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RETROPRITONEAL

LYMPH NODE
DISSECTION
Dr.S.Veda padma priya
Post graduate in general surgery
Department of surgical oncology
Clinical summary
 30 year old bachelor underwent high
orchidectomy for suspected testicular cancer

 Referred to the dept of surgical oncology for


further management.

 Post-op HPE :Tumour composed of


teratomatous components as well as
endodermal sinus components - MIXED
NSGCT
Staging work-up
 CXR PA view : NAD

 USG Abdomen & pelvis : NAD

 CT abdomen : no evidence of
retroperitoneal lymph nodes

STAGE I NSGCT
Semen Analysis

 quantity : 2.5 ml
 count : 48 million/mm3
 pus cells : +++
 motility : 35 %
 viscosity : moderate
Operative procedure

 ETGA
 supine position
 midline incision
 transabdominal approach
 right sided modified template
primary retroperitoneal
dissection
 split & roll technique
 gonadal vein excision in toto
Split & roll technique
Rt-sided modified
template primary RPLND
IVC

Aorta

IMA
Rt gonadal vein
excised
Management of NSGCT

Post diagnostic
work -up

CT abdomen & Pelvis


Ct chest if – abnormal
CXR
- Abnormal CT
abdomen
Rpt tumor markers (β-
Doctor ... Will I Still Be Able
To Have Children?

Sperm
Management of Stage I NSGCT

 Primary open nerve sparing RPLND – 1A & B

 Surveillance in compliant patients – 1A & B(T2)


Cisplatin based therapy on relapse identical survival as RPLND.
30% of patients will relapse
Usually relapse with IGCCCG good-prognosis disease

 Chemotherapy – 1B & S (persistent marker elevation)


Reduce rate of recurrence to 2% (0 to 7%)
BEP x 2 – 1B
BEP x 3 / EP x 4 – 1S
RPLND

 Bland-Sutton - first
RPLND
 removal of all
fibrofatty/celluloadip
ose tissue in the
aortocaval area of
retroperitoneum
 primary / secondary
 standard / modified
Rationale for RPLND
 Testicular tumors
generally spread via the
lymphatics.
 Testicular descent from
retroperitoneum
 First echelon-paraaortic
nodes
 From retroperitoneal
nodes to the cisterna
chyli, thoracic duct,
supradiaphragmatic
nodes, and finally, to
extranodal/distant
metastasis.
 Crossover of right sided
lymphatics
Indications for RPLND

• Low-volume NSGCTs localized to the


retroperitoneum.(stage I & II)

• Non germ cell tumours with nodal disease

• Post chemotherapy residual masses in


NSGCTs

• Post RT;FDGPET + seminoma > 3 cms


Contraindications

• Abnormal levels of serum tumor


markers after orchiectomy
• Pure seminoma
• Bulky retroperitoneal
lymphadenopathy (ie, clinical stage
>IIB)
• Comorbid conditions that preclude
general anesthesia
Is RPLND justified in stage 1 NSGCT ?
 Most accurate technique for
discriminating between pStage I and
pStage II disease.
 30-50% of patients harbor occult
metastatic disease.
 In the hand of an experienced surgeon,
minimal risk of morbidity.
 Eradicating mature teratoma, a
chemotherapy insensitive entity.
 Retroperitoneal relapse-20 to 25% on
surveillance protocols.
 Infield recurrence after RPLND-rare.
 poor patient compliance for
surveillance.
Approach

• Open/laparoscopic

• Thoracoabdominal/transabdominal

• Extraperitoneal/transperitoneal
Thoracoabdominal approach
• Good exposure to the upper
retroperitoneum & renal hilum
• useful in patients with advanced
disease, with a large retroperitoneal
mass.
• a complete suprahilar dissection,
• easy access to retrocrural lymph nodes.
• extraperitoneal in patients with lower-
stage disease.
• decreases the risks of small bowel
obstruction and ileus.
Trans abdominal
approach…..
• Faster opening and
closing time.

• Exposure to the
suprahilar region at the
expense of mobilization
of the pancreas and
spleen.

