Overview
Retroperitoneal lymph node dissection, commonly referred to as RPLND, is a procedure to remove abdominal lymph nodes to treat testicular cancer, as well as help establish its exact stage. It is usually performed using an incision that extends from just below the breastbone (sternum) to just below the navel. While laparoscopic methods may be used, they have been performed mainly in centers of excellence with wide experience in laparoscopic approaches, have not been proven to be equal in outcomes to standard ‘open’ surgery, and have even been considered less effective by some surgeons.
Testicular cancer spreads in a well-known pattern, and the lymph nodes in the retroperitoneum are a primary landing site during spread of the disease. Examining the removed lymphatic tissue will determine the extent of spread of any malignant disease and if no malignant tissue is found, the cancer may be more accurately considered as a stage I cancer, limited to the testis.
The procedure is one of the standard treatment options for clinical stage I and II non-seminomatous germ cell tumors (NSGCT) because of the low mortality and relapse rate with this procedure. Also, NSGCT is considered more aggressive than seminomas, the “other” kind of testicular cancer. Seminomas are also much more sensitive to radiation than NSGCT’s, so the noninvasive radiation treatment can be delivered effectively.
There are two different main situations where RPLND is considered. The first situation is in the clinical stage I NSGCT where the tumor appears confined to the testicle area, but may have spread to the abdominal lymph nodes. In this situation, some patients choose to undergo what is called a “Primary RPLND” to find out whether the tumor has spread to the abdominal lymph nodes and potentially serve as a curative procedure by removing the cancerous lymph nodes. In this first situation, the patient should undergo a nerve-sparing (or template) RPLND (see below). The second situation for RPLND is in the setting of advanced testicular cancer (already spread to abdominal lymph nodes) after chemotherapy to treat the cancer that had spread. After chemotherapy for metastatic NSGCT, if there are residual, visible lymph nodes in the retroperitoneum, then the recommendation would be for a “Post-chemotherapy RPLND”. In this situation, the surgeon will remove all the lymph nodes in the retroperitoneum and the residual masses because they might harbor teratoma, viable cancer, or merely scar tissue. Without further treatment, teratoma may once more become malignant and may be resistant to the combination of chemotherapy previously used. There are more rare cases where RPLND is used, such as after chemotherapy for metastatic seminoma or in ‘late recurrences’ or ‘salvage/desperation’ settings.
Description
The goal of the RPLND procedure (either open or laparoscopic) is removal of all target lymph nodes in the retroperitoneum. There are well-recognized ‘boundaries’ of lymph node spread from the right versus the left testicle. There are also nerves in the retroperitoneum that run on each side of the spinal cord and aorta, and these nerves are directly next to the retroperitoneal lymph nodes on each side. If these nerves are damaged during the RPLND, the semen is not propelled forward through the urethra to exit the body but rather goes backwards into the bladder. This is known as retrograde ejaculation. This type of surgery does not cause impotence — a man can still have erections and sexual intercourse — but retrograde ejaculation can make it harder to father children. To save the normal ejaculation function, surgeons have developed a type of retroperitoneal lymph node surgery called nerve-sparing surgery that has a very high rate of success in experienced hands.
The surgical approach involves one of two approaches:
- Template RPLND where the surgeon attempts to remove all the lymph nodes on either the right or left side of the retroperitoneum (depending on which testicle was involved with cancer). In this process, the nerves on the side of the operation are removed also. The nerves on the other side are not affected, and thus patients usually can still have normal ejaculation.
- Nerve-sparing RPLND where the surgeon attempts to remove all the lymph nodes, yet prospectively identifies and spares the nerves during the surgery. These procedures can be performed on both sides of the retroperitoneum and often are used when the surgeon performs a bilateral RPLND. When performed by experienced surgeons, the nerve-sparing RPLND should result in >90% of patients recovering normal ejaculatory function.
Sometimes, usually in the post-chemotherapy setting with very large residual masses, the nerve-sparing approach is not possible. When fertility is an issue, sperm banking is recommended. Additionally, viable sperm still are potentially available in the testicle and can be harvested at a later time by an infertility specialist.
Preoperative Considerations
One common preoperative consideration is the issue of sperm banking. As noted above, there are situations where nerve-sparing RPLND is not utilized, and thus patients are encouraged to consider sperm-banking before RPLND. Other preoperative considerations mainly involve unique considerations in the post-chemotherapy setting. Chemotherapy affects the patient’s blood count and sometimes lung function. Thus, it is important to evaluate the blood count and lung status before surgery. RPLND may be delayed until the blood count is adequate to tolerate surgery, and the anesthesia team will need to understand that the patient may be at risk for lung complications during/after surgery.
Postoperative Care
The postoperative care mainly occurs in the immediate postoperative setting, in other words, in the first 5-7 days after surgery. In standard open RPLND, the patient’s bowels usually take a few days to recover, and during this time, the patient is restricted from any oral intake. Gradually, the bowel function returns, and the patient is allowed to start taking oral diet. Patients are maintained on narcotic medications for pain control over the first 1-2 weeks, then they are gradually weaned off these strong pain medications in favor of Tylenol or ibuprofen. Additionally, patients are placed on strict activity restrictions, usually involving no straining or lifting more than 10 pounds for 4-6 weeks. As with any major surgery, infection is a possibility but very rare, and bowel obstructions and adhesions are another rare possible side effect.