Retroperitoneal Lymph Node Dissection
- Author: Jared M Whitson, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Retroperitoneal lymph node dissection (RPLND) has a diagnostic and therapeutic role in many urologic malignancies. Testicular carcinoma is the most common urologic indication for RPLND, followed by renal cell carcinoma and upper urinary tract urothelial carcinoma.
In the setting of testicular tumors, RPLND may be used as a primary treatment modality for low-volume nonseminomatous germ cell tumors (NSGCTs) localized to the retroperitoneum. In addition, RPLND may be used as a salvage therapy for residual masses following chemotherapy in NSGCTs and in seminomatous tumors that are refractory to chemoradiotherapy.
RPLND was initially a component of all radical nephrectomy procedures, as outlined by Robson. RPLND subsequently evolved mainly into a staging procedure, believed to confer limited therapeutic benefit in most circumstances. In 1999, a randomized trial conducted by the European Organisation for Research and Treatment of Cancer (EORTC) evaluated whether RPLND conferred a benefit in the management of renal cell cancer. The patients studied were randomized to undergo either radical nephrectomy alone or in conjunction with RPLND. Among the patients who underwent RPLND, only 3.3% were found to have positive lymph nodes, and the addition of RPLND did not change 5-year progression-free survival or overall survival rates.
However, new adjuvant therapies, as well as laparoscopic RPLND (L-RPLND), have renewed interest in the topic. One study demonstrated a nodal yield of 12.1 toward the end of their series of 50 patients with clinically node-negative renal cell carcinoma undergoing laparoscopic nephrectomy and L-RPLND. In another study, a very experienced laparoscopist found laparoscopic nephrectomy with hilar lymph node dissection to be feasible and safe in patients with clinically node-positive disease.
Similarly, RPLND has not had a traditional role in the management of upper urinary tract urothelial carcinoma. A provocative retrospective report recently showed that RPLND conferred a significant survival advantage in univariate analysis, although, in multivariate analysis, the improved overall survival occurred without improvement in local recurrence or disease-specific survival rates, suggesting selection bias or unexplained confounding factors.
This article focuses primarily on RPLND in the setting of testicular tumors. For additional information on testicular cancer, see Medscape’s Testicular Cancer Resource Center.
History of the Procedure
The famous English surgical oncologist Bland-Sutton is credited with performing the first RPLND in the early 1900s following radical orchiectomy for NSGCTs. Pioneering work by Jamieson, Dobson, and others over the next few decades led to detailed anatomic descriptions of testicular lymphatic drainage.[6, 7] Hinman et al also described a series of RPLND procedures performed via a transabdominal approach. In 1950, Cooper et al published his experience with thoracoabdominal RPLND, stating that this modification provided excellent exposure of the renal pedicle.
During the 1960s, the advent of lymphangiography led to more complete mapping of lymphatic drainage patterns, including to suprahilar regions and crossover to the contralateral side.[10, 11] This finding led to the implementation of bilateral retroperitoneal dissection combined with suprahilar dissection. In the 1960s, this classic technique became the standard operative procedure for patients with low-stage NSGCTs. 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.
The major shortcoming of bilateral retroperitoneal dissection combined with suprahilar dissection was the high incidence of postoperative ejaculatory dysfunction, ie, anejaculation or failure of seminal emission. In the 1980s, Narayan et al detailed the sympathetic neuroanatomy involved in antegrade ejaculation. These studies led to the conclusion that injury to the hypogastric plexus during RPLND was the most plausible etiology for ejaculatory dysfunction.
In 1990, Richie reported his experience with modified RPLND for clinical stage I NSGCTs. He theorized that, because the primary landing site for regional metastasis was located well above the aortic bifurcation, his limit of distal dissection should be at the level of the inferior mesenteric artery (IMA). By operating only on the ipsilateral side and limiting his dissection cranial to the IMA, Richie discovered that he could preserve contralateral sympathetic pathways and maintain normal ejaculatory function without compromising the overall prognosis. Using this new modified template, he was able to preserve antegrade ejaculation in 95% of these men while keeping the relapse rate comparable to that associated with standard bilateral RPLND.
