Comparative Study to Evaluate the Effect of Using an Electro-Thermal Bipolar Sealing Device and Conventional Ligation on the Incidence of Post-Renal Transplant Lymphoceles in Recipients The Effect of Using Electro-Thermal Bipolar Sealing on Post Renal Transplant Lymphocele in Recipients
Main Article Content
Keywords
Electro- Thermal Bipolar Sealing Device, LigasureTM, Kidney Transplant, Lymphocele.
Abstract
Background: Lymphocele development is a well-established complication following kidney transplant. Some devices, such as electrothermal bipolar sealing devices, have been found to reduce lymphatic drain following kidney transplantation.
The aim of the study: The purpose of the study is to compare the usage of conventional lymphatic ligation with the electrothermal bipolar sealing device and its influence on the formation of lymphoceles after kidney transplantation surgery.
Patients and methods: A cohort retrospective and prospective study was conducted from May 2015 to November 2020 at the Basrah renal transplantation center in Al-Sader Teaching Hospital, Basrah. One hundred and thirty anonymized patients with end-stage renal diseases were involved in the present study. They were categorized into two groups: group 1 (conventional ligation group) with 70 patients and group 2 (electrothermal bipolar sealing device group) with 60 patients. The groups were compared and matched for possible risk factors. Patients were followed up for six weeks with full laboratory investigation (complet blood count, renal function tests, and liver function tests) and medical and surgical assessments. Statistical package of social siences version 25 was used for the statistical analysis of the data. Confidence intervals of 95% were applied as the dependent interval in statistics, and p-values < 0.05 were considered significant.
Results: The mean age of the patients was parallel for both conventional ligation and electrothermal bipolar sealing device groups (34.69 ± 10.28 vs. 33.68 ± 10.35). The operative time (155.57 ± 17.9 vs. 140.33 ± 17.07), lymphocele development (12 (17.1%) vs. 4 (6.7%)), lymphatic drainage volume (974.57 ± 178.39 vs. 493.83 ± 163.65), and the days of drainage (8.28 ± 3.3 vs. 4.6 ± 1.4) showed statistically significant differences between the conventional ligation technique and the electrothermal bipolar sealing device technique (p < 0.05).
Conclusion: The cautery of bipolar vessels is advantageous when compared to conventional ligation in kidney transplant lymphatic dissection, reducing the risk of lymphocele occurrence, in addition to its feasibility, safety, and easy performance
References
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2. Wong G, Howard K, Chapman JR, Chadban S, Cross N, Tong A, et al. Comparative survival and economic benefits of deceased donor kidney transplantation and dialysis in people with varying ages and co-morbidities. PloS one. 2012;7(1):e29591.
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4. Nghiem DD, Beckman I. Intraperitoneal catheter drainage of lymphocele: an outpatient procedure. Transplant international. 2005;18(6):721-3.
5. Doehn C, Fornara P, Fricke L, Jocham D. Laparoscopic fenestration of posttransplant lymphoceles. Surgical endoscopy. 2002;16(4):690-5.
6. Duepree HJ, Fornara P, Lewejohann JC, Hoyer J, Bruch HP, Schiedeck THK. Laparoscopic treatment of lymphoceles in patients after renal transplantation. Clinical transplantation. 2001;15(6):375-9.
7. Tonelli M, Wiebe N, Knoll G, Bello A, Browne S, Jadhav D, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. American journal of transplantation. 2011;11(10):2093-109.
8. Golriz M, Klauss M, Zeier M, Mehrabi A. Prevention and management of lymphocele formation following kidney transplantation. Transplantation Reviews. 2017;31(2):100-5.
9. Ebadzadeh MR, TAVAKOLI M. LYMPHOCELE AFTER KIDNEY TRANSPLANTATION WHERE ARE WE STANDING NOW? 2008.
10. Lima MLd, Cotrim CAC, Moro JC, Miyaoka R, D'Ancona CAL. Laparoscopic treatment of lymphoceles after renal transplantation. International braz j urol. 2012;38(2):215-21.
11. Samhan M, Al-Mousawi M. Lymphocele following renal transplantation. Saudi Journal of Kidney Diseases and Transplantation. 2006;17(1):34.
