Retroperitoneal Lymph Node Dissection 

Updated: Sep 28, 2018
Author: Jared M Whitson, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS 

Overview

Background

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.[1] 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.[2]

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.[3] 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.[4]

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.[5]

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, 8]  Hinman et al also described a series of RPLND procedures performed via a transabdominal approach.[9] In 1950, Cooper et al published his experience with thoracoabdominal RPLND, stating that this modification provided excellent exposure of the renal pedicle.[10]

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.[11, 12] 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.[13] 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.[14]

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.[15] 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.[16] 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.[17]

L-RPLND was introduced into the surgical armamentarium beginning with a case report in 1992 by Rukstalis and Chodak.[18] 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.[19] 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.[20] 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.[21] 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.[22, 23]

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.[24]

Indications

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%.[25, 26] 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.[27] 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.[28] 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.[29]

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.[30] 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.[31] 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%).[30] However, up to 33% of patients with a normal CT scan findings may have viable germ cell tumor in the retroperitoneum.[32]

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.[33] In contrast, another study reported that, among 51 patients with teratoma on RPLND, only 28% of the primary specimen had teratoma.[34] Similarly, a third study found retroperitoneal teratoma in 16% of patients with clinical stage I/IIA disease with pure embryonal carcinoma.[35]

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.[36] 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.

Relevant Anatomy

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.

For more information about the relevant anatomy, see Testes and Epididymis Anatomy and Lymphatic System Anatomy.

Contraindications

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).

 

Workup

Laboratory Studies

See the list below:

  • Serum tumor markers: Prior to performing retroperitoneal lymph node dissection (RPLND) for nonseminomatous germ cell tumors (NSGCTs), levels of serum tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [hCG], lactate dehydrogenase [LDH]) should be within reference ranges after orchiectomy or after chemotherapy for more advanced disease.

  • CBC count: Patients with advanced testicular cancer may have anemia.

  • Basic metabolic panel: The serum creatinine level may be elevated in patients with ureteral obstruction due to sizable retroperitoneal disease. Renal function tests are mandatory in patients who require chemotherapy (eg, platinum) for advanced disease.

  • Liver panel: Liver function test results may be elevated in patients who present with hepatic metastasis.

Imaging Studies

See the list below:

  • Scrotal ultrasonography: This is the definitive diagnostic test for testicular tumors. Its sensitivity for revealing a solid mass within the parenchyma of the testis is greater than 90%. Scrotal ultrasonography is useful and may be required if physical examination findings of the testis are equivocal or cannot be adequately assessed because of a hydrocele.

  • Chest radiography: Obtain anteroposterior and lateral chest radiographs to stage the disease. Chest radiography carries a sensitivity of 85-90% in detecting pulmonary metastasis. Although chest CT scanning is more sensitive, it is thought to be of limited prognostic value because of decreased specificity. Reports indicate that approximately 70% of the lesions detected with chest CT scanning turn out to be benign. Individual disease characteristics and findings on abdominal imaging should dictate whether to obtain chest radiography or chest CT scanning.

  • CT scanning: This is the most effective method of detecting retroperitoneal lymph node involvement. This imaging modality has replaced intravenous pyelography and lymphangiography as the diagnostic study of the retroperitoneum. Abdominal CT scanning can help identify retroperitoneal lymphadenopathy smaller than 2 cm in diameter. However, CT scans cannot differentiate malignancy, fibrosis, or the presence of teratoma based on these size criteria alone. MRI: This modality is useful in evaluating the brain or spine for evidence of metastasis in patients with localizing symptoms.

  • Positron emission tomography (PET) scanning: Currently experimental and expensive, PET scanning may have a role in evaluating persistent retroperitoneal adenopathy in patients with seminoma who have undergone chemotherapy.

  • Pedal lymphangiography: This imaging modality is of historical importance, particularly in mapping testicular lymphatics and landing sites for metastases. For diagnostic purposes, it has an error rate of 25%.

Staging

Many systems for staging testicular cancer exist. Almost all systems in use today are variations of the original staging criteria established by Boden and Gibb (1951). In their original system, stage A (or I) testicular cancer was located within the testis, stage B (or II) included regional lymph node spread, and stage C (or III) indicated spread beyond the retroperitoneal lymph nodes (eg, pulmonary, visceral, brain, bone).

