Risk Factors for Lymphoceles following Robot-Assisted Laparoscopic Prostatectomy: Insights from NSQIP Data
Muhieddine Labban, MD, Vincent D. D'Andrea, MD, Benjamin V. Stone, MD, Dejan K. Filipas, MD, Edoardo Beatrici, MD, Jane R. Kielhofner, BS, Alexander P. Cole, MD, Quoc-Dien Trinh, MD, MBA.
Brigham and Women's Hospital, BOSTON, MA, USA.
BACKGROUND: Lymphocele is a common cause for morbidity following robot-assisted laparoscopic prostatectomy (RALP). While previous studies have reported rates of lymphocele after RALP, few have investigated specific patient-level and operative-level factors that may contribute to its development. This study aims to address this gap in the literature by examining a recent and large cohort of patients undergoing RALP.
METHODS: We queried the National Surgical Quality Improvement Program (NSQIP) between 2019 and 2021 for men who underwent RALP with pelvic lymph node dissection for prostate cancer. The primary endpoints were 30-day lymphocele development and lymphocele development requiring intervention or reoperation. The patient-level factors were age, clinical T, body mass index, race/ethnicity, 5-item frailty index, bleeding diathesis, prior pelvic operation, and prior pelvic radiotherapy. The operative-level factors were operative time, number of lymph nodes dissected, whether the patient was kept NPO (fasting) for a prolonged time, and whether a drain was placed postoperatively. We fitted a multivariable logistic regression to examine the patient- and operative-level factors associated with lymphocele development and lymphocele requiring intervention adjusting for the aforementioned covariates. RESULTS: Our cohort included 14,697 men of whom 303 (2.1%) developed a post-operative lymphocele. Out of 303 men who developed a lymphocele, 123 (40.6%) required an intervention or reoperation. Table 1 compares the baseline characteristics between those who developed and those who did not develop a lymphocele 30 days after RALP. Patient-level factors associated with lymphocele development included prior pelvic operations [OR: 1.56; 95%CI (1.18 - 2.05); p<0.01], obesity [OR: 1.50; 95%CI (1.04 - 2.16); p=0.03, and older age (61-69; OR: 1.38; 95%CI (1.04 - 1.84); p=0.03]. The operative-level factors included prolonged postoperative fasting or nasogastric tube use (OR: 8.69; 95%CI (5.43 - 13.92); p<0.01], and prolonged operative time (3-4 hours; OR: 1.58 95%CI (1.16 - 2.16); p <0.01]. For every one lymph node dissected, the odds of lymphocele development increased by [2%; 95%CI (1 - 3); p<0.01]. Nevertheless, postoperative drain placement was not associated with lymphocele development. Similar predictors were found for lymphocele requiring intervention or reoperation (Table 2).
CONCLUSIONS: We identified patient- and operative level factors associated with lymphocele development after RALP. Postoperative prolonged fasting emerged as the strongest predictor of lymphocele development and intervention, while drain placement was not protective. While we could only capture 30-day outcomes, the lymphoceles captured in this cohort were likely symptomatic or detected incidentally. Our findings provide valuable real-world data using a diverse patient population and a mix of surgeons with varying levels of expertise. Table 1: Comparison of baseline patient characteristics and operative data between men who developed postoperative lymphocele and patients who did not within 30-days of RALP
| No Lymphocele | Lymphocele | Total | p-value | |
| N=14,394 | N=303 | N=14,697 | ||
| Age | 0.09 | |||
| ≤ 60 | 4,602 (32.0%) | 79 (26.1%) | 4,681 (31.9%) | |
| 61-69 | 7,095 (49.3%) | 162 (53.5%) | 7,257 (49.4%) | |
| ≥ 70 | 2,697 (18.7%) | 62 (20.5%) | 2,759 (18.8%) | |
| Race and Ethnicity | 0.67 | |||
| Non-Hispanic White | 10,008 (69.5%) | 212 (70.0%) | 10,220 (69.5%) | |
| Non-Hispanic Black | 1,875 (13.0%) | 44 (14.5%) | 1,919 (13.1%) | |
| Hispanic | 692 (4.8%) | 15 (5.0%) | 707 (4.8%) | |
| Other | 1,819 (12.6%) | 32 (10.6%) | 1,851 (12.6%) | |
| Body Mass Index | < 0.01 | |||
