Abstract / Summary
This study aimed to systematically evaluate the perioperative risk factors and preventive strategies associated with lymphocele formation and prolonged lymphatic drainage after radical prostatectomy with pelvic lymph node dissection, to assess the effect of peritoneal reconstruction techniques on symptomatic lymphocele reduction, and to provide an integrated clinical framework for evaluating etiological factors and preventive strategies.
A comprehensive search of Embase, MEDLINE (PubMed), and the Cochrane Library was performed through December 2025 according to PRISMA guidelines (PROSPERO ID: CRD420251164157). Thirty-one studies evaluating preoperative, intraoperative, and postoperative risk factors and preventive strategies were included. Risk of bias was assessed using RoB 2, ROBINS-I, and ROBINS-E tools. A primary meta-analysis of randomized controlled trials and a predefined sensitivity analysis including all comparative studies were conducted for symptomatic lymphocele (sLC) using random-effects models.
High BMI and selected metabolic parameters, including low fibrinogen and hypoalbuminemia, emerged as potential preoperative risk factors, although supporting evidence was limited and not consistently reported across studies. Peritoneal flap-based reconstruction significantly reduced symptomatic lymphocele in pooled randomized data (RR 0.57, 95% CI 0.35-0.95). A predefined sensitivity analysis including six comparative studies (n = 3840) suggested a larger effect (RR 0.18, 95% CI 0.09-0.37), although these findings should be interpreted cautiously because of potential confounding and heterogeneity across study designs and surveillance protocols. Preventive strategies such as peritoneal reconstruction and selective drain management were associated with reduced lymphatic complications, whereas octreotide and lymphatic embolization were effective management options for established or refractory lymphatic leakage.
Lymphocele formation after radical prostatectomy is multifactorial. Restoration of peritoneal continuity appears to be the most consistent and modifiable strategy for reducing symptomatic lymphocele. These findings support a comprehensive, risk-adapted approach integrating patient- and procedure-related factors beyond isolated technical interventions and highlight the need for further multicenter randomized studies.