A system devised by the Memorial Sloan-Kettering Cancer Center further delineates stage B into the following:

  • Stage B1 - Retroperitoneal lymph node involvement smaller than 5 cm in diameter

  • Stage B2 - Retroperitoneal nodes measuring 5-10 cm in diameter

  • Stage B3 - Retroperitoneal nodes larger than 10 cm in maximum diameter

M.D. Anderson has also modified this system, as follows:

  • Stage I - Lesion confined to the testes

  • Stage IIA - Retroperitoneal node involvement smaller than 10 cm in diameter

  • Stage IIB - Retroperitoneal node involvement larger than 10 cm in diameter

  • Stage III - Supradiaphragmatic nodal involvement and/or visceral involvement

Low-stage disease refers to stages I and IIA (A and B1), and high-stage disease includes stages IIB and III (B2, B3, C) of testicular cancer.

The TNM classification system devised by the American Joint Committee on Cancer (AJCC) has standardized staging of testicular cancer. This staging system is depicted below.

  • Primary tumor (T)

    • pTX - Primary tumor cannot be assessed (ie, no radical orchiectomy has been performed)

    • pT0 - No evidence of primary tumor (eg, histologic scar in testis)

    • pTis - Intratubular germ cell neoplasia (carcinoma in situ)

    • pT1 - Tumor limited to testis and epididymis without lymphatic/vascular invasion

    • pT2 - Tumor limited to testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis

    • pT3 - Tumor invades the spermatic cord with or without vascular/lymphatic invasion

    • pT4 - Tumor invades the scrotum with or without vascular/lymphatic invasion

  • Regional lymph nodes (N)

    • NX - Regional lymph nodes cannot be assessed

    • N0 - No regional lymph node metastasis

    • N1 - Metastasis in a single lymph node, 2 cm or smaller in greatest dimension

    • N2 - Metastasis in a single lymph node, larger than 2 cm but 5 cm or smaller in greatest dimension; or multiple lymph nodes, none larger than 5 cm in greatest dimension

    • N3 - Metastasis in a lymph node larger than 5 cm in greatest dimension

  • Distant metastasis (M)

    • MX - Presence of distant metastasis cannot be assessed

    • M0 - No distant metastasis

    • M1 - Distant metastasis

    • M1a - Nonregional nodal or pulmonary metastasis

    • M1b - Distant metastasis other than to nonregional nodes and lungs

  • Serum tumor markers (S)

    • SX - Tumor marker studies not available or not performed

    • S0 - Tumor marker levels within the reference range

    • S1 - LDH level less than 1.5 times the reference range AND HCG level less than 5000 mIU/mL AND AFP level less than 1000 ng/mL

    • S2 - LDH level 1.5-10 times the reference range OR HCG level 5000-50,000 mIU/mL OR AFP level 1000-10,000 ng/mL

    • S3 - LDH level more than 10 times the reference range OR HCG level greater than 50,000 mIU/mL OR AFP level greater than 10,000 ng/mL

The AJCC staging system is as follows:

  • Stage 0 - [pTis, N0, M0, S0]

  • Stage I - [pT1-4, N0, M0, SX]

  • Stage IA - [pT1, N0, M0, S0]

  • Stage IB - [pT2, N0, M0, S0]; [pT3, N0, M0, S0]; [pT4, N0, M0, S0]

  • Stage IS - [Any pT/Tx, N0, M0, S1-3]

  • Stage II - [Any pT/Tx, N1-3, M0, SX]

  • Stage IIA - [Any pT/Tx, N1, M0, S0]; [Any pT/Tx, N1, M0, S1]

  • Stage IIB - [Any pT/Tx, N2, M0, S0]; [Any pT/Tx, N2, M0, S1]

  • Stage IIC - [Any pT/Tx, N3, M0, S0]; [Any pT/Tx, N3, M0, S1]

  • Stage III – [Any pT/Tx, Any N, M1, SX]

  • Stage IIIA – [Any pT/Tx, Any N, M1a, S0]; [Any pT/Tx, Any N, M1a, S1]

  • Stage IIIB – [Any pT/Tx, N1-3, M0, S2]; [Any pT/Tx, Any N, M1a, S2]

  • Stage IIIC – [Any pT/Tx, N1-3, M0, S3]; [Any pT/Tx, Any N, M1a, S3]; [Any pT/Tx, Any N, M1b, Any S]

 

Treatment

Surgical Therapy

Clinical stage I disease

Recent National Comprehensive Cancer Network Guidelines recommend surveillance (in compliant patients only), nerve-sparing retroperitoneal lymph node dissection (RPLND), or chemotherapy (IB) for patients with stage I NSGCT.[37] For those patients who choose RPLND over surveillance, ipsilateral modified nerve-sparing RPLND can be performed. If minimal retroperitoneal disease is discovered, the surgeon may choose to perform a full ipsilateral dissection, although nerve-sparing is still likely to be performed.

