Retroperitoneal Lymph Node Dissection

Testicular cancer is a rare disease with approximately 8800 new cases diagnosed annually. However, it is the most common solid tumor in men aged 15 to 35 years. Retroperitoneal lymph node dissection (RPLND) plays an integral role in the management of men with both early stage and advanced testicular cancer. A unique aspect of testicular cancer is surgery can be curative in the metastatic setting in appropriately selected patients. Therefore, a properly performed RPLND can be both diagnostic and therapeutic.

Preoperative Staging and Surgical Planning

After radical orchiectomy and histopathologic confirmation of a nonseminomatous germ cell tumor, the next step of management consists of clinical staging:

1.

Repeat serum alpha-fetoprotein (AFP) and β-human chorionic gonadotropin (b-hCG) levels
2.

Chest computed tomography (CT) or posteroanterior and lateral chest radiography
3.

Abdominal and pelvic CT scan with IV contrast.

Indications for Primary Retroperitoneal Lymph Node Dissection

1.

Clinical stage I disease (i.e., normal serum tumor markers after orchiectomy, normal chest and abdominal imaging)
2.

Clinical stage IIA and IIB disease (i.e., normal serum tumor markers after orchiectomy, normal chest imaging, and nonbulky retroperitoneal disease)

For patients with low-volume clinical stage IIA and IIB disease, the decision to proceed with primary RPLND versus cisplatin-based chemotherapy is assessed for each patient. General considerations include fertility concerns, testicular histopathology, and morbidity of surgery versus chemotherapy in both the short and long terms. Typically, primary RPLND is offered in the IIA setting, and either primary RPLND or chemotherapy is offered in patients with IIB disease.

Indications for chemotherapy are:

1.

Bulky retroperitoneal disease
2.

Disease in both the retroperitoneum and chest
3.

Elevated serum tumor markers after orchiectomy (even with normal imaging studies)

After cisplatin-based induction chemotherapy, patients are reimaged with chest CT or chest radiography, CT of the abdomen and pelvis, and repeat serum tumor markers (AFP and b-hCG). Patients with normal imaging (complete resolution of retroperitoneal mass) and normal serum tumor markers after induction chemotherapy are observed. Patients with normal serum tumor markers and a residual retroperitoneal tumor should undergo a postchemotherapy (PC) RPLND. Patients with elevated serum tumor markers and a residual retroperitoneal mass typically received salvage chemotherapy; however, treatment in these cases must be individualized.

Preoperative Preparation

Primary and Postchemotherapy Retroperitoneal Lymph Node Dissection

Discussion of the patient’s future fertility plans must occur. In the primary RPLND setting, a left- or right-sided nerve-sparing surgery will result in normal ejaculation postoperatively in up to 99% of cases. A nerve-sparing technique in the PC setting depends on several factors such as tumor location, patient preferences, and intraoperative judgment. Thus, loss of antegrade ejaculation must be discussed with the patient. Preoperative bowel preparation and dietary changes are not necessary before surgery. An intraoperative orogastric tube is placed, but routine use of a nasogastric tube postoperatively is unnecessary. A type and screen is sufficient for a primary RPLND. In the PC RPLND setting, a type and cross for 2 units of packed red blood cells is ordered. In patients who have received bleomycin preoperatively, the anesthesia team must be aware and comfortable with the management of these patients intraoperatively. Intravenous fluid management must be conservative when necessary, and a low fraction of inspired oxygen should be used. For larger masses in the PC RPLND setting, additional procedures may be necessary depending on the location of the masses and clinical scenario (i.e., desperation or late relapse) such as nephrectomy, inferior vena cava (IVC) reconstruction or resection, and aortic replacement.

Surgical Approaches and Technique

The surgical approach has migrated over time from a thoracoabdominal incision to almost exclusively a transabdominal midline incision. Lower retrocrural masses can be approached using a transabdominal transdiaphragmatic approach, avoiding the need for a thoracotomy in select cases.

The patient is placed on the operative table in the supine position, and a Foley catheter is anchored. A midline incision is made and carried down into the peritoneal cavity. After the peritoneal cavity is entered, the falciform ligament is identified and divided to avoid a retraction injury to the liver. The abdominal cavity is carefully inspected and palpated for signs of disease. A self-retaining retractor is placed.

For clinical stage I or smaller volume paracaval or interaortocaval tumors, the retroperitoneum is accessed by incising the root of the small bowel mesentery from the cecum to the ligament of Treitz, stopping just before the inferior mesenteric vein. However, for larger volume tumors, this incision is extended around the cecum and up the white line of Toldt to the foramen of Winslow to permit the right colon and small intestine to be placed on the chest. In the case of large left paraaortic tumors, this same approach is used in addition to ligation of the inferior mesenteric vein and artery, allowing lateral retraction of the left mesocolon to expose to the left retroperitoneum. When a left modified template is planned for clinical stage I disease, mobilizing the left colon medially along the white line of Toldt can access the left retroperitoneum and paraaortic packet ( Fig. 118.1 ).

After the retroperitoneum is opened, identifying the gonadal vein and staying on its anterior surface ensure the correct plane. The duodenum is swept superiorly off the IVC and left renal vein. When the retroperitoneum is exposed, the intestines are packed out of harm’s way using retractors placed on either side of the superior mesenteric artery.

The split and roll maneuver is performed over the left renal vein from its origin distally. The larger lymphatics on the superior surface of the left renal vein should be ligated to decrease the risk of a postoperative chylous leak. Typically, the split and roll maneuver is then started on the aorta, which aids in identification of accessory lower pole renal arteries that were perhaps not identified on the preoperative CT scan ( Fig. 118.2 ). When a right-sided nerve-sparing procedure is planned, the split can begin on the IVC. This makes identification of the right-sided postganglionic sympathetic nerve fibers easier and allows them to be traced to the superior hypogastric plexus, thus minimizing the risk of injury during the aortic split and roll. However, when splitting on the IVC first, visualization of potential right-sided lower pole renal arteries is imperative. The split is performed on the anterior aorta in the 12 o’clock position just inferior to the crossover of the left renal vein ( Fig. 118.3 ). It is carried caudally to prospectively identify the origin of the inferior mesenteric artery (IMA). When a right modified template is planned, the IMA is preserved. In larger volume masses requiring a bilateral template, the IMA is ligated and divided to allow retraction of the left mesocolon and exposure of the left-sided retroperitoneum. The surgeon must be aware that the left- and right-sided postganglionic nerves fibers coalesce just distal to the IMA to form the superior hypogastric plexus if a nerve-sparing procedure is planned.