Postrenal Transplantation Isolated Scrotal Lymphocele Managed by Scrotal Approach

Dear Editor, Lymphocele is one of the common complications following renal transplantation.[1] Extension of the lymphocele into the scrotum with resolution of retroperitoneal part is rare.[2] Scrotal lymphoceles are usually managed by combined retroperitoneal and open approach.[3] We describe the details of a patient who developed postrenal transplantation perigraft lymphocele extending to scrotum, progressing to isolated scrotal lymphocele, managed by scrotal approach alone. A 48-year-old male underwent renal transplantation for end-stage renal disease. He developed subcapsular hematoma postoperatively and exploration and clot evacuation was performed. He had acute antibody-mediated rejection and managed with escalation of immunosuppressants. His renal function started improving, drain was removed on the postoperative day (POD) 8 when it was <40 ml. Stent was removed on POD 21. He developed perigraft collection (lymphocele) and was followed up with ultrasonogram (USG) for resolution. He also had right scrotal fluid collection. Perigraft lymphocele gradually reduced on serial USG and computed tomogram (CT) and scrotal collection increased. By the 6th month, his creatinine was 1.4 mg/dl. CT showed gross scrotal lymphocele (250 ml) and minimal perigraft lymphocele (40 ml) [Figure 1a]. He had discomfort and dragging sensation in the scrotum and he was planned for intervention.Figure 1: (a) CT image showing gross scrotal lymphocele and small perigraft lymphocele, (b) Scrotal lymphocele on exploration; ☆ indicates testis with tunica vaginalis, (c) Pear shaped sac with narrowing at the level of deep inguinal ring, (d) Proximal end of sactransfixed with suturesHe was planned for management by scrotal approach and later laparoscopic marsupialization if required. Scrotal exploration was done by midline raphe incision. Lymphocele was minimally adherent to internal spermatic fascia and free from tunica vaginalis. It was a pear-shaped collection having hemorrhagic fluid, with the apex in the region of deep inguinal ring [Figure 1b] and no obvious communication to retroperitoneum. The apex was closed with transfixation sutures and lymphocele was excised [Figure 1c and d]. He had no recurrence and the perigraft collection had completely resolved at a 1-year follow-up. Perigraft lymphocele and hydrocele are not uncommon following renal transplantation. The incidence of lymphocele following transplantation varies between 1% and 26%.[1] Hydrocele is also one of the complications following renal transplantation.[4] However, scrotal lymphocele is very rare, especially after the resolution of perigraft lymphocele. Scrotal lymphoceles usually present as perigraft lymphocele with communication to the scrotum.[3] Lymphocele initially forms around the graft. If it increases in size, it follows the track of least resistance. It might track along the cord structures and enter the scrotum.[5] Since the peritoneum does not slide down, there is no hernia. The narrowing at the level of the deep ring might close resulting in two separate collections in the retroperitoneum and the scrotum. Complete removal usually involves a combined retroperitoneal and scrotal approach to prevent recurrence.[2] In the index patient, perigraft collection was gradually reducing, but the scrotal lymphocele was persistent. CT showed the communication at the level of the deep inguinal ring to be gradually narrowing in width. The inadvertent hemorrhage into the lymphocele might have probably aided fibrosis and closure of the communication and persistence of the scrotal collection. Without the inadvertent hemorrhage into the lymphocele, gradual resorption of scrotal collection might have been feasible (the retroperitoneal lymphocele gradually reduced). Aspiration of fluid was also an option in this patient,[2] but it was deferred due to the risk of introducing infection. We did not proceed retroperitoneally to open up the perigraft collection since it was small and there was no discernible communication. To conclude, scrotal lymphocele postrenal transplant can be followed up serially with imaging and can be dealt with by scrotal approach alone in selected cases. Declaration of patient consent The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patient understand that the name and initial would not be published and all standard protocols will be followed to conceal their identity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.