0022-5347/04/1721-0157/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 172, 157–158, July 2004
Printed in U.S.A.
DOI: 10.1097/01.ju.0000129010.49244.3d


MANUAL LYMPHATIC DRAINAGE FOR THE TREATMENT OF ACUTE GENITAL LYMPHEDEMA
ERIN E. KATZ,* MARK B. LYON, DIANE DAVIS, LAWRENCE J. GOTTLIEB AND CHARLES B. BRENDLER

From the Department of Surgery, Section of Urology (EEK, MBL, CBB), Section of Plastic and Reconstructive Surgery (LJG) and Department of Physical Therapy (DD), University of Chicago, Chicago, Illinois
KEY WORDS: lymphedema; prostatectomy; surgical procedures, minimally invasive
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 usu- ally results from surgical, traumatic or inflammatory dis- ruption 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 success- fully 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 gen- ital 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 ade- nocarcinoma 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 bilat- erally. Both neurovascular bundles were excised widely around the prostate because of high volume, poorly differen- tiated tumor. Final pathological evaluation revealed bilateral Gleason grade 5 􏰀 4 􏰁 9 adenocarcinoma of the prostate confined within the prostatic capsule, with all surgical mar- gins, 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 exami- nation demonstrated the genitalia to be markedly edema- tous 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 evi- dence of either deep venous thrombosis or venous obstruc- tion in the lower extremities or pelvis, and pelvic comput- erized tomography revealed no evidence of a pelvic fluid collection. During the next week the genital edema per- sisted and was refractory to the usual treatments of geni- tal 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 trans-
Accepted for publication February 27, 2004.
* Correspondence: University of Chicago Pritzker School of Medi- cine, Department of Surgery, Section of Urology, 5841 S. Maryland Ave., MC 6038, Chicago, Illinois 60637 (telephone: 773-702-6105; FAX: 773-702-1001; e-mail: ekatz13@hotmail.com).
ferring lymph from the edematous tissues to nonedema- tous cutaneous sites. Nonelastic compressive wrappings were applied after each session of MLD and worn contin- uously 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 ther- apy the genital lymphedema and pain improved consider- ably, and after 2 weeks of treatment it had resolved com- pletely. 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 spe- cific antigen.

DISCUSSION
Manual lymphatic drainage administered by a trained phys- ical therapist is a specialized massage technique that enhances lymphatic contractility and attempts to redirect lymph flow through nonobstructed cutaneous lymphatics. In addition to regional massage, this therapy is generally combined with skin care, remedial exercises and compressive elastic garments or wraps. The compressive wrappings cause mild tissue compres- sion, which is thought to improve lymphatic filling, enhance transport capacity and enhance the development of accessory cutaneous lymphatics. Decongestive lymphatic therapy consist- ing of MLD, extremity stretching exercises and nonelastic com- pressive dressings have been the mainstay of treatment of up- per extremity lymphedema in women with breast cancer following axillary lymphadenectomy.1
Secondary lower extremity and genital lymphedema fol- lowing pelvic lymphadenectomy occurs frequently, with a reported incidence as high as 47%.1 The edema usually re- solves spontaneously during the course of several days and is managed expectantly with genital support. For patients who experience severe, painful and/or prolonged lymphedema MLD should be considered. If lymphedema fails to resolve spontaneously and is not treated effectively in the acute stage, it may become chronic with associated irreversible skin changes, recurrent cellulitis and ischemia. Chronic lymphedema may require extensive surgery to correct.2 Early aggressive decongestive lymphatic therapy of genital lymphedema decreases the risk of cellulitis, and, thus, may prevent these chronic pathological changes, making such surgical intervention unnecessary.
Microsurgical reconstruction of disrupted lymphatics is difficult to perform. Although various microsurgical free flap transfer and limb replantation are routinely performed with reconnection of arteries, veins and occasionally nerves, dis- rupted lymphatics are difficult to identify and are usually not reconnected. The majority of these patients experience little or no transient lymphedema despite the absence of lymphatic anastomoses, most likely due to spontaneous regeneration of lymphatics.3 It has been proved that lymphatic regeneration

157158 MANUAL LYMPHATIC DRAINAGE FOR ACUTE GENITAL LYMPHEDEMA
in humans occurs between 2 and 4 weeks after disruption.3 However, during this period prolonged lymphedema may occasionally lead to cellulitis and measurable skin changes. To our knowledge this is the first reported case in which noninvasive decongestive lymphatic therapy was used suc- cessfully to alleviate acute genital edema following pelvic lymphadenectomy.


