Retroperitoneal lymph node dissection (RPLND)

Indications

• Testicular cancer
  • Primary treatment for low-volume non-seminoma testicular tumor
  • Salvage therapy for residual mass in post-chemo non-seminoma
  • RPLND is more difficult in post-chemo seminoma due to desmoplastic reaction
  • In testicular cancer, also resect ipsilateral spermatic cord + gonadal vein from prior radical orchiectomy
• Paratesticular rhabdomyosarcoma in patients > 10yo or evidence of RP involvement
• RPLND does not improve survival in RCC patients (T1-T3N0M0) undergoing radical nephrectomy

Anesthesia considerations

• If received bleomycin previously - sensitizes lungs to ROS/free radical injury from oxygen (potential ARDS). Typically minimize FIO2 (30-40%), avoid supplemental O2 post-op (accept SaO2 > 90%). Also run dry.

RPLND templates:

• "Modified" template avoids nerve injury/retroperitoneal dissection on the contralateral side below the IMA
  • Lymphatic spread is R -> L, e.g. R sided disease more likely to have contralateral RP disease (25%) compared to L side (15%). L sided disease rarely ends up with positive nodes on the right/right of the cava
  • Modified R for R primary tumor - go all the way to the left ureter
  • Modified L for L primary tumor - only have to go to alteral edge of cava
• Nerve-sparing (NS-RPLND) preserves nerves within the template

Notes

• IMA can be ligated if the marginal colonic artery is intact for collateral
• Incise medial to IMV (eg like in trauma nephrectomy) to expose retroperitoneum
• Three pairs of equally spaced lumbar arteries between left renal artery and bifurcation. Vein: superior by gonadal, interaortocaval common lumbar trunk, small ones down below by bifurcation
• Nerves
  • R: postganglionic fibers and sympathetic chain posterior to vena cava
  • L: sympathetic chain dorsolateral to aorta
  • L1-L4 - anterolateral aspect of lower aorta
  • 

Mobilization of bowel for RP exposure - Cattel Braasch maneuver

Complications

• Post-operative tachycardia - common, caused by sympathetic discharge
• Impaired ejaculation (damage to sympathetic nerves T12-L3, hypogastric plexus near IMA)
  • 10-30% in non-nerve sparing RPLND
  • 10% in nerve-sparing (NS-RPLND)
• Chylous ascites (in 2%, can give octreotide)
• Renal vascular injury (3%), bowel obstruction (1-3%)

Postoperative management after RPLND

• pN0 - surveillance
• pN1 - surveillance, maybe BEP x 2-3
• pN2 - BEP x 2-3, maybe surveillance
• pN3 - BEP x 3-4