Retroperitoneal Lymph Node Dissection (RPLND)

Retroperitoneal lymph node dissection (RPLND) is a cornerstone of NSGCT management — for primary staging/treatment of clinical stage I or low-volume stage II disease, and for resection of a residual mass after chemotherapy. Because testicular cancer can be cured surgically even in the metastatic setting, a properly performed RPLND is both diagnostic and therapeutic. The clinical indications by stage are detailed in the Testicular Cancer topic; this page is the operative reference. Candidates should be referred to an experienced surgeon at a high-volume centre.

Classification

• Primary RPLND — after orchiectomy for CS I or low-volume CS II NSGCT with normal post-orchiectomy markers.
• Post-chemotherapy RPLND (PC-RPLND) — after induction chemotherapy, generally for a residual retroperitoneal mass with normal markers. Elevated markers after induction usually warrant salvage chemotherapy instead.
• Salvage PC-RPLND — after induction and salvage (standard- or high-dose) chemotherapy.
• Desperation PC-RPLND — performed despite elevated markers.
• Reoperative RPLND — after a prior primary or PC-RPLND.
• Resection of late relapse — for retroperitoneal recurrence > 5 years after complete response.

Preoperative Staging

After radical orchiectomy confirms an NSGCT, stage with repeat serum AFP and β-hCG, chest CT (or PA and lateral chest radiography), and abdomen/pelvis CT with IV contrast.

• Primary RPLND is offered for clinical stage I (normal markers and imaging) and for non-bulky CS IIA/IIB — typically primary RPLND in IIA, and either RPLND or chemotherapy in IIB (weighing fertility, histology, and the morbidity of surgery vs chemotherapy).
• Chemotherapy is preferred for bulky retroperitoneal disease, retroperitoneal + chest disease, or elevated markers after orchiectomy (even with normal imaging).
• After induction chemotherapy: normal markers and imaging → observe; normal markers with a residual retroperitoneal mass → PC-RPLND; elevated markers with a residual mass → usually salvage chemotherapy (individualised).

Pre-operative Planning

• Discuss fertility and ejaculation — a primary nerve-sparing RPLND preserves normal antegrade ejaculation in up to 99%; in the PC setting, nerve-sparing depends on tumour location and intraoperative judgement, so loss of antegrade ejaculation must be discussed.
• No bowel prep or dietary change is needed; place an intraoperative orogastric tube (a routine postoperative nasogastric tube is unnecessary). A type and screen suffices for a primary RPLND; order type and cross for 2 units for a PC-RPLND.
• Bleomycin exposure risks postoperative respiratory distress — minimise with a low fraction of inspired oxygen (FIO2) and conservative intraoperative fluids. (MD Anderson, 1998: transfusion volume, preoperative forced vital capacity, and operative time — not maintained FIO2 — predicted pulmonary toxicity.)
• Identify the renal arterial anatomy, including accessory branches (a high-fat meal the night before helps visualise lymphatics). For larger PC masses, be prepared for nephrectomy, IVC resection/reconstruction, or aortic replacement.

Anatomic Principles and Landing Zones

• Primary landing zones: a right testis tumour drains to the paracaval and interaortocaval nodes; a left testis tumour drains to the left para-aortic nodes. Modified templates and PC resections are planned around these.
• Lumbar arteries are predictable — around the infrarenal aorta (renal hilum to bifurcation) there are six: three along the medial and three along the lateral posterior border, ligated to give total aortic vascular control.
• Lumbar veins are variable in number and location, exiting the posterior IVC; controlling them mobilises the IVC.
• Sympathetic pathway: preganglionic fibres (T10–L2) synapse in the sympathetic chain, then postganglionic fibres (L1–L4) coalesce just distal to the IMA in the superior hypogastric plexus. The right chain lies posterior to the IVC; the left chain lies posterolateral to the aorta.

Templates

Full bilateral template — boundaries: superiorly the diaphragmatic crura and skeletonised renal vessels; inferiorly the common iliac bifurcation / ureteric crossing of the common iliac artery; laterally the ureters. It removes the para-aortic, retro-aortic, pre-aortic, left common iliac, interaortocaval, pre-caval, para-caval, retro-caval, and right common iliac nodes, plus the ipsilateral gonadal vessels (removed in all patients).

Modified templates (for low-stage, clinically negative nodes — relative indication):

• Right modified — packets are paracaval, interaortocaval, and the (right) gonadal vein; may omit para-aortic nodes below the IMA (omission above the IMA is controversial).
• Left modified — packets are para-aortic and the left gonadal vein; may omit paracaval, precaval, and retrocaval nodes (omission of interaortocaval nodes is controversial).

Indications (2019 AUA)

• Absolute: suspicious lymph nodes on CT or intraoperative assessment; or somatic-type malignancy in the primary tumour (malignant transformation of a teratomatous component — e.g. sarcoma, carcinoma, PNET).
• Relative: clinically negative lymