Lymphography with Patent Blue for Identification of Lymphatic Fistula After Radical Hysterectomy

Introduction

Pelvic lymphatic fistula is an uncommon complication after radical hysterectomy. The usual clinical presentation of this disorder is a significant amount of clear vaginal discharge.^1,2 Rarely, this type of fistula may appear as ascites. ³ With rapid diagnosis and appropriate management, the prognosis is good.^2,4 However, the treatment for this type of fistula is complex. A medical or surgical approach may be used, depending on the clinical condition of the patient.^1,2,4,5

Case

A 27-year-old female patient underwent radical hysterectomy due to stage 1 cervical squamous cell carcinoma. The patient was discharged from hospital on the third postoperative day. A week later, she returned to the hospital with a suspected hemoperitoneum. Abdominal ultrasonography revealed free intra-abdominal fluid. Since the patient was hemodynamically stable, afebrile, and had a good clinical course, she was discharged from hospital 48 hours after admission. A presumptive diagnosis of stable hemoperitoneum was made. Three weeks later, she returned with abdominal distension. Abdominal ultrasound detected massive ascites. Excretory urography, abdominal computed tomography (CT), and retrograde and voiding urethrocystography were performed. The right terminal ureter was incompletely visualized and a large amount of intra-abdominal fluid was seen. An ureteral fistula was presumed to be the cause. The patient underwent exploratory laparotomy, and obstruction of the right terminal ureter was observed. A double-J stent was inserted into the right ureter. A drain was left in the abdominal cavity.

In the postoperative period, the patient presented with a non-urinary light yellow fluid through the drain. Average fistula output was 700 mL/24 hours. Urea in the drained fluid was normal, and protein content was elevated. The diagnostic hypothesis was a lymphatic fistula. Treatment with total parenteral nutrition and somatostatin analogue was begun. After 10 days, the clinical condition of the patient worsened with tachycardia, fever, and persistent high-output fistula drainage. A reoperation was indicated.

Immediately after anesthesia induction, 2 mL of patent blue was injected into the right inguinal and right hip regions in an attempt to identify the pelvic lymphatic fistula. The abdominal cavity was opened at the site of persistent obstruction of the right terminal ureter. After 45 minutes, the orifice of the lymphatic duct was identified at the topography of the right external iliac artery by extravasation of patent blue through a single lymphatic duct. Suture ligation of the lymphatic channel was performed with a Prolene 5-0 vascular suture. A suction drain was left inside the abdominal cavity. Fistula output was 150 mL on the first day postoperatively. On the fourth postoperative day, the drain was removed, since drainage had decreased to less than 50 mL/24 hours. Parenteral nutrition and somatostatin analogue were discontinued. A double-J stent was removed from the right ureter and the patient was discharged from hospital. Thirty months have passed since her last surgery and the patient is doing well, with no evidence of active oncologic disease.

Discussion

In pelvic lymph node dissection during radical gynecologic surgeries, injury to the lymphatic vessels may occur. This injury leads to lymphocyst formation in 20% to 32% of patients in the postoperative period. Lymphatic fistulas may also occur, but this is rare. ⁶ These fistulas usually cause a high amount of vaginal discharge, similar to vesicovaginal or ureterovaginal discharge. ¹ The English scientific literature included 33 case reports of chylous ascites in gynecologic cancers by 2011, with only five cases describing ascites after retroperitoneal lymph node dissection without adjuvant radiotherapy. ³

The diagnosis of a urinary tract fistula may be confirmed by biochemical and cytological examination of the fluid obtained from the vaginal secretion. Lymph has a protein content of 1–6 g/dL fat and electrolyte concentration similar to that of serum and 2,000 to 20,000 white blood cells/mm⁴ consisting primarily of lymphocytes, which is markedly different from urine. In this patient, lymphatic fluid was not draining externally from the vaginal canal. However, moderate ascites occurred, which is an uncommon event.

Management of the patient involved conservative treatment, with total parenteral nutrition and somatostatin analogue. Spontaneous closure of the fistula was awaited.^2,7 Drainage failed to decrease and the clinical condition of the patient worsened. Reoperation was required using intraoperative lymphography with patent blue technique for identification and ligation of the lymphatic duct.^5,8,9

Diagnosis of a lymphatic fistula may be considered when postoperative ascites develops in patients undergoing radical hysterectomy with pelvic lymphadenectomy. Rapid treatment can then be initiated, preventing these patients from having unnecessary and invasive urinary tract tests.