Around the same time, Donohue et al created a separate modification that included identification and preservation of the lumbar postganglionic sympathetic nerves. During the dissection, only the node-bearing tissue around the postganglionic sympathetic fibers was removed. This was known as nerve-sparing RPLND. Using this technique, Donohue reported that 98% of patients experienced antegrade ejaculation, with cure rates comparable to those who underwent classic RPLND.
L-RPLND was introduced into the surgical armamentarium beginning with a case report in 1992 by Rukstalis and Chodak. As with the open approach, numerous refinements have been made. In 2000, Janetschek et al reported on 76 patients with a nearly 4-year median follow-up who had undergone L-RPLND for clinical stage I disease. Antegrade ejaculation was preserved in 99% of these patients. Retroperitoneal recurrence occurred in one patient, who was cured with 2 cycles of chemotherapy. Of note, in contrast to experience with the open approach, all patients who underwent L-RPLND with proven pathologic stage II disease routinely received adjuvant chemotherapy.
In 2002, Peschel et al described a laparoscopic nerve-sparing approach. This may allow for the performance of therapeutic ipsilateral complete template dissections and for the avoidance of adjuvant chemotherapy in patients with low-volume stage II disease. Recently, a robotic-assisted laparoscopic approach has been described. A few reports have described port-site spread of the cancer and extratemplate recurrences in patients with otherwise-favorable features, which have tempered some of the enthusiasm for minimally invasive testis cancer surgery.[21, 22]
In 2012, a midline extraperitoneal approach to postchemotherapy RPLND was described. This may limit the small risk of long-term bowel complications and achieve an earlier discharge and resumption of a normal diet.
Retroperitoneal lymph node dissection (RPLND) is an important component in the management of low-stage nonseminomatous germ cell tumors (NSGCTs), as well as in patients with higher-stage disease who have residual retroperitoneal masses or enlarging retroperitoneal masses (termed growing teratoma syndrome) following chemotherapy.
Clinical stage I disease
The management options for patients with no clinical or radiographic evidence of residual tumor after orchiectomy include surveillance, RPLND, and adjuvant chemotherapy.
The argument for surveillance is that relapse occurs in only approximately 30% of all patients with cT1N0M0 disease during surveillance and that the survival rate after salvage therapy is between 96-100%.[24, 25] Thus, 70% of patients avoid an unnecessary abdominal operation. The 30% of patients in whom relapse occurs are exposed to 4 cycles of chemotherapy, and as many as 20% may still require RPLND to manage residual masses. Postchemotherapy RPLND is usually more extensive and more difficult and often cannot be performed in a prospective nerve-sparing fashion.
The argument for initial RPLND is that, of the 30% of patients who have true pathologic stage IIA disease, at least 65% will be cured with surgery alone. In addition, most patients in whom RPLND confirms pathologic stage I disease can be reassured that the risk of distant relapse is only 5%. Finally, following open RPLND, most patients return to basic activities within 2 weeks and full activity within 4-6 weeks, with long-term small-bowel obstruction occurring in less than 1% of patients. Thus, the potential morbidity caused by RPLND is well-defined and generally limited compared with the as-yet-undefined sequelae of adjuvant chemotherapy. The decreased morbidity afforded by L-RPLND must also be weighed into decisions made by the patient and clinician, although additional study and follow-up are needed.
Currently, clinicians can use risk stratification to assist patients with clinical stage I NSGCT select therapy. High-risk patients include those with embryonal carcinoma involving over 40% of the orchiectomy specimen, T stage greater than T1, and any lymphatic or vascular invasion. Using this strategy, patients with all low-risk features have a 5%-20% risk of harboring microscopic retroperitoneal metastasis, and patients with one or more high-risk features have a 40%-80% risk.