• Familiarity and comfort


for the surgeon

• Tolerable morbidity for


the patient.
Split & Roll technique

• The "split-and-roll" technique popularized by


Donohue requires division of the lumbar arteries
and veins to allow access to the lymphatic tissue
dorsal to the great vessels
Bilateral Infrahilar RPLND -
standard

Removal of
• Precaval
• Paracaval
• Interaortocaval
• Preaortic
• Paraaortic
• Common iliac nodes
bilaterally
Preservation of ejaculation
• sympathetic nerves course along
the anterolateral aspect of the
vertebral bodies of the lumbar
spine.
• ramify about the inferior
mesenteric artery & ganglion
(inferior mesenteric plexus).
• Once ramified, these fibers are
referred to as the superior
hypogastric plexus.
• control normal transport of
sperm and prevent retrograde
ejaculation by closing the bladder
neck during ejaculation.
• Nerve sparing RPLND
• Nerve dissecting RPLND
• Nerve avoiding RPLND
Nerve dissecting RPLND

• Indications- Stage 1 & 2a disease

• Preservation of ejaculation 95%

• Duration of operation longer


Nerve avoiding RPLND templates

• Designed to avoid hypogastric plexus


and contralateral sympathetic fibres
responsible for ejaculation

• Preservation of ejaculation in 50 to
80%

• Right greater than left


Right-sided modified template
primary RPLND

• Right ureter,
• Renal veins,
• The lateral edge of the
aorta,
• IMA,
• Ipsilateral iliac artery,
where the ureter
crosses.
Interaortocaval and
retrocaval tissue is
completely removed.
Aort
a
IVC

RPLND – IMA

Limits of
Dissectio
Rt
n ureter
Left-sided modified template
primary RPLND

• Left ureter,
• Left renal vein,
• Left edge of vena cava,
• IMA,
• Ipsilateral iliac artery,
where the ureter
crosses.
• Interaortocaval tissue is
included with the
retroaortic lymphatics.
Postchemotherapy RPLND

• Identify patients who need more chemotherapy


• Remove teratoma, thus preventing growing
teratoma syndrome and/or malignant degeneration
• “Control Retroperitoneum”, prevent late local relapse
• Bilateral dissection of retroperitoneal lymphatics
• Between both ureters,
• From the diaphragmatic crus to the bifurcation of
the common iliac arteries.
• Greater likelihood of bilateral disease with greater
tumor burden.
• Increased incidence of renovascular involvement
Aortic encasement - grafted
IVC infiltration – caval replacement
Postoperative details

• Routine postoperative care.


• Appropriate amount of intravenous fluid
replacements for the first 24-48 hours
because of third-spacing.
• Nasogastric suction to minimize postoperative
ileus
• The pulmonary function in patients
undergoing postchemotherapy RPLND should
be closely monitored since they may have
received bleomycin.
Complications

• Ejaculatory dysfunction
• Chylous ascites - 1-3%
• Renovascular injury - 1-3%
• Small bowel obstruction - 1-3%
• Spinal cord ischemia - Less than 1%
• Wound infection – 15 %
• Urinary tract infection – 12 – 15 %
• Ileus – 15 – 16 %
Ejaculatory dysfunction-Management

 Total loss of seminal emission


 Retrograde ejaculation
 Pre - op sperm banking
 Alpha-adrenergic drugs
 Transrectal electroejaculation
 Sperm banking 20%–30% of
patients on surveillance will recur and
require aggressive chemotherapy
Follow-up

• history taking,
• physical examination (including examination
of the contralateral testis),
• assessment of serum tumor markers,
• chest radiography,
• abdominal imaging.
• every 2-3 months for the first 2 years,
• every 4 months for the subsequent 2 years,
• every 6 months for the fifth year,
• and yearly thereafter.
Drive home message

 presented to kindle the scientific


rage on management of testicular
tumour.
 to demonstrate that RPLND is not
a very technically challenging
procedure.
 minimal morbidity can be achieved
 accurate pathological staging has
the final say in the management of
malignancy.