12. Padera TP, Meijer EFJ, Munn LL. The Lymphatic System in Disease Processes and Cancer Progression. Annual Review of Biomedical Engineering. 2016;18(1):125-58.
13. Rohn D, Stewart R, Elk J, Laine G, Drake R. Renal lymphatic function following venous pressure elevation. Lymphology. 1996;29(2):67-75.
14. Karpanen T, Alitalo K. Molecular biology and pathology of lymphangiogenesis. Annu Rev Pathol Mech Dis. 2008;3:367-97.
15. Goel M, Flechner SM, Zhou L, Mastroianni B, Savas K, Derweesh I, et al. The influence of various maintenance immunosuppressive drugs on lymphocele formation and treatment after kidney transplantation. The Journal of urology. 2004;171(5):1788-92.
16. Dean PG, Lund WJ, Larson TS, Prieto M, Nyberg SL, Ishitani MB, et al. Wound-healing complications after kidney transplantation: a prospective, randomized comparison of Sirolimus and Tacrolimus1. Transplantation. 2004;77(10):1555-61.
17. Tiong HY, Flechner SM, Zhou L, Wee A, Mastroianni B, Savas K, et al. A systematic approach to minimizing wound problems for de novo sirolimus-treated kidney transplant recipients. Transplantation. 2009;87(2):296-302.
18. Zagdoun E, Ficheux M, Lobbedez T, Chatelet V, Thuillier-Lecouf A, Bensadoun H, et al., editors. Complicated lymphoceles after kidney transplantation. Transplantation proceedings; 2010: Elsevier.
19. Heer MK, Clark D, Trevillian PR, Sprott P, Palazzi K, Hibberd AD. Functional significance and risk factors for lymphocele formation after renal transplantation. ANZ journal of surgery. 2018;88(6):597-602.
20. Mokos I, Basic-Jukic N, Kastelan Z, Kes P, Pasini J, editors. Influence of long-term dialysis treatment on operative complications after renal transplantation. Transplantation proceedings; 2010: Elsevier.
21. Ranghino A, Segoloni GP, Lasaponara F, Biancone L. Lymphatic disorders after renal transplantation: new insights for an old complication. Clinical kidney journal. 2015;8(5):615-22.
22. Ziętek Z, Iwan-Ziętek I, Sulikowski T, Sieńko J, Nowacki M, Żukowski M, et al., editors. The outcomes of treatment and the etiology of lymphoceles with a focus on hemostasis in kidney recipients: a preliminary report. Transplantation proceedings; 2011: Elsevier.
23. Lundin C, Bersztel A, Wahlberg J, Wadström J. Low molecular weight heparin prophylaxis increases the incidence of lymphocele after kidney transplantation. Upsala journal of medical sciences. 2002;107(1):9-15.
24. Benavides C, Mahmoud K, Knight R, Barcenas C, Kahan B, Van Buren C, editors. Rabbit antithymocyte globulin: a postoperative risk factor for sirolimus-treated renal transplant patients? Transplantation proceedings; 2005: Elsevier.
25. Rogers C, Hanaway M, Alloway R, Alexander J, Boardman R, Trofe J, et al., editors. Corticosteroid avoidance ameliorates lymphocele formation and wound healing complications associated with sirolimus therapy. Transplantation proceedings; 2005: Elsevier.
26. Woodle ES, Vincenti F, Lorber MI, Gritsch HA, Hricik D, Washburn K, et al. A multicenter pilot study of early (4‐day) steroid cessation in renal transplant recipients under simulect, tacrolimus and sirolimus. American journal of Transplantation. 2005;5(1):157-66.
27. Sandrini S, Setti G, Bossini N, Maffei C, Iovinella L, Tognazzi N, et al. Steroid withdrawal five days after renal transplantation allows for the prevention of wound‐healing complications associated with sirolimus therapy. Clinical transplantation. 2009;23(1):16-22.
28. Minetti EE. Lymphocele after renal transplantation, a medical complication. Journal of nephrology. 2011;24(6):707-16.
29. Caglar M, Ergün EL. Lymphatic leakage in a renal transplant: The role of lymphoscintigraphy. Clinical nuclear medicine. 2006;31(8):486-9.
30. Saidi R, Wertheim J, Kennealey P, Ko D, Elias N, Yeh H, et al. Donor kidney recovery methods and the incidence of lymphatic complications in kidney transplant recipients. International journal of organ transplantation medicine. 2010;1(1):40.
31. Sah BK, Yang J, Yang G, Zhang X. Clinical uses of ligasure vessel sealing system (LVSS) in surgery. Journal of Nanjing Medical University. 2008;22(2):102-6.
32. Mazzucchi E, Souza AA, Nahas WC, Antonopoulos IM, Piovesan AC, Arap S. Surgical complications after renal transplantation in grafts with multiple arteries. International braz j urol. 2005;31(2):125-30.
33. Nelson E, Gross M, Mone M, Hansen H, Sheng X, Cannon K, et al., editors. Does ultrasonic energy for surgical dissection reduce the incidence of renal transplant lymphocele? Transplantation proceedings; 2011: Elsevier.
34. Cash H, Slowinski T, Buechler A, Grimm A, Friedersdorff F, Schmidt D, et al. Impact of surgeon experience on complication rates and functional outcomes of 484 deceased donor renal transplants: a single‐centre retrospective study. BJU international. 2012;110(8b):E368-E73.
35. Macario A, Dexter F, Sypal J, Cosgriff N, Heniford BT. Operative time and other outcomes of the electrothermal bipolar vessel sealing system (LigaSure™) versus other methods for surgical hemostasis: a meta-analysis. Surgical innovation. 2008;15(4):284-91.
36. Heniford B, Matthews B, Sing R, Backus C, Pratt B, Greene F. Initial results with an electrothermal bipolar vessel sealer. Surgical endoscopy. 2001;15(8):799-801.
37. Leonardo C, Guaglianone S, Carli PD, Pompeo V, Forastiere E, Gallucci M. Laparoscopic nephrectomy using Ligasure system: preliminary experience. Journal of endourology. 2005;19(8):976-8.
38. Lamberton GR, Hsi RS, Jin DH, Lindler TU, Jellison FC, Baldwin DD. Prospective comparison of four laparoscopic vessel ligation devices. Journal of Endourology. 2008;22(10):2307-12.
39. Metzelder M, Kübler J, Petersen C, Glüer S, Nustede R, Ure B. Laparoscopic nephroureterectomy in children: a prospective study on Ligasure™ versus clip/ligation. European journal of pediatric surgery. 2006;16(04):241-4.
40. Targarona EM, Balague C, Marin J, Neto RB, Martinez C, Garriga J, et al. Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis. Surgical innovation. 2005;12(4):339-44.
41. Daskalopoulos G, Karyotis I, Heretis I, Delakas D. Electrothermal bipolar coagulation for radical prostatectomies and cystectomies: a preliminary case-controlled study. International urology and nephrology. 2004;36(2):181-5.
42. Lucan CV, Jurchis I, Suciu M, Selicean SE, Buttice S. Modern lymphatic dissection techniques for preventing post renal transplant lymphocele. Clujul Medical. 2017;90(4):416.
43. Constant DL, Florman SS, Mendez F, Thomas R, Slakey DP. Use of the LigaSure vessel sealing device in laparoscopic living-donor nephrectomy. Transplantation. 2004;78(11):1661-4.
44. Manouras A, Filippakis G, Tsekouras D, Lagoudianakis E, Genetzakis M, Markogiannakis H, et al. Sutureless open low anterior resection with total mesorectal excision for rectal cancer with the use of the electrothermal bipolar vessel sealing system. Medical science monitor. 2007;13(5):CR224-CR30.
45. Seki T, Hayashida T, Takahashi M, Jinno H, Kitagawa Y. A randomized controlled study comparing a vessel sealing system with the conventional technique in axillary lymph node dissection for primary breast cancer. Springerplus. 2016;5(1):1-8.
46. Tsuda N, Ushijima K, Kawano K, Takemoto S, Nishio S, Sonoda G, et al. Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device. Journal of gynecologic oncology. 2014;25(3):229.
47. Simforoosh N, Tabibi A, Rad HM, Gholamrezaie HR. Comparison Between Bipolar Lymphatic Vessels Cautery and Suture Ligature in Prevention of Postrenal Transplant Lymphocele Formation: A Randomized Controlled Trial. Exp Clin Transplant. 2019;17(1):26-30.
48. Simforoosh N, Nasseh H, Masoudi P, Aslzare M, Ghahestani SM, Eshratkhah R, et al. Clipless laparoscopic retroperitoneal lymph node dissection using bipolar electrocoagulation for sealing lymphatic vessels: initial series. Urology journal. 2012;9(2):480-5.
49. Farouk K, Bano U, Ahmad N, Khan AR. Electocoagulation Versus Suture-Ligation of Lymphatics in Kidney Transplant Recipient surgery. Journal of Postgraduate Medical Institute (Peshawar-Pakistan). 2006;20(4).
50. Atray NK, Moore F, Zaman F, Caldito G, Abreo K, Maley W, et al. Post transplant lymphocele: a single centre experience. Clinical transplantation. 2004;18:46-9.
2. Wong G, Howard K, Chapman JR, Chadban S, Cross N, Tong A, et al. Comparative survival and economic benefits of deceased donor kidney transplantation and dialysis in people with varying ages and co-morbidities. PloS one. 2012;7(1):e29591.
3. Dubeaux VT, Oliveira RM, Moura VJ, Pereira JMS, Henriques FP. Assessment of lymphocele incidence following 450 renal transplantations. International braz j urol. 2004;30(1):18-21.
4. Nghiem DD, Beckman I. Intraperitoneal catheter drainage of lymphocele: an outpatient procedure. Transplant international. 2005;18(6):721-3.
5. Doehn C, Fornara P, Fricke L, Jocham D. Laparoscopic fenestration of posttransplant lymphoceles. Surgical endoscopy. 2002;16(4):690-5.
6. Duepree HJ, Fornara P, Lewejohann JC, Hoyer J, Bruch HP, Schiedeck THK. Laparoscopic treatment of lymphoceles in patients after renal transplantation. Clinical transplantation. 2001;15(6):375-9.
7. Tonelli M, Wiebe N, Knoll G, Bello A, Browne S, Jadhav D, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. American journal of transplantation. 2011;11(10):2093-109.
8. Golriz M, Klauss M, Zeier M, Mehrabi A. Prevention and management of lymphocele formation following kidney transplantation. Transplantation Reviews. 2017;31(2):100-5.
9. Ebadzadeh MR, TAVAKOLI M. LYMPHOCELE AFTER KIDNEY TRANSPLANTATION WHERE ARE WE STANDING NOW? 2008.
10. Lima MLd, Cotrim CAC, Moro JC, Miyaoka R, D'Ancona CAL. Laparoscopic treatment of lymphoceles after renal transplantation. International braz j urol. 2012;38(2):215-21.
11. Samhan M, Al-Mousawi M. Lymphocele following renal transplantation. Saudi Journal of Kidney Diseases and Transplantation. 2006;17(1):34.
12. Padera TP, Meijer EFJ, Munn LL. The Lymphatic System in Disease Processes and Cancer Progression. Annual Review of Biomedical Engineering. 2016;18(1):125-58.
13. Rohn D, Stewart R, Elk J, Laine G, Drake R. Renal lymphatic function following venous pressure elevation. Lymphology. 1996;29(2):67-75.
14. Karpanen T, Alitalo K. Molecular biology and pathology of lymphangiogenesis. Annu Rev Pathol Mech Dis. 2008;3:367-97.
15. Goel M, Flechner SM, Zhou L, Mastroianni B, Savas K, Derweesh I, et al. The influence of various maintenance immunosuppressive drugs on lymphocele formation and treatment after kidney transplantation. The Journal of urology. 2004;171(5):1788-92.
16. Dean PG, Lund WJ, Larson TS, Prieto M, Nyberg SL, Ishitani MB, et al. Wound-healing complications after kidney transplantation: a prospective, randomized comparison of Sirolimus and Tacrolimus1. Transplantation. 2004;77(10):1555-61.
17. Tiong HY, Flechner SM, Zhou L, Wee A, Mastroianni B, Savas K, et al. A systematic approach to minimizing wound problems for de novo sirolimus-treated kidney transplant recipients. Transplantation. 2009;87(2):296-302.
