Drains versus no drains after pelvic lymphadenectomy to prevent lymphocyst formation in patients with gynaecological cancer

Background

Pelvic lymphadenectomy, the procedure to remove lymph nodes surrounding major blood vessels in the pelvis, is an important component of the surgical management of gynaecological cancers. However, it can lead to complications, especially lymphocyst formation (collection of lymphatic fluid in the pelvis) and its related consequences such as leg swelling, blockage of the ureter, pelvic pain, clot formation in the leg and pelvic vein, bowel motility disorder, and infection. Without clear evidence, placement of suction drains to remove lymphatic fluid that accumulates in the operative area between the peritoneum and the posterior abdominal wall has been traditionally recommended to prevent such complications.

Review question

The aim of this review is to compare the effects of drains versus no drains in preventing lymphocyst formation following pelvic lymphadenectomy.

Main findings

The searches were updated in January 2014. We identified four studies (571 particpants) for inclusion. The participants were primarily those who had cancer of the cervix and endometrium, with only one study also including patients with cancer of the ovary. The findings have demonstrated that placement of suction drains is not effective in preventing lymphocysts, especially when the peritoneum (pelvic lining) is left open. In fact, such practice increases the risk of short and long-term lymphocyst formation with related symptoms.

Quality of the evidence

The review includes four good-quality (low to moderate risk of bias) clinical trials in its final analysis.

Authors' conclusions: 

Placement of retroperitoneal tube drains has no benefit in prevention of lymphocyst formation after pelvic lymphadenectomy in patients with gynaecological malignancies. When the pelvic peritoneum is left open, the tube drain placement is associated with a higher risk of short and long-term symptomatic lymphocyst formation.

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Background: 

This is an updated version of the original Cochrane review published in Issue 1, 2010. Pelvic lymphadenectomy is associated with significant complications including lymphocyst formation and related morbidities. Retroperitoneal drainage using suction drains has been recommended as a method to prevent such complications. However, this policy has been challenged by the findings from recent studies.

Objectives: 

To assess the effects of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy on lymphocyst formation and related morbidities in gynaecological cancer patients.

Search strategy: 

We searched the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 12) in The Cochrane Library, electronic databases MEDLINE (Nov Week 3, 2013), EMBASE (2014, week 1), and the citation lists of relevant publications. The latest searches were performed on 10 January 2014.

Selection criteria: 

Randomised controlled trials (RCTs) that compared the effect of retroperitoneal drainage versus no drainage after pelvic lymphadenectomy in gynaecological cancer patients. Retroperitoneal drainage was defined as placement of passive or active suction drains in pelvic retroperitoneal spaces. No drainage was defined as no placement of passive or active suction drains in pelvic retroperitoneal spaces.

Data collection and analysis: 

We assessed studies using methodological quality criteria. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs). We examined continuous data using mean difference (MD) and 95% CI.

Main results: 

Since the last version of this review, no new studies have been identified for inclusion. The review included four studies with 571 participants. Considering the short-term outcomes (within four weeks after surgery), retroperitoneal drainage was associated with a comparable rate of overall lymphocyst formation when all methods of pelvic peritoneum management were considered together (two studies, 204 patients; RR 0.76, 95% CI 0.04 to 13.35). When the pelvic peritoneum was left open, the rates of overall lymphocyst formation (one study, 110 patients; RR 2.29, 95% CI 1.38 to 3.79) and symptomatic lymphocyst formation (one study, 137 patients; RR 3.25, 95% CI 1.26 to 8.37) were higher in the drained group. At 12 months after surgery, the rates of overall lymphocyst formation were comparable between the groups (one study, 232 patients; RR 1.48, 95% CI 0.89 to 2.45). However, there was a trend toward increased risk of symptomatic lymphocyst formation in the group with drains (one study, 232 patients; RR 7.12, 95% CI 0.89 to 56.97). The included trials were of low to moderate risk of bias.

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