| Underweight and Normal | 2,595 (18.0%) | 41 (13.5%) | 2,636 (17.9%) | |
| Overweight | 6,405 (44.5%) | 121 (39.9%) | 6,526 (44.4%) | |
| Obesity | 5,338 (37.1%) | 139 (45.9%) | 5,477 (37.3%) | |
| Missing | 56 (0.4%) | 2 (0.7%) | 58 (0.4%) | |
| 5-item Frailty Index | 0.05 | |||
| 0 | 6,289 (43.7%) | 118 (38.9%) | 6,407 (43.6%) | |
| 1 | 6,251 (43.4%) | 134 (44.2%) | 6,385 (43.4%) | |
| ≥2 | 1,404 (9.8%) | 41 (13.5%) | 1,445 (9.8%) | |
| Missing | 450 (3.1%) | 10 (3.3%) | 460 (3.1%) | |
| Bleeding Diathesis | 0.01 | |||
| No | 14,246 (99.0%) | 295 (97.4%) | 14,541 (98.9%) | |
| Yes | 148 (1.0%) | 8 (2.6%) | 156 (1.1%) | |
| Prior Pelvic Operations | <0.01 | |||
| No | 12,019 (83.5%) | 224 (73.9%) | 12,243 (83.3%) | |
| Yes | 2,375 (16.5%) | 79 (26.1%) | 2,454 (16.7%) | |
| Prior Pelvic Radiotherapy | 0.58 | |||
| No | 14,291 (99.3%) | 300 (99.0%) | 14,591 (99.3%) | |
| Yes | 103 (0.7%) | 3 (1.0%) | 106 (0.7%) | |
| Clinical T | 0.39 | |||
| T1 or T2 | 7,781 (54.1%) | 155 (51.2%) | 7,936 (54.0%) | |
| T3 or T4 | 6,566 (45.6%) | 146 (48.2%) | 6,712 (45.7%) | |
| Unknow | 47 (0.3%) | 2 (0.7%) | 49 (0.3%) | |
| Prolonged Postoperative NPO or NGT Use | <0.01 | |||
| No | 14,265 (99.1%) | 278 (91.7%) | 14,543 (99.0%) | |
| Yes | 129 (0.9%) | 25 (8.3%) | 154 (1.0%) | |
| Operative time | <0.01 | |||
| < 3 hours | 4,786 (33.2%) | 69 (22.8%) | 4,855 (33.0%) | |
| 3-4 hours | 5,169 (35.9%) | 123 (40.6%) | 5,292 (36.0%) | |
| ≥ 4 hours | 4,438 (30.8%) | 111 (36.6%) | 4,549 (31.0%) | |
| Median Number of Lymph Nodes | 1 (0.0%) | 0 (0.0%) | 1 (0.0%) | |
| Postoperative Drain Placement | 7.0 (4.0-12.0) | 8.0 (4.0-15.0) | 7.0 (4.0-12.0) | <0.01 |
| No | 0.70 | |||
| Yes | 9,699 (67.4%) | 201 (66.3%) | 9,900 (67.4%) |
Table 2: Multivariate logistic regression assessing the patient- and operative-level factors associated with lymphocele development
| Lymphocele (n=14,178) | Lymphocele Requiring Intervention (n=14,178) | |||
| Odds Ratio (95%CI) | p-value | Odds Ratio (95%CI) | p-value | |
| Age | ||||
| ≤ 60 | Reference | Reference | ||
| 61-69 | 1.38 (1.04 - 1.84) | 0.03 | 1.29 (0.82 - 2.04) | 0.27 |
| ≥ 70 | 1.33 (0.93 - 1.90) | 0.12 | 1.74 (1.02 - 2.98) | 0.04 |
| Body Mass Index | ||||
| Underweight or normal | Reference | Reference | ||
| Overweight | 1.19 (0.83 - 1.71) | 0.35 | 1.82 (0.94 - 3.53) | 0.07 |
| Obese | 1.50 (1.04 - 2.16) | 0.03 | 2.57 (1.32 - 4.99) | 0.01 |
| Race and Ethnicity | ||||
| Non-Hispanic White | Reference | Reference | ||
| Non-Hispanic Black | 1.00 (0.70 - 1.43) | 0.99 | 0.60 (0.30 - 1.17) | 0.13 |
| Hispanic | 1.06 (0.62 - 1.82) | 0.83 | 0.82 (0.33 - 2.03) | 0.67 |
| Other | 0.84 (0.57 - 1.24) | 0.38 | 0.53 (0.25 - 1.09) | 0.09 |
| 5-item Frailty Index | ||||
| 0 | Reference | Reference | ||
| 1 | 1.00 (0.77 - 1.30) | 0.98 | 0.80 (0.54 - 1.19) | 0.27 |
| ≥ 2 | 1.25 (0.85 - 1.82) | 0.26 | 0.81 (0.42 - 1.56) | 0.53 |
| Bleeding Diathesis | ||||
| No | Reference | Reference | ||
| Yes | 2.05 (0.89 - 4.74) | 0.09 | 1.70 (0.41 - 7.04) | 0.46 |
| Prior Pelvic Operations | ||||
| No | Reference | Reference | ||
| Yes | 1.56 (1.18 - 2.05) | < 0.01 | 1.19 (0.75 - 1.88) | 0.19 |
| Prior Pelvic Radiotherapy | ||||
| No | Reference | Reference | ||
| Yes | 1.07 (0.33 - 3.51) | 0.91 | 0.83 (0.11 - 6.29) | 0.86 |
| Clinical T | ||||
| T1 or T2 | Reference | Reference | ||
| T3 or T4 | 1.05 (0.83 - 1.33) | 0.71 | 0.85 (0.58 - 1.24) | 0.40 |
| Unknown | 2.53 (0.60 - 10.59) | 0.20 | 5.76 (1.35 - 24.7) | 0.02 |
| Prolonged Postoperative NPO or NGT use | ||||
| No | Reference | Reference | ||
| Yes | 8.69 (5.43 - 13.92) | < 0.01 | 8.67 (4.22 - 17.8) | < 0.01 |
| Operative Time | ||||
| < 3 hours | Reference | Reference | ||
| 3-4 hours | 1.58 (1.16 - 2.16) | < 0.01 | 1.75 (1.07 - 2.87) | 0.03 |
| ≥ 4 hours | 1.52 (1.10 - 2.11) | 0.01 | 1.63 (0.97 - 2.74) | 0.06 |
| Number of Lymph Nodes | 1.02 (1.01 - 1.04) | < 0.01 | 1.03 (1.01 - 1.04) | < 0.01 |
| Postoperative Drain Placement | ||||
| No | Reference | Reference | ||
| Yes | 0.99 (0.77 - 1.27) | 0.94 | 0.89 (0.59 - 1.32) | 0.56 |
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