The development of advanced laparoscopic techniques has provided the opportunity to perform laparoscopic RPLND (L-RPLND), both template and nerve-sparing. However, debate persists regarding whether L-RPLND is merely a diagnostic staging procedure or yields cancer control comparable to that of open RPLND in the 30% of patients with pathologic stage II disease. The nodal count possible with L-RPLND and the adherence to the template format are persistent questions. Research is ongoing as to the appropriate threshold number of nodes removed for diagnostic and therapeutic efficacy.[38]

A review of the literature identified 333 patients who underwent L-RPLND for stage I disease.[39] Positive nodes were found in 22% of patients, 97% of whom received adjuvant chemotherapy. Only a 0.3% incidence of retroperitoneal recurrence occurred, again with the caveat that the vast majority of patients with pathologic stage II disease received chemotherapy.

Clinical stage II disease

Patients with low-volume stage II disease who undergo primary RPLND are also candidates for ipsilateral modified nerve-sparing RPLND. Candidates for primary RPLND include patients with normal tumor marker levels, adenopathy smaller than 2 cm in diameter within the primary landing zone, and the absence of multiple enlarged lymph nodes.[40] However, in this case, if the clinical stage is underestimated and high-volume stage II disease is detected, the surgeon should perform a full ipsilateral dissection. Once again, the sympathetic nerves can be prospectively identified and preserved.

Many patients with clinical stage IIB disease who undergo initial chemotherapy have residual retroperitoneal masses and require salvage RPLND. Recently, both Janetschek et al[41] and Kavoussi[42] reported series of patients in whom L-RPLND in this setting was successful. A recent review of the literature identified 117 patients who underwent L-RPLND in the setting of clinical stage II disease or postchemotherapy.[39] Viable NSGCT was found in 6.8%, with teratoma identified in 23%. Recurrence occurred in 5.1% of patients, with the location of recurrence not reported in most instances. A single institution reported very similar results on 100 patients, in whom 1 recurrence occurred and 100% disease-specific survival was seen at 5-years median follow-up.[43]

Clinical stage IIc/III disease

Patients with residual masses following chemotherapy for advanced disease usually require standard RPLND with full bilateral dissection from the crura of the diaphragm to below the aortic bifurcation. Proponents of this method argue that 7-32% of patients will have tumor or teratoma outside a modified template, with decreasing percentages associated with decreased prechemotherapy clinical staging.[44] In initial experience, Rassweiller et al found a high open conversion rate with postchemotherapy L-RPLND.[45]

Preoperative Details

Preoperative preparation for RPLND involves obtaining informed consent and arranging a mechanical bowel preparation. Type and crossmatch for possible blood transfusion, especially in preparation for complex RPLND. In patients exposed to chemotherapy, WBC and platelet counts should be within the reference range or stabilized prior to surgery. Preoperatively evaluate patients receiving bleomycin with pulmonary function testing. Preoperatively evaluate patients with comorbid disease presentations (eg, renal insufficiency, anemia, heart conditions, liver pathology) with the appropriate consultations and/or laboratory studies.

Patients who have received bleomycin as a component of chemotherapy should probably undergo pulmonary function testing to evaluate for restrictive pulmonary fibrosis. Low inspired oxygen levels were once recommended during surgery; however, the most predictive factors for pulmonary complications include transfusion and total intravenous fluids.[46] Therefore, fluids must be limited to the greatest degree possible during and after surgery.

Intraoperative Details

From the time of its inception, RPLND has undergone many modifications and enhancements. Today, the two most popular approaches are the transabdominal and thoracoabdominal techniques. A laparoscopic alternative to the open procedure has been reported, but is limited to a few centers in the United States and Europe with significant laparoscopic experience.

The thoracoabdominal approach offers good exposure to the upper retroperitoneum and exposes the renal hilum in the center of the operating field. This procedure is useful in patients with advanced disease, who may present with a large retroperitoneal mass. This approach also allows for a complete suprahilar dissection, as well as the opportunity to easily access the retrocrural lymph nodes. Another advantage of this approach for RPLND is that it can be performed completely extraperitoneally in patients with lower-stage disease. This decreases the risks of small-bowel obstruction and ileus.

The second most common approach to RPLND is the transabdominal incision. This modification allows for faster opening and closing time. Additionally, this approach allows for good exposure to the suprahilar region, at the expense of mobilization of the pancreas and spleen. Advantages of a midline transperitoneal approach include familiarity and comfort for the surgeon and tolerable morbidity for the patient.

