Massive Ascites Following Robot-Assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection: A Case Report

Background: Lymph leakage is regarded as one of the rare complications of major abdominal, pelvic, and thoracic surgeries. Lymphangiogram seems to be the principal diagnostic modality. Management strategies that have been shown in the literature range from conservative measures to surgical exploration. However, the rarity and diversity in the presentation of this complication have attributed to the lack of consensus and guideline on its management. Case Presentation: A 49-year-old obese man with prostate-specific antigen of 10 and preoperative Gleason score of 8 prostate cancer and initial staging of T 3 N 0 M 0 has undergone robot-assisted radical prostatectomy and extended pelvic lymph node dissection with unilateral nerve sparing. Our patient was admitted with significant ascites on day 14 postoperative, which was confirmed on CT abdomen and initially managed with nutritional support and percutaneous drainage. A lipidiol lymphangiogram demonstrated lymphatic leakage near the right external iliac vein. While he was awaiting elective surgical exploration, he has had two further successive admissions with massive ascites, anemia and raised C-reactive protein with acute kidney injury. A laparoscopic exploration was performed with interventional radiology assistance to direct dissection to the site of leak. An abscess cavity was found and excised. The lymphatic leak tailed off to insignificance rapidly thereafter. Conclusion: Each case of lymphatic leakage seems to require an individualized approach according to the nature and severity of the lymphatic leak and patient condition. Although it is possible that the collection was infected lymphatic fluid, the position of the abscess cavity in proximity to the site where the lipidiol was seen to leak from the lymphatics suggests that it is possible that the lipidiol was the nidus for infection. Either way what is interesting is that the presence of the abscess caused prolonged and profuse lymphatic leakage.