Refractory Chylous Ascites After Robot-Assisted Radical Prostatectomy With Sequential Anatomically Distinct Lymphatic Leak Sites Identified by Repeat Lymphangiography.

BACKGROUND Chylous ascites is a rare, potentially life-threatening complication of pelvic surgery, characterized by progressive malnutrition, immune dysfunction, and massive fluid accumulation. When the condition is refractory, its management represents a complex challenge requiring sequential escalation across multiple therapeutic modalities. CASE REPORT A 72-year-old man developed refractory chylous ascites after robot-assisted radical prostatectomy with extended pelvic lymph node dissection for high-grade prostate cancer (Gleason score 5+4=9). Despite conservative measures, consisting of low-fat diet and continuous subcutaneous octreotide infusion, the ascites persisted. Repeated large-volume paracentesis with cell-free concentrated ascites reinfusion therapy (CART) and total parenteral nutrition (TPN) were required to manage worsening malnutrition. Lymphangiography and N-butyl cyanoacrylate (NBCA) embolization provided no sustained relief. Subsequent surgical lymphatic ligation identified active leakage alongside floating solidified NBCA in the internal iliac region, confirming the prior embolization site. Although the leak was temporarily controlled by ligation, chylous drainage recurred on postoperative day 2. Repeat lymphangiography revealed a new, anatomically distinct leak in the external iliac region, suggesting dynamic redistribution of lymphatic flow through a collateral pathway. Repeat NBCA embolization of this secondary site achieved definitive resolution. Supported by TPN and CART, the patient was discharged on postoperative day 117 with improved nutritional status. He had no recurrence over a 5-year follow-up, with clinical and laboratory assessment every 3 months. CONCLUSIONS This case suggests that lymphatic leak sites may shift during treatment. Repeat lymphangiography may be considered when chylous drainage recurs after apparently successful intervention. Multidisciplinary management, including TPN and CART, was integral to sustaining this patient through a prolonged and complex treatment course.