RETROPRITONEAL LYMPH NODE DISSECTION

Dr.S.Veda padma priyaPost graduate in general surgeryDepartment 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 procedureOperative procedure

ETGAETGA supine positionsupine position midline incisionmidline incision transabdominal approachtransabdominal approach right sided modified template right sided modified template

primary retroperitoneal primary retroperitoneal dissectiondissection

split & roll techniquesplit & roll technique gonadal vein excision in totogonadal 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-hcg, LDH, αFP)

Bone scan/brain MRI if symptomatic

Doctor ... Will I Still Be Able To Have Children?

Sperm banking ???

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/celluloadipose 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 ?Is RPLND justified in stage 1 NSGCT ?

Most Most accurate accurate technique for technique for discriminating between pStage I and discriminating between pStage I and pStage II disease.pStage II disease.

30-50% of patients harbor occult 30-50% of patients harbor occult metastatic disease.metastatic disease.

In the hand of an experienced surgeon, In the hand of an experienced surgeon, minimal risk of morbidity.minimal risk of morbidity.

Eradicating mature teratoma, a Eradicating mature teratoma, a chemotherapy insensitive entity.chemotherapy insensitive entity.

Retroperitoneal relapse-20 to 25% on Retroperitoneal relapse-20 to 25% on surveillance protocols.surveillance protocols.

Infield recurrence after RPLND-rare. Infield recurrence after RPLND-rare.

poor patient compliance for surveillance.poor patient compliance for surveillance. cost – effective.surveillance protocols cost – effective.surveillance protocols

prove expensive.prove expensive.

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.

Rt ureter

IVC

Aorta

IMARPLND – Limits of Dissection

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 messageDrive home message

presented to kindle the scientific presented to kindle the scientific rage on management of testicular rage on management of testicular tumour.tumour.

to demonstrate that RPLND is not to demonstrate that RPLND is not a very technically challenging a very technically challenging procedure.procedure.

minimal morbidity can be achievedminimal morbidity can be achieved accurate pathological staging has accurate pathological staging has

the final say in the management of the final say in the management of malignancy.malignancy.