Retroperitoneal Lymp Node Dissection for Testicular Cancer

Lymph nodes are shown in green.

The peritoneum is the membrane that lines the cavity which houses many of the abdominal organs such as the stomach, the majority of the small bowel, part of the large bowel, liver, spleen, and tail of the pancreas. The region behind this membrane is termed the retroperitoneum, which literally means "behind the peritoneum". This space contains parts of the bowel, the head, and body of the pancreas, kidneys and the lymph nodes known as retroperitoneal lymph nodes.

These lymph nodes contain sub-groups such as the paracaval, precaval, interaortocaval, preaortic, para-aortic, suprahilar and iliac lymph nodes.

What Is Retroperitoneal Lymph Node Dissection?

Retroperitoneal lymph node dissection (RPLND) is the surgical removal of specified retroperitoneal lymph nodes. Typically 40-50 nodes are removed.

How Is It Performed?

An incision is made just below the sternum (chest bone) down to below the umbilicus (belly button). Less-invasive laparoscopic surgery is available in certain locations, although it is not the standard. The bowel is displaced revealing the retroperitoneal space. This is the space depicted by the illustration above, although it does not depict the surgery itself. The major vessels are revealed along with the retroperitoneal lymph nodes that run in parallel. The lymph nodes are excised exercising care to avoid damaging the surrounding nerves.

The nodes are sent to the pathologist to evaluate for the presence of cancer. The bowel is returned to its usual position and the wounds are closed. The duration of the surgery can vary but is measured in hours.

When Is It Used?

The primary treatment for most testicular cancers is the removal of the cancerous testis, a surgical procedure known as a radical orchiectomy.

Following radical orchiectomy, there are several different options depending on the stage and type of testicular cancer: surveillance, chemotherapy and/or RPLND.

RPLND is used primarily in a type of testicular germ cell cancer known as nonseminoma.

Staging is very important when determining treatment options. In general terms, stage I cancer is confined to the testis, stage II involves the retroperitoneal lymph nodes and stage III involves any other organs or nodes such as the lungs. Stage I is followed by letters A or B. Stage II is followed by letters A, B or C. These letters indicate how invasive the primary tumor is in stage I or how large the lymph nodes are in stage II.

In stage IA (tumor confined to testis and epididymis), RPLND is an option, but surveillance (just keeping an eye on things) is typically preferred. However, in stage IB disease (tumor invading blood or lymph vessels, scrotum or spermatic cord), either RPLND or chemotherapy is recommended. In stage IIA (lymph nodes not greater than 2 cm in diameter) RPLND is the preferred treatment. In stage IIB  (lymph nodes are between 2-5 cm in diameter) RPLND can be considered in selected cases, but chemotherapy is typically the treatment of choice.

Stage II cancer can also be treated with chemotherapy up-front. If there is still evidence of residual cancer after chemotherapy (lymph nodes or masses > 1 cm), RPLND is an option, although it is technically more difficult to perform the following chemotherapy.

When It's Not Used 

It should not be used in other types of testicular cancer such as seminoma. It should not be done if the lymph nodes are greater than 5 cm in diameter. It should not be used if blood tumor markers have not returned to normal following radical orchiectomy. It should not be used in any other situation where the surgery and anesthesia cannot be safely tolerated.

Advantages, Disadvantages, and Side-Effects

The biggest advantage to RPLND is curing cancer. Another advantage is knowing for certain if the lymph nodes contain cancer or not. In addition, many nonseminoma testicular cancers will contain teratoma. Teratoma is a fairly benign tumor and typically does not spread by itself. However, it can spread when mixed with other nonseminoma types. Why is this a concern? Teratoma is not very responsive to chemotherapy or radiation therapy so the only way to eliminate it if it has spread to the lymph nodes is through surgery. If teratoma is left behind the following chemotherapy, it may grow and cause symptoms or transform into a more aggressive type of cancer.

RPLND can affect fertility by resulting in a complication known as retrograde ejaculation. In regular ejaculation, muscle contracts to prevent semen from going backward (retrograde) in the urethra and ending up in the bladder instead of being propelled through and out the penis. This may occur because the nerves responsible for contraction of this muscle run alongside the lymph nodes and are damaged during surgery. However, with modern nerve-sparing techniques, this risk is well below 10% in most cases.

Other possible side-effects of treatment are similar to other abdominal surgery: bowel obstructions, infections, and reactions to anesthesia.

The decision to proceed with RPLND is one that needs to be thoroughly discussed with your cancer professional to determine its benefit and to discuss alternatives.