PMC9705082_01
Timeline of interventions and outcomes. BMI = body mass index, ccRCC = clear cell renal cell carcinoma, LV = lymphovascular invasion, R = margin status.
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Metastasis of ccRCC was found in two out of five lymph nodes without evidence of tumor in kidney tissue (pT0pN1).  Figure 1 summarizes the timeline of interventions and outcomes.
Computed tomography scan. Massive ascites can be seen in the (a) axial and (b) coronal sections.
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April 2019, the patient presented to the emergency service complaining of generalized abdominal pain, marked abdominal distension, nausea, and vomiting. Abdominopelvic computed tomography (AP-CT) scan revealed many intra-abdominal free fluids (Figure 2).
Magnetic resonance lymphangiogram with Lipiodol. Dynamic contrast-enhanced magnetic resonance lymphangiogram (a) with maximum intensity projection and the subtraction of noncontrasted structures shows a leak site at the L4-L5 level (arrow). (b) Shows the percutaneous embolization with Histoacryl  (head arrow) after identifying the leakage point in the lymphography with Lipiodol.
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The patient was diagnosed with CA based on the findings in both diagnostic paracentesis and dynamic contrast-enhanced magnetic resonance lymphangiogram (DCMRL) (Figure 3(a)). Due to the persistence of an active CL, the point of CL was identified using an intranodal lymphangiography with Lipiodol and embolized with Histoacryl  (Braun) in a 1 : 4 ratio (Figure 3(b)).
Evolution of the appearance of the abdominal drainage fluid. Milky white ascites obtained during surgery can be seen in the suction receptacles (a). Since the first postoperative day, clear liquid can be seen in the intra-abdominal drainage collecting bag (b).
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Intraoperatively, nine liters of chyle was drained (Figure 4(a)). However, during the immediate postoperative period, the liquid coming from the drainage was clear (Figure 4(b)), and the biochemical analyses confirmed transudative fluid (low triglyceride and protein content).
Identification of the point of chylous leakage. External (a) and ultrasound vision (b) of a transnodal injection of methylene blue under image guidance (lymph node, head arrow; needle, and arrow). Two leak points (stars) can be observed in the retroperitoneum (c) after seven minutes of percutaneous administration of methylene blue.
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US access approach (Figures 5(a)-5(b)). Under sterile conditions, a linear 10-14 MHz probe was used to explore the inguinal region, identifying a lymph node with adequate size and depth for punction. Seven minutes later, two methylene blue leak points into the retroperitoneum were identified in the para-aortic region, 4 cm below the old renal hilum (Figure 5(c)).