18. Zagdoun E, Ficheux M, Lobbedez T, Chatelet V, Thuillier-Lecouf A, Bensadoun H, et al., editors. Complicated lymphoceles after kidney transplantation. Transplantation proceedings; 2010: Elsevier.
19. Heer MK, Clark D, Trevillian PR, Sprott P, Palazzi K, Hibberd AD. Functional significance and risk factors for lymphocele formation after renal transplantation. ANZ journal of surgery. 2018;88(6):597-602.
20. Mokos I, Basic-Jukic N, Kastelan Z, Kes P, Pasini J, editors. Influence of long-term dialysis treatment on operative complications after renal transplantation. Transplantation proceedings; 2010: Elsevier.
21. Ranghino A, Segoloni GP, Lasaponara F, Biancone L. Lymphatic disorders after renal transplantation: new insights for an old complication. Clinical kidney journal. 2015;8(5):615-22.
22. Ziętek Z, Iwan-Ziętek I, Sulikowski T, Sieńko J, Nowacki M, Żukowski M, et al., editors. The outcomes of treatment and the etiology of lymphoceles with a focus on hemostasis in kidney recipients: a preliminary report. Transplantation proceedings; 2011: Elsevier.
23. Lundin C, Bersztel A, Wahlberg J, Wadström J. Low molecular weight heparin prophylaxis increases the incidence of lymphocele after kidney transplantation. Upsala journal of medical sciences. 2002;107(1):9-15.
24. Benavides C, Mahmoud K, Knight R, Barcenas C, Kahan B, Van Buren C, editors. Rabbit antithymocyte globulin: a postoperative risk factor for sirolimus-treated renal transplant patients? Transplantation proceedings; 2005: Elsevier.
25. Rogers C, Hanaway M, Alloway R, Alexander J, Boardman R, Trofe J, et al., editors. Corticosteroid avoidance ameliorates lymphocele formation and wound healing complications associated with sirolimus therapy. Transplantation proceedings; 2005: Elsevier.
26. Woodle ES, Vincenti F, Lorber MI, Gritsch HA, Hricik D, Washburn K, et al. A multicenter pilot study of early (4‐day) steroid cessation in renal transplant recipients under simulect, tacrolimus and sirolimus. American journal of Transplantation. 2005;5(1):157-66.
27. Sandrini S, Setti G, Bossini N, Maffei C, Iovinella L, Tognazzi N, et al. Steroid withdrawal five days after renal transplantation allows for the prevention of wound‐healing complications associated with sirolimus therapy. Clinical transplantation. 2009;23(1):16-22.
28. Minetti EE. Lymphocele after renal transplantation, a medical complication. Journal of nephrology. 2011;24(6):707-16.
29. Caglar M, Ergün EL. Lymphatic leakage in a renal transplant: The role of lymphoscintigraphy. Clinical nuclear medicine. 2006;31(8):486-9.
30. Saidi R, Wertheim J, Kennealey P, Ko D, Elias N, Yeh H, et al. Donor kidney recovery methods and the incidence of lymphatic complications in kidney transplant recipients. International journal of organ transplantation medicine. 2010;1(1):40.
31. Sah BK, Yang J, Yang G, Zhang X. Clinical uses of ligasure vessel sealing system (LVSS) in surgery. Journal of Nanjing Medical University. 2008;22(2):102-6.
32. Mazzucchi E, Souza AA, Nahas WC, Antonopoulos IM, Piovesan AC, Arap S. Surgical complications after renal transplantation in grafts with multiple arteries. International braz j urol. 2005;31(2):125-30.
33. Nelson E, Gross M, Mone M, Hansen H, Sheng X, Cannon K, et al., editors. Does ultrasonic energy for surgical dissection reduce the incidence of renal transplant lymphocele? Transplantation proceedings; 2011: Elsevier.
34. Cash H, Slowinski T, Buechler A, Grimm A, Friedersdorff F, Schmidt D, et al. Impact of surgeon experience on complication rates and functional outcomes of 484 deceased donor renal transplants: a single‐centre retrospective study. BJU international. 2012;110(8b):E368-E73.
35. Macario A, Dexter F, Sypal J, Cosgriff N, Heniford BT. Operative time and other outcomes of the electrothermal bipolar vessel sealing system (LigaSure™) versus other methods for surgical hemostasis: a meta-analysis. Surgical innovation. 2008;15(4):284-91.
