You are in: eMedicine Specialties > Urology > Surgery Lymph Node Dissection, RetroperitonealArticle Last Updated: Sep 14, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 13
  Author: Jared M Whitson, MD, Resident, Department of Urology, University of California at San Francisco Jared M Whitson is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and Endourological Society Coauthor(s): Maxwell Meng, MD, Assistant Professor in Residence, Department of Urology, University of California at San Francisco; Rajesh Prasad, MD, Staff Physician, Department of Surgery, Division of Urology, University of Cincinnati Medical Center Editors: Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related 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 INTRODUCTIONSection 2 of 13
  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 usually has a limited role in renal cell and urothelial carcinomas and is performed as a staging exercise. In the vast majority of patients, it does not confer a therapeutic effect. This article focuses on RPLND in the setting of testicular tumors. History of the ProcedureThe 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.1 Hinman et al also described a series of RPLND procedures performed via a transabdominal approach.2 In 1950, Cooper et al published his experience with thoracoabdominal RPLND, stating that this modification provided excellent exposure of the renal pedicle.3 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. 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.4 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.5 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.6 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.7 Laparoscopic RPLND (L-RPLND) was introduced into the surgical armamentarium beginning with a case report in 1992 by Rukstalis and Chodak.8 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.9 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.10 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. INDICATIONSSection 3 of 13
Retroperitoneal lymph node dissection (RPLND) is an important component in the management of patients with low-stage nonseminomatous germ cell tumors (NSGCTs), as well as in patients with higher-stage disease who have residual retroperitoneal masses 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%. 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 risk of harboring microscopic retroperitoneal metastasis that ranges from 5-20%, and patients with one or more high-risk features have a risk of between 40% and 80%. 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 carry a cure rate that approaches 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%).11 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.12 In contrast, another study reported that, among 51 patients with teratoma on RPLND, only 28% of the primary specimen had teratoma.13 Similarly, a third study found retroperitoneal teratoma in 16% of patients with clinical stage I/IIA disease with pure embryonal carcinoma.14 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. RELEVANT ANATOMYSection 4 of 13
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 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. CONTRAINDICATIONSSection 5 of 13
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). WORKUPSection 6 of 13
Lab Studies
Imaging Studies
StagingMany 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
M.D. Anderson has also modified this system, as follows:
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.
The AJCC staging system is as follows:
TREATMENTSection 7 of 13
Surgical therapyClinical stage I disease Patients who choose retroperitoneal lymph node dissection (RPLND) over surveillance and chemotherapy are candidates for ipsilateral modified nerve-sparing RPLND. If minimal retroperitoneal disease is discovered, the surgeon may choose to perform an ipsilateral full bilateral dissection, although nerve-sparing will most likely still be performed. The development of advanced laparoscopic techniques has provided the opportunity to perform 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. Clinical stage II disease Patients with low-volume stage II disease who undergo primary RPLND are also candidates for ipsilateral modified nerve-sparing RPLND. 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 al9 and Kavoussi reported series of patients in whom L-RPLND in this setting was successful. 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. Nerve-sparing may be attempted but is often impossible. In initial experience, Rassweiller et al found a high open conversion rate with postchemotherapy L-RPLND.15 Preoperative detailsPreoperative 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. In patients who have received bleomycin as part of their chemotherapy, advise the anesthesiologist to maintain a low oxygen inspiratory level and limit intravenous fluids. Intraoperative detailsFrom the time of its inception, the RPLND procedure has undergone many modifications and enhancements. Today, the 2 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 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 (see Image 1) 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. Left-sided modified template primary retroperitoneal lymph node dissection The limits of dissection for the modified template RPLND on the left side (see Image 2) 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. Postchemotherapy retroperitoneal lymph node dissection Postchemotherapy RPLND typically entails full bilateral dissection of retroperitoneal lymphatics (see Images 3-4). 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. Postoperative detailsProvide 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 in 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-upAll 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. COMPLICATIONSSection 8 of 13
Complications from 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).
OUTCOME AND PROGNOSISSection 9 of 13
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 CONTROVERSIESSection 10 of 13
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, flow cytometry, and advanced imaging modalities may play an important role in more accurately predicting true stage in patients with clinical stage I disease. 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. ACKNOWLEDGMENTSSection 11 of 13
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jong M. Choe, MD, FACS, to the development and writing of this article. MULTIMEDIASection 12 of 13
REFERENCESSection 13 of 13
Lymph Node Dissection, Retroperitoneal excerpt Article Last Updated: Sep 14, 2007 | |||||||||||||||||||||||||||||||||
