymocyte globulin and methylprednisolone, followed by maintenance therapy with tacrolimus, mycophenolate mofetil, and prednisolone. Early allograph complications, such as acute tubular necrosis and delayed graft function, severely alter local interstitial fluid dynamics and predispose the recipient to impaired lymphatic regeneration. When the mTOR inhibitors are introduced, it acts synergistically to disrupt local tissue healing and drastically accelerate high-output retroperitoneal lymphatic leakage. ^4,5,6 Everolimus was administered transiently during the first postoperative month due to delayed graft function, a factor known to increase the risk of lymphocele formation.⁷^,⁸

The patient stabilized with a baseline serum creatinine of 1.5 mg/dL. Eighty days post-transplantation, he presented with progressive right lower limb swelling. Doppler studies of the lower limb and iliac vessels were unremarkable. Within ten days, serum creatinine increased to 5.8 mg/dL.

On examination, a tense hypogastric swelling was noted, mimicking a distended urinary bladder. Ultrasonography revealed a large anechoic collection without internal echoes, consistent with lymphocele.³ Repeat assessment after bladder emptying confirmed the diagnosis.

Management and Outcome

Ultrasound-guided drainage was performed with insertion of a pigtail catheter. Fluid analysis demonstrated lymphocyte-rich fluid with creatinine levels similar to serum, consistent with lymphocele. There was no evidence of vascular compromise on Doppler imaging. Renal biopsy revealed acute tubular injury without features of rejection.

Serial drainage combined with sclerotherapy was performed, an approach supported by existing literature demonstrating efficacy in symptomatic lymphocele management.⁵ The combined use of percutaneous drainage and embolic or chemical sclerotherapy continues to be the standard initial approach for treatment of symptomatic fluid collections following transplantation with very reproducible clinical success rates.^6,7 While the choice of agent is inconsistent, long-term cohort data underscore the fact that careful volume-targeted instillation markedly reduces local inflammation and maintains vascular integrity.⁸ However, even with optimal initial tract closure, technical limitations related to catheter use and localized fluid accumulation continue to contribute to significant rates of clinical recurrence.⁹^,¹⁰^,¹¹ The patient initially improved; however, catheter blockage resulted in recurrence of the collection, causing hydronephrosis and severe graft dysfunction.

Following prompt percutaneous correction of the catheter obstruction, there was rapid improvement in the renal function, with serum creatinine returning to the baseline of 1.5mg/dl. The catheter and use of sclerosing agent did not completely solve the issue in this case. He was taken for laparoscopic unroofing. It solved the issue and serum creatinine stabilised.

Table 1- Demonstrates the post-transplantation clinical timeline and procedural events.

Figure 1- Demonstrates the post-transplantation clinical timeline

Figure 2. Ultrasound image showing a well-defined anechoic fluid collection in the pelvis adjacent to the renal allograft, with posterior acoustic enhancement and no internal echoes, consistent with a lymphocele.

Figure 3. Repeat ultrasonography demonstrating persistence of a large anechoic pelvic collection occupying the hypogastric region, mimicking a distended urinary bladder.

Figure 4. Clinical photograph showing tense hypogastric swelling corresponding to underlying fluid collection in a post–renal transplant recipient.

DISCUSSION

Lymphocele remains one of the most common surgical complications following renal transplantation, with incidence ranging widely depending on diagnostic criteria.¹ It typically develops within weeks to months after transplantation and may present with nonspecific symptoms, often mimicking rejection or drug toxicity.¹^,⁶

The underlying pathophysiology involves lymphatic leakage from disrupted vessels during surgical dissection.¹ Multiple risk factors have been implicated, including obesity, delayed graft function, use of mTOR inhibitors such as everolimus,^4,5,10 high-dose steroids, anticoagulation therapy, and acute rejection episodes⁷^,8,⁹. The use of everolimus in our patient likely contributed to lymphocele formation by delaying endothelial healing and tissue repair.

While most lymphoceles are asymptomatic, larger collections may exert mass effect on adjacent structures. Ureteric compression can lead to hydroureteronephrosis and obstructive uropathy, as demonstrated in previous reports.⁴ In severe cases, compression of the renal parenchyma may mimic the Page kidney phenomenon¹.

Ultrasonography remains the cornerstone of diagnosis, typically demonstrating an anechoic perinephric collection³. Differentiation from other fluid collections, particularly the urinary bladder, is critical and can be achieved through dynamic assessment before and after voiding.

Management strategies depend on symptom severity and size of the collection. Small lymphoceles often resolve spontaneously, whereas symptomatic cases require intervention.⁵ Percutaneous drainage with or without sclerotherapy is widely accepted as first-line therapy, although recurrence rates remain significant⁵^,¹⁰^,11,¹². Various sclerosing agents, including ethanol, povidone-iodine, and tetracycline derivatives, have been used with variable success¹¹,¹².

For recurrent or large lymphoceles, laparoscopic fenestration into the peritoneal cavity is considered an effective and definitive treatment option⁹,¹³. Adjunctive therapies such as octreotide have also been explored in refractory cases¹³.

Despite advancements in surgical techniques, including robotic-assisted transplantation, lymphocele formation cannot be entirely prevented². This case underscores the importance of considering structural causes in the differential diagnosis of graft dysfunction. Early recognition and timely intervention are crucial, as prompt drainage can reverse renal impairment and prevent unnecessary renal replacement therapy³.

CONCLUSION

Lymphocele remains a significant and potentially reversible cause of graft dysfunction following renal transplantation, even in the era of robotic-assisted surgery. A high index of suspicion, early imaging, and prompt intervention are essential to preserve graft function and improve patient outcomes.

REFERENCES

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