36. Heniford B, Matthews B, Sing R, Backus C, Pratt B, Greene F. Initial results with an electrothermal bipolar vessel sealer. Surgical endoscopy. 2001;15(8):799-801.
37. Leonardo C, Guaglianone S, Carli PD, Pompeo V, Forastiere E, Gallucci M. Laparoscopic nephrectomy using Ligasure system: preliminary experience. Journal of endourology. 2005;19(8):976-8.
38. Lamberton GR, Hsi RS, Jin DH, Lindler TU, Jellison FC, Baldwin DD. Prospective comparison of four laparoscopic vessel ligation devices. Journal of Endourology. 2008;22(10):2307-12.
39. Metzelder M, Kübler J, Petersen C, Glüer S, Nustede R, Ure B. Laparoscopic nephroureterectomy in children: a prospective study on Ligasure™ versus clip/ligation. European journal of pediatric surgery. 2006;16(04):241-4.
40. Targarona EM, Balague C, Marin J, Neto RB, Martinez C, Garriga J, et al. Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis. Surgical innovation. 2005;12(4):339-44.
41. Daskalopoulos G, Karyotis I, Heretis I, Delakas D. Electrothermal bipolar coagulation for radical prostatectomies and cystectomies: a preliminary case-controlled study. International urology and nephrology. 2004;36(2):181-5.
42. Lucan CV, Jurchis I, Suciu M, Selicean SE, Buttice S. Modern lymphatic dissection techniques for preventing post renal transplant lymphocele. Clujul Medical. 2017;90(4):416.
43. Constant DL, Florman SS, Mendez F, Thomas R, Slakey DP. Use of the LigaSure vessel sealing device in laparoscopic living-donor nephrectomy. Transplantation. 2004;78(11):1661-4.
44. Manouras A, Filippakis G, Tsekouras D, Lagoudianakis E, Genetzakis M, Markogiannakis H, et al. Sutureless open low anterior resection with total mesorectal excision for rectal cancer with the use of the electrothermal bipolar vessel sealing system. Medical science monitor. 2007;13(5):CR224-CR30.
45. Seki T, Hayashida T, Takahashi M, Jinno H, Kitagawa Y. A randomized controlled study comparing a vessel sealing system with the conventional technique in axillary lymph node dissection for primary breast cancer. Springerplus. 2016;5(1):1-8.
46. Tsuda N, Ushijima K, Kawano K, Takemoto S, Nishio S, Sonoda G, et al. Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device. Journal of gynecologic oncology. 2014;25(3):229.
47. Simforoosh N, Tabibi A, Rad HM, Gholamrezaie HR. Comparison Between Bipolar Lymphatic Vessels Cautery and Suture Ligature in Prevention of Postrenal Transplant Lymphocele Formation: A Randomized Controlled Trial. Exp Clin Transplant. 2019;17(1):26-30.
48. Simforoosh N, Nasseh H, Masoudi P, Aslzare M, Ghahestani SM, Eshratkhah R, et al. Clipless laparoscopic retroperitoneal lymph node dissection using bipolar electrocoagulation for sealing lymphatic vessels: initial series. Urology journal. 2012;9(2):480-5.
49. Farouk K, Bano U, Ahmad N, Khan AR. Electocoagulation Versus Suture-Ligation of Lymphatics in Kidney Transplant Recipient surgery. Journal of Postgraduate Medical Institute (Peshawar-Pakistan). 2006;20(4).
50. Atray NK, Moore F, Zaman F, Caldito G, Abreo K, Maley W, et al. Post transplant lymphocele: a single centre experience. Clinical transplantation. 2004;18:46-9.
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Comparative Study to Evaluate the Effect of Using an Electro-Thermal Bipolar Sealing Device and Conventional Ligation on the Incidence of Post-Renal Transplant Lymphoceles in Recipients: The Effect of Using Electro-Thermal Bipolar Sealing on Post Renal Transplant Lymphocele in Recipients. Iraqi Natl J Med [Internet]. 2022 Jan. 24 [cited 2024 Dec. 12];4(1):61-70. Available from: https://iqnjm.com/index.php/homepage/article/view/66
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