Currently, at the authors' institution, L-RPLND is used for select patients with low-stage disease. The procedure mimics the open operation in order to obtain similar oncologic and functional outcomes. A 4-port, transperitoneal technique is used, similar to that for laparoscopic nephrectomy. The authors perform a modified template operation with prospective nerve-sparing, adhering to the boundaries for each side outlined below. Intraoperative frozen-section analysis of the lymphatic tissue is used to determine whether the dissection is carried out to extended boundaries or an open conversion is necessary.

Right-sided modified template primary retroperitoneal lymph node dissection

The limits of dissection for the modified template RPLND on the right side include the right ureter, the renal veins, the lateral edge of the aorta, the IMA, and the ipsilateral iliac artery, where the ureter crosses. Note that the interaortocaval and retrocaval tissue is completely removed.

Limited right-sided retroperitoneal lymph node dis Limited right-sided retroperitoneal lymph node dissection (boundaries of dissection indicated by yellow border).

Left-sided modified template primary retroperitoneal lymph node dissection

The limits of dissection for the modified template RPLND on the left side include the left ureter, left renal vein, left edge of vena cava, IMA, and ipsilateral iliac artery, where the ureter crosses. Again, the interaortocaval tissue is included with the retroaortic lymphatics.

Limited left-sided retroperitoneal lymph node diss Limited left-sided retroperitoneal lymph node dissection (boundaries of dissection indicated by yellow border).

Postchemotherapy retroperitoneal lymph node dissection

Postchemotherapy RPLND typically entails full bilateral dissection of retroperitoneal lymphatics. This procedure involves removal of lymphatic tissue between both ureters, spanning from the diaphragmatic crus to the bifurcation of the common iliac arteries. The rationale for this extended region of dissection is the greater likelihood of bilateral disease with greater tumor burden. However, some patients with smaller-volume, localized disease within the primary landing site may be candidates for less-extensive RPLND.

Full right-sided retroperitoneal lymph node dissec Full right-sided retroperitoneal lymph node dissection (boundaries of dissection indicated by yellow border).
Full left-sided retroperitoneal lymph node dissect Full left-sided retroperitoneal lymph node dissection (boundaries of dissection indicated by yellow border).

Postoperative Details

Provide routine postoperative care. Patients should receive an appropriate amount of intravenous fluid replacements for the first 24-48 hours because of third-spacing.

Postoperative ileus is minimized with the retroperitoneal approach, and most patients are discharged within 3-6 days. If ileus is encountered, institute nasogastric suction for several days until symptoms resolve.

The pulmonary function in patients undergoing postchemotherapy RPLND should be closely monitored since they may have received bleomycin. Minimizing inspired oxygen concentration and intravenous fluids limits the risk of respiratory distress.

Follow-up

All patients with testicular cancer, regardless of stage, require frequent follow-up care. Many different follow-up protocols exist, and they vary depending on the clinical and pathologic stage and whether the patient is on a surveillance, post-RPLND, or post-chemotherapy protocol.

Most protocols involve history taking, physical examination (including examination of the contralateral testis), assessment of serum tumor markers, chest radiography, and abdominal imaging. After RPLND, postoperative baseline CT scanning, along with chest radiography, examinations, and assessment of serum tumor markers, is recommended 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.

Complications

Complications of retroperitoneal lymph node dissection (RPLND) vary widely and can include injuries to major vascular structures such as the aorta and vena cava; to solid organs including the liver, kidney, and pancreas; and to smaller tubular structures such as the ureters and cisterna chyli.

Most of these injuries can be managed with primary repair and conservative management, which may include placement of a nephrostomy tube or ureteral stent, prolonged drainage of lymphatic fluid, and modified low-fat diets.

The overall complication rates of primary RPLND and postchemotherapy RPLND vary but probably lie between 1% and 5% for major complications and around 15% for minor complications (eg, wound infection, urinary tract infection, ileus).

  • Chylous ascites - 1-3%

  • Renovascular injury - 1-3%

  • Small-bowel obstruction - 1-3%

  • Spinal cord ischemia - Less than 1%

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,[47] flow cytometry,[48, 49] and advanced imaging modalities may play an important role in more accurately predicting true stage in patients with clinical stage I disease.[50] 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.[51] 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.

Whether robotic-assistance facilitates more widespread implementation of the laparoscopic approach remains to be determined.

A single institution study evaluated outcomes of the first 18 patients treated with robot-assisted retroperitoneal lymph node dissection for non-seminomatous germ cell tumors (NSGCT) and paratesticular rhabdomyosarcoma (RMS). The study reported that this initial selected case series shows that the procedure is safe, reproducible, and feasible for stage I-IIB NSGCT and RMS in the hands of experienced robotic surgeons although the authors added that larger studies are needed to confirm the diagnostic and therapeutic utility of this technique.[52, 53]

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.