Clinical stage II disease
Stage II disease is broken down into 3 groups based on the size of retroperitoneal nodes on imaging (IIA, < 2 cm; IIB, 2-5 cm; IIC, >5 cm). The general agreement is that patients with IIC disease have significant disease burden and a high likelihood of pre-existing microscopic pulmonary or visceral metastases and should therefore be treated with initial chemotherapy, similar to the management strategy for stage III disease. To complicate matters, clinical practice diverges even further from the staging system in that many authors recommend RPLND over chemotherapy based on a 3-cm nodal cut-off value.
Up to 25% of patients with clinical stage II disease have false-positive CT scan findings and have pathologic stage I disease. By undergoing RPLND, these patients avoid 4 cycles of chemotherapy. In addition, 65-80% of patients with pathologic stage IIA disease are cured with RPLND alone. In the 20% who subsequently develop pulmonary metastases, 4 cycles of chemotherapy confers a cure rate approaching 100%. If RPLND reveals pathologic stage IIB disease, relapse occurs in 65% of patients, but 2 cycles of adjuvant chemotherapy decrease this relapse rate to 2%.
Alternatively, all patients with clinical stage II disease can be given 4 cycles of chemotherapy. A complete response is seen in 40-70% of patients and major abdominal surgery is initially avoided. Unfortunately, 30-60% of these patients have residual retroperitoneal masses larger than 1 cm or have tumors that are reduced by less than 90%. In these patients, salvage RPLND is indicated, and complication rates are higher; in addition, nerve sparing is often impossible. Among patients with viable germ cell tumor at the time of RPLND, salvage chemotherapy regimens are often necessary.
Clinical stage III disease
Patients with stage III disease, as well as those with stage IIC and stage IIB with poor prognostic factors, undergo primary chemotherapy.
The role of adjunctive RPLND in these patients is controversial. Multiple series have shown that, on average, masses that persist after chemotherapy are composed of necrosis (40%), teratoma (40%), or viable germ cell tumor (20%). However, up to 33% of patients with a normal CT scan findings may have viable germ cell tumor in the retroperitoneum.
Among patients with no teratoma in the primary specimen, if the volume was reduced by 90% after chemotherapy, one study found no viable tumor or teratoma on RPLND. In contrast, another study reported that, among 51 patients with teratoma on RPLND, only 28% of the primary specimen had teratoma. Similarly, a third study found retroperitoneal teratoma in 16% of patients with clinical stage I/IIA disease with pure embryonal carcinoma.
Despite the use of variables including tumor shrinkage, size of residual mass, teratoma in primary specimen, and pretreatment markers, the false-negative rate is still 20%. Thus, unless the CT scan shows no abnormalities or the primary tumor was 100% embryonal and no residual masses are larger than 2 cm, expert opinion is that patients should undergo salvage RPLND. The goal of aggressive surgical management in these patients is to prevent growing teratoma syndrome, which is characterized by a residual mass that continues to grow in the absence of viable germ cell. Because only complete surgical resection can achieve a cure in such patients, early RPLND to prevent progression to inoperable disease is crucial.
Choriocarcinoma is the only testicular tumor that spreads hematogenously. With the exception of choriocarcinoma, testicular tumors generally spread via the lymphatics. Lymph nodes of the testis extend from T1 to L4 but are concentrated in the region of the renal hilum because of their common embryologic origin with the kidney.
Stepwise spread for right-sided testicular cancer is from the testis to interaortocaval, precaval, preaortic, paracaval, right common iliac, and right external iliac lymph nodes. The most common landing site for a right-sided testicular tumor is the interaortocaval lymph nodes.
The testicular lymphatics of the left testis drain stepwise from the testis to the nodes of the paraaortic, preaortic, left common iliac, left external iliac, interaortocaval, precaval, and finally, to the paracaval nodes. The primary landing site for the left testis is the para-aortic area at the level of the left renal hilum.
Stepwise systemic spread occurs from retroperitoneal nodes to the cisterna chyli, thoracic duct, supradiaphragmatic nodes, and finally, to extranodal/distant metastasis. These include (in decreasing frequency) lung, liver, brain, bone, kidney, adrenal, and gastrointestinal tract.