REFERENCES
1. Rockson, S. G.: Lymphedema. Am J Med, 110: 288, 2001 2. McDougal, W. S.: Lymphedema of the external genitalia. J Urol,
170: 711, 2003 3. Slavin, S. A., Upton, J., Kaplan, W. D. and Van den Abbeele,
A. D.: An investigation of lymphatic function following free- tissue transfer. Plast Reconstr Surg, 99: 730, 1997

DRENAJE LINFATICO MANUAL

Única alternativa para linfedemas de cualquier
etiología y coadyuvante como técnica
de limpieza en múltiples patologías


Hace solo 50 años se reconoció al linfocito, célula del sistema linfático como la 2ª célula en importancia en el organismo, la neurona célula del sistema nervioso central ya había sido identificada como la más importante.

Llama la atención que siendo así se le de tan poca importancia al sistema linfático o sistema de defensa del organismo, el cual esta conformado por órganos que precisamente son los que producen los linfocitos y por conductos o vasos por donde viajan estas células, encargándose de mantener limpio el sistema.

Este proceso se inicia por medio de canales en el espacio intercelular- o matriz extracelular para recoger los desechos del metabolismo celular: agua, toxinas, células muertas…Etc. Y en general partículas grandes que el sistema venoso no puede recoger, pero que el sistema linfático si y fluye a través de vasos que están en casi todo nuestro cuerpo; para luego evacuar ya limpio al sistema sanguíneo.

Esta limpieza se realiza precisamente por acción de los ganglios o filtros que están en todo el recorrido de los vasos linfáticos y mas precisamente a nivel de las articulaciones formando las cadenas ganglionares que es donde los linfocitos o células de defensa se clonan o reproducen en gran cantidad según la necesidad del medio.

De allí la importancia de la manipulación especializada para estimular el funcionamiento del fluido linfático, ayudando a través de esta técnica manual en los procesos de limpieza de la matriz extracelular.

El sistema linfático recoge las partículas grandes entre ellas las proteínas que están saliendo continuamente de las arterias y que devuelve a ellas, por eso cuando falla, la linfa acumulada en el espacio intersticial es hiperproteica (mayor concentración de proteínas) dando un aspecto de gel en un inicio y de pasta o sólido en etapas mas avanzadas, condición conocida como linfedema o linfoedema indicación mas evidentes de que se requiere estimulación manual técnica conocida como DRENAJE LINFÁTICO MANUAL. (DLM)

El DLM se realiza por medio de maniobras específicas muy suaves y direccionadas, por lo cual se debe conocer el recorrido de los conductos para estimularlos y drenar la linfa de los sitios acumulados.

Son muchos los factores o causas que producen un linfedema; ya sea por obstrucción, disfunción o destrucción del sistema linfático.
En edemas generalizados por causas hormonales o intolerancias alimenticias donde hay relentización del sistema, se hace necesario estimularlo para regular el fluido.

En bloqueos producidos en las vías de evacuación, por lesiones, vaciamiento ganglionar, traumas, posquirúrgicos etc. se hace necesario reorientar los canales de evacuación.

El DLM debe estimular el fluido linfático, no se trata de obligar a la linfa a circular por vasos tan vulnerables y delicados con maniobras fuertes que solo logran traumatizar mas el tejido.

El Linfo-terapeuta debe adaptar las maniobras según la necesidad del organismo, sin olvidar que son maniobras lentas y suaves, que no producen dolor alguno aún realizándose en etapas posquirúrgicas y postraumáticas; no debe aplicarse cremas o aceites que deslicen las manos pues no permitan la acción de bombeo que estimula el automatismo del angión.
La adecuada aplicación del DLM reabsorbe líquidos acumulados, siendo así recomendado en todas las formas de linfedema.

Actúa sobre el sistema nervioso autónomo produciendo relajación y sedación, disminuyendo por tanto los niveles de stress a los que estamos sometidos hoy día.
Actúa sobre la regeneración del tejido ayudando en todos los procesos de reparación tisular

Las indicaciones de esta técnica son muchas y requiere de un amplio conocimiento anatomofisiopatologico y de de habilidad bimanual.
Lo más importante es que los médicos que son los que diagnostican y deciden el tratamiento a seguir, tengan presentes esta valiosa ayuda terapéutica para el manejo adecuado de su paciente.
Guía de indicaciones para realizar DLM (Sea que se haya iniciado el edema o para prevenir la aparición de este)

Linfedema
Lipedema
Postmastetomia
Postradioterapia
Embarazo
Edemas posquirúrgicos
Edemas postraumáticos
Trastornos Reumáticos: Poli artritis, artrosis…
Insuficiencia venosa crónica

Enfermedades inflamatorias cronicas: tonsilitis, sinusitis, laringitis, faringitis

Encefalopatías Linfostáticas
Enteropatías Linfostáticas
Cefaleas y Migrañas
Neuralgia del trigémino
Procesos donde se requiera estimular las defensas naturales del organismo.
Intoxicación
Tendencias depresivas
Reacción alérgica

Todo el mundo puede beneficiarse del DLM .Es útil en todos los períodos de vida. Permite prevenir numerosos problemas y enfermedades

Margie López Valderruten
Fisioterapeuta UV