機器人輔助前列腺根除手術術後乳糜腹水併發症之案例報告

邱士庭¹，蔣智宏²，黃昭淵¹

¹國立台灣大學附設醫院 泌尿部

²臺北榮民總醫院 員山/蘇澳分院 泌尿部

Chylous Ascites after Robot-Assisted Laparoscopic Radical Prostatectomy

Shih-Ting Chiu¹, Chih-Hung Chiang², Chao-Yuan Huang¹

¹Department of Urology, National Taiwan University Hospital

²Department of Urology, Taipei Veterans General Hospital, Yuan-Shan/ Su-Ao Branch

Chylous ascites is a barely reported complication in urologic pelvic surgery. Here we report a case of chylous ascites following robotic-assisted laparoscopic radical prostatectomy.

  Our case is a 66-year-old man had underlying disease of hyperuricemia and hyperlipidemia with regular medication control. He had no prior abdominal or pelvic surgery. He underwent robotic-assisted laparoscopic radical prostatectomy and bilateral lymph node dissection with a total 17 lymph nodes dissected in final specimen. Pathology showed prostate adenocarcinoma, Gleason score 3+4 =7, pT2, without lymph node involvement. Initially, he had a smooth post-operative course and was discharged on the 8^th post-operative day. However, he returned to the emergency department on 21^st post-operative day with complaint of abdominal distention for one week. His vital signs were within normal limits. Laboratory test showed normal blood cell count, renal function test and serum electrolytes. Computed tomography revealed massive ascites. An abdominal pigtail was inserted, draining milky chylous fluid. Analysis for ascitic fluid showed highly elevated triglyceride (TG, 5229 mg/dL) and normal cholesterol, creatinine, and albumin level. Serum ascites albumin gradient (SAAG) was less than 1.1 g/dL. Ascites culture and cytology were both negative. The daily output of the chylous drainage was about 1000mL per day, even under low-fat plus medium-chain triglycerides (MCT) diet. Lymphangiography with lipiodol showed lymphatic leakage from right pelvic sidewall lymph nodes and was subsequently embolized with 0.5cc 16% n-butyl cyanoacrylate glue. The output decreased drastically to less than 200ml per day and decreased day by day. The drain was removed 6 days after embolization.

 Lymphatics can transport proteins and interstitial fluid back into systemic circulation. Operation may traumatize the lymphatic system, leading to lymph leakage. Post-operative lymphatic leakage is classified into lymphorrhea and chylorrhea. (1) Chylorrhea is odorless, sterile, and rich in TG (>200mg/dL), and usually resulted a result of trauma of thoracic duct, cistern chyli or main tributes. Post-operative chylous drainage is more common in upper gastrointestinal surgery, colorectal surgery, radical nephrectomy, and retroperitoneal lymph node (LND) dissection. (2) There are only cases reports of chylous ascites after radical prostatectomy in current literature. Possible causes in pelvic operation cases may be inadvertent unrecognized injury to the major intestinal lymphatic trunk or congenital anomaly of retroperitoneal lymphatics draining the pelvis. (3)