Contraindications to primary retroperitoneal lymph node dissection (RPLND) include (1) abnormal levels of serum tumor markers after orchiectomy (see Lab Studies), (2) pure seminoma, (3) bulky retroperitoneal lymphadenopathy (ie, clinical stage >IIB), and (4) comorbid conditions that preclude general anesthesia (rare given the high incidence in young adults).
ROBSON CJ. Radical nephrectomy for renal cell carcinoma. J Urol. 1963 Jan. 89:37-42. [Medline].
Blom JH, van Poppel H, Marechal JM, Jacqmin D, Sylvester R, Schröder FH, et al. Radical nephrectomy with and without lymph node dissection: preliminary results of the EORTC randomized phase III protocol 30881. EORTC Genitourinary Group. Eur Urol. 1999 Dec. 36(6):570-5. [Medline].
Chapman TN, Sharma S, Zhang S, Wong MK, Kim HL. Laparoscopic lymph node dissection in clinically node-negative patients undergoing laparoscopic nephrectomy for renal carcinoma. Urology. 2008 Feb. 71(2):287-91. [Medline].
Simmons MN, Kaouk J, Gill IS, Fergany A. Laparoscopic radical nephrectomy with hilar lymph node dissection in patients with advanced renal cell carcinoma. Urology. 2007 Jul. 70(1):43-6. [Medline].
Brausi MA, Gavioli M, De Luca G, Verrini G, Peracchia G, Simonini G, et al. Retroperitoneal lymph node dissection (RPLD) in conjunction with nephroureterectomy in the treatment of infiltrative transitional cell carcinoma (TCC) of the upper urinary tract: impact on survival. Eur Urol. 2007 Nov. 52(5):1414-8. [Medline].
Jamieson JK, Dobson JF. The lymphatics of the testicle. Lancet. 1910. 1:493.
Rouvier H. Lymphatic system of. the abdomen and pelvis. Anatomy of the human lymphatic system. 1938.
Hinman F, Gibson TE, Kutzmann AA. Radical operation for teratoma testis. Surg Gynecol Obstet. 1923. 37:429-451.
Cooper JF, Leadbetter WH, Chute R. The thoracoabdominal approach for retroperitoneal lymph node dissection: Its application to testis tumors. Surg Gynecol Obstet. 1950. 90:486.
Busch FM, Sayegh ES, Chenault OW Jr. Some uses of Lymphangiography in the Management of testicular tumors. J Urol. 1965 Apr. 93:490-5. [Medline].
Chiappa S, Uslenghi C, Bonadonna G, Marano P, Ravasi G. Combined testicular and foot lymphangiography in testicular carcinomas. Surg Gynecol Obstet. 1966 Jul. 123(1):10-4. [Medline].
Skinner DG, Leadbetter WF. The surgical management of testis tumors. J Urol. 1971 Jul. 106(1):84-93. [Medline].
Donohue JP. Retroperitoneal lymphadenectomy: the anterior approach including bilateral suprarenal-hilar dissection. Urol Clin North Am. 1977 Oct. 4(3):509-21. [Medline].
Narayan P, Lange PH, Fraley EE. Ejaculation and fertility after extended retroperitoneal lymph node dissection for testicular cancer. J Urol. 1982 Apr. 127(4):685-8. [Medline].
Richie JP. Clinical stage 1 testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol. 1990 Nov. 144(5):1160-3. [Medline].
Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Retroperitoneal lymphadenectomy for clinical stage A testis cancer (1965 to 1989): modifications of technique and impact on ejaculation. J Urol. 1993 Feb. 149(2):237-43. [Medline].
Rukstalis DB, Chodak GW. Laparoscopic retroperitoneal lymph node dissection in a patient with stage 1 testicular carcinoma. J Urol. 1992 Dec. 148(6):1907-9; discussion 1909-10. [Medline].
Janetschek G, Hobisch A, Peschel R. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: long-term outcome. J Urol. 2000 Jun. 163(6):1793-6. [Medline].
Peschel R, Gettman MT, Neururer R, Hobisch A, Bartsch G. Laparoscopic retroperitoneal lymph node dissection: description of the nerve-sparing technique. Urology. 2002 Aug. 60(2):339-43; discussion 343. [Medline].
Williams SB, Lau CS, Josephson DY. Initial Series of Robot-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer. Eur Urol. 2011 Mar 21. [Medline].
Cresswell J, Scheitlin W, Gozen A, Lenz E, Teber D, Rassweiler J. Laparoscopic retroperitoneal lymph node dissection combined with adjuvant chemotherapy for pathological stage II disease in nonseminomatous germ cell tumours: a 15-year experience. BJU Int. 2008 Sep. 102(7):844-8. [Medline].
Spermon JR, Witjes JA. Case report: the danger of postchemotherapy laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma. J Endourol. 2008 May. 22(5):1013-6. [Medline].
Kim P, Syan-Bhanvadia S, Djaladat H, Faber K, Tadros NN, Nichols C. Midline extraperitoneal approach for retroperitoneal lymph node dissection for testicular germ cell tumor. Urology. 2012 Oct. 80(4):941-5. [Medline].
Nicolai N, Pizzocaro G. A surveillance study of clinical stage I nonseminomatous germ cell tumors of the testis: 10-year followup. J Urol. 1995 Sep. 154(3):1045-9. [Medline].
Sogani PC, Perrotti M, Herr HW, Fair WR, Thaler HT, Bosl G. Clinical stage I testis cancer: long-term outcome of patients on surveillance. J Urol. 1998 Mar. 159(3):855-8. [Medline].
Lashley DB, Lowe BA. A rational approach to managing stage I nonseminomatous germ cell cancer. Urol Clin North Am. 1998 Aug. 25(3):405-23. [Medline].
Hoskin P, Dilly S, Easton D, Horwich A, Hendry W, Peckham MJ. Prognostic factors in stage I non-seminomatous germ-cell testicular tumors managed by orchiectomy and surveillance: implications for adjuvant chemotherapy. J Clin Oncol. 1986 Jul. 4(7):1031-6. [Medline].
Heidenreich A, Sesterhenn IA, Mostofi FK, Moul JW. Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis. Cancer. 1998 Sep 1. 83(5):1002-11. [Medline].
Steele GS, Richie JP. Current role of retroperitoneal lymph node dissection in testicular cancer. Oncology (Williston Park). 1997 May. 11(5):717-29; discussion 730-37 passim. [Medline].
Swanson DA. Should chemotherapy replace retroperitoneal lymphadenectomy for clinical stage II testicular tumors?. Mayo Clin Proc. 1995 Sep. 70(9):911-3. [Medline].
Stomper PC, Kalish LA, Garnick MB, Richie JP, Kantoff PW. CT and pathologic predictive features of residual mass histologic findings after chemotherapy for nonseminomatous germ cell tumors: can residual malignancy or teratoma be excluded?. Radiology. 1991 Sep. 180(3):711-4. [Medline].
Donohue JP, Rowland RG. Complications of retroperitoneal lymph node dissection. J Urol. 1981 Mar. 125(3):338-40. [Medline].
Loehrer PJ Sr, Hui S, Clark S, Seal M, Einhorn LH, Williams SD. Teratoma following cisplatin-based combination chemotherapy for nonseminomatous germ cell tumors: a clinicopathological correlation. J Urol. 1986 Jun. 135(6):1183-9. [Medline].
Stephenson AJ, Bosl GJ, Bajorin DF, Stasi J, Motzer RJ, Sheinfeld J. Retroperitoneal lymph node dissection in patients with low stage testicular cancer with embryonal carcinoma predominance and/or lymphovascular invasion. J Urol. 2005 Aug. 174(2):557-60; discussion 560. [Medline].
Beck SD, Foster RS, Bihrle R, Donohue JP, Einhorn LH. Is full bilateral retroperitoneal lymph node dissection always necessary for postchemotherapy residual tumor?. Cancer. 2007 Sep 15. 110(6):1235-40. [Medline].
[Guideline] Testicular Cancer Guideline v2.2011. Network NCC. Available at http://www.nccn.org. Accessed: 6/29/2011.
Thompson RH, Carver BS, Bosl GJ, Bajorin D, Motzer R, Feldman D. Evaluation of lymph node counts in primary retroperitoneal lymph node dissection. Cancer. 2010 Nov 15. 116(22):5243-50. [Medline].
Finelli A. Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: long-term oncologic outcomes. Curr Opin Urol. 2008 Mar. 18(2):180-4. [Medline].
Stephenson AJ, Bosl GJ, Motzer RJ, Bajorin DF, Stasi JP, Sheinfeld J. Nonrandomized comparison of primary chemotherapy and retroperitoneal lymph node dissection for clinical stage IIA and IIB nonseminomatous germ cell testicular cancer. J Clin Oncol. 2007 Dec 10. 25(35):5597-602. [Medline].
Albqami N, Janetschek G. Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol. 2005 Jul-Aug. 19(6):683-92; discussion 692. [Medline].
Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology. 2003 Aug. 62(2):324-7. [Medline].
Steiner H, Leonhartsberger N, Stoehr B, Peschel R, Pichler R. Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients. Eur Urol. 2013 Jun. 63(6):1013-7. [Medline].
Carver BS, Shayegan B, Eggener S, Stasi J, Motzer RJ, Bosl GJ, et al. Incidence of metastatic nonseminomatous germ cell tumor outside the boundaries of a modified postchemotherapy retroperitoneal lymph node dissection. J Clin Oncol. 2007 Oct 1. 25(28):4365-9. [Medline].
Rassweiler JJ, Frede T, Lenz E, Seemann O, Alken P. Long-term experience with laparoscopic retroperitoneal lymph node dissection in the management of low-stage testis cancer. Eur Urol. 2000 Mar. 37(3):251-60. [Medline].
Donat SM, Levy DA. Bleomycin associated pulmonary toxicity: is perioperative oxygen restriction necessary?. J Urol. 1998 Oct. 160(4):1347-52. [Medline].
Albers P, Orazi A, Ulbright TM, Miller GA, Haidar JH, Donohue JP, et al. Prognostic significance of immunohistochemical proliferation markers (Ki-67/MIB-1 and proliferation-associated nuclear antigen), p53 protein accumulation, and neovascularization in clinical stage A nonseminomatous testicular germ cell tumors. Mod Pathol. 1995 Jun. 8(5):492-7. [Medline].
de Riese W, Walker EB, de Riese C, Ulbright TM, Crabtree WN, Messemer J, et al. Quantitative DNA measurement by flow cytometry and image analysis of human nonseminomatous germ cell testicular tumors. Urol Res. 1994. 22(4):213-20. [Medline].
Moul JW, Foley JP, Hitchcock CL, McCarthy WF, Sesterhenn IA, Becker RL, et al. Flow cytometric and quantitative histological parameters to predict occult disease in clinical stage I nonseminomatous testicular germ cell tumors. J Urol. 1993 Sep. 150(3):879-83. [Medline].
Foster RS, Nichols CR. Testicular cancer: what's new in staging, prognosis, and therapy. Oncology (Williston Park). 1999 Dec. 13(12):1689-94; discussion 1697-700, 1703. [Medline].
Schrader AJ, Seger M, Konrad L, Olbert P, Hegele A, Hofmann R, et al. Clinical impact of MDR1-expression in testicular germ cell cancer. Exp Oncol. 2007 Sep. 29(3):212-6. [Medline].
Cheney SM, Andrews PE, Leibovich BC, Castle EP. Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients. BJU Int. 2015 Jan. 115 (1):114-20. [Medline].