MANUAL LYMPHATIC DRAINAGE FOR THE TREATMENT OF ACUTE GENITAL LYMPHEDEMA

Lymphedema is the swelling of a body part due to the accumulation of excessive amounts of regional interstitial fluid and decrease or blockage of lymphatic transport.1 Secondary lymphedema is the most common form and usually results from surgical, traumatic or inflammatory disruption or obstruction of the lymphatic pathways. Acute genital lymphedema usually resolves spontaneously but occasionally becomes chronic and may require surgical treatment.2 We report a case of severe acute postoperative genital edema following radical retropubic prostatectomy and bilateral pelvic lymphadenectomy that was successfully managed with 2 weeks of manual lymphatic drainage (MLD) therapy. To our knowledge this is the first case reported in the urological literature of postoperative genital edema treated with decongestive lymphatic therapy. CASE REPORT A 71-year-old man with a prostate specific antigen of 4.5 ng/ml and clinical stage T2a Gleason grade 5 4 9 adenocarcinoma of the prostate underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. Lymphadenectomy included removal of all the tissue from the obturator fossa and along the hypogastric vessels bilaterally. Both neurovascular bundles were excised widely around the prostate because of high volume, poorly differentiated tumor. Final pathological evaluation revealed bilateral Gleason grade 5 4 9 adenocarcinoma of the prostate confined within the prostatic capsule, with all surgical margins, seminal vesicles and lymph nodes negative for tumor. Postoperative hospital stay was uneventful, and the patient was discharged home on postoperative day 3. At postoperative day 11 the patient complained of severe debilitating swelling and pain in the penis and scrotum that interfered with sitting and walking. Physical examination demonstrated the genitalia to be markedly edematous with the scrotum the size of a grapefruit. There was mild penile edema that was not troublesome, and there was no lower extremity edema. There was no evidence of cellulitis. Venous duplex ultrasonography showed no evidence of either deep venous thrombosis or venous obstruction in the lower extremities or pelvis, and pelvic computerized tomography revealed no evidence of a pelvic fluid collection. During the next week the genital edema persisted and was refractory to the usual treatments of genital support and diuretics. Three weeks postoperatively daily decongestive therapy was started, consisting of MLD, lower extremity stretching exercises and overlapping circumferential compressive wrappings to the scrotum that transmitted low pressure compression (20 to 30 mm Hg). MLD was initiated in the inguinal region, moving cephalad, with the goal of transferring lymph from the edematous tissues to nonedematous cutaneous sites. Nonelastic compressive wrappings were applied after each session of MLD and worn continuously between treatments. Each daily therapy session of MLD lasted 3 to 4 hours. Between therapy sessions the patient was also instructed to wear tight briefs or an athletic supporter continuously. After several days of therapy the genital lymphedema and pain improved considerably, and after 2 weeks of treatment it had resolved completely. The patient was able to return to normal activities of daily living without sequelae. He was instructed to continue to wear tight supportive undergarments at home for 2 weeks. At 3 months postoperatively he was doing well, with no residual genital edema, and with excellent urinary control and an undetectable serum prostate specific antigen. DISCUSSION