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


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


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-

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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

 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

• 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.

• 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 lowerstage 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

RPLND – Limits of Dissectio n


Rt 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.

• 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

• 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.