eMedicine Specialties > Urology > Surgery

Lymph Node Dissection, Retroperitoneal: Follow-up

Author: Jared M Whitson, MD, Resident, Department of Urology, University of California at San Francisco
Coauthor(s): Maxwell Meng, MD, Associate Professor-in-Residence, Department of Urology, University of California at San Francisco
Contributor Information and Disclosures

Updated: Nov 14, 2008

Outcome and Prognosis

The survival rate among patients with testicular cancer who undergo retroperitoneal lymph node dissection (RPLND) has improved significantly since the early 1980s. All stages are associated with a cure rate of at least 90%. Stages I, IIA, and IIB are associated with a 98-100% cure rate. Stages IIC and III have a response rate of approximately 90% with chemotherapy and RPLND, with an 86% durable response rate.

Investigators generally agree that the presence of mediastinal primary tumor and metastasis to visceral sites indicates a poor prognostic outcome. Significantly elevated levels of the tumor serum markers are thought to be a significant independent predictor of poor outcome.

Future and Controversies

Progress in the management of testicular cancer has resulted from a multimodal treatment strategy, yielding excellent oncologic outcomes in most men with the disease. Despite the advances in chemotherapy and the ability to assess risk in patients with low clinical stage, surgical therapy, involving removal of retroperitoneal lymph nodes, continues to play a crucial role in management algorithms for low-stage to advanced cases and for all histologic subtypes, including nonseminomatous germ cell tumors (NSGCTs) and seminoma.

The surgical techniques of retroperitoneal lymph node dissection (RPLND) have evolved. In patients with low-clinical-stage NSGCT, the preservation of ejaculatory function has minimized morbidity, while oncologic efficacy has been maintained through meticulous removal of all lymphatic tissue within the desired boundaries.

Currently, the inaccuracy of clinical staging and selection of appropriate therapy in patients with low-stage NSGCT is controversial. For example, testis-confined tumors (pathologic stage I) may be indistinguishable from occult microscopic stage II/III disease; approximately 30% of retroperitoneal disease cases are not categorized as such using initial imaging studies. Conversely, 70% of patients who undergo RPLND for clinical stage I disease are overtreated.

Presently, the most useful prognostic factors in risk stratification of low-clinical-stage NSGCT include the percentage of embryonal carcinoma and presence or absence of lymphatic/vascular invasion by tumor cells in the primary tumor. In the future, oncogene markers, tumor-suppressor gene markers,39 flow cytometry,40,41 and advanced imaging modalities may play an important role in more accurately predicting true stage in patients with clinical stage I disease.42 The prediction of a response to chemotherapy based on the expression of multidrug resistance protein 1 (MDR1) efflux pump has recently showed a trend toward significance.43 Should L-RPLND prove to be as accurate and useful as the traditional open RPLND approach, the reduced morbidity of L-RPLND may shift more patients toward surgical intervention, away from either initial surveillance or chemotherapy. Nevertheless, L-RPLND remains technically challenging and requires further study and refinement.

Although contemporary postchemotherapy RPLND has attained a higher success rate, it still is a relatively morbid procedure. The operation is best performed via an open incision and requires wide exposure of the retroperitoneal structures. Careful and extensive removal of lymph nodes is balanced against potential injury to major vascular structures and organs such as the kidneys and ureters. In the future, methods of differentiating fibrosis and scar from viable germ cell tumor and/or teratoma after chemotherapy may spare some patients RPLND.

Further improvements in the management of testicular cancer may result from better selection of patients with low-stage and high-stage disease for adjuvant therapy. RPLND remains an integral part of all treatment approaches and has a role in staging and cure in those with low-stage disease; in addition, it can be used effectively to treat teratoma and germ cell tumor in patients with advanced disease after systemic therapy.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jong M. Choe, MD, FACS, and previous coauthor, Rajesh Prasad, MD, to the development and writing of this article.



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Further Reading

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Keywords

retroperitoneal lymph node dissection, RPLND, testicular cancer, testicular carcinoma, renal cell carcinoma, upper urinary tract urothelial carcinoma, nonseminomatous germ cell tumor, NSGCT, metastatic testicular tumors, seminomatous germ cell tumor, nerve-sparing retroperitoneal lymph node dissection, nerve-sparing RPLND, lymphangiography, thoracoabdominal retroperitoneal lymph node dissection, bilateral retroperitoneal dissection, suprahilar dissection, split-and-roll technique, bilateral retroperitoneal lymph node dissection, laparoscopic retroperitoneal lymph node dissection, laparoscopic RPLND, L-RPLND, laparoscopic nerve-sparing retroperitoneal lymph node dissection, ipsilateral modified nerve-sparing RPLND

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Contributor Information and Disclosures

Author

Jared M Whitson, MD, Resident, Department of Urology, University of California at San Francisco
Jared M Whitson, MD is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Urological Association, and Endourological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Maxwell Meng, MD, Associate Professor-in-Residence, Department of Urology, University of California at San Francisco
Maxwell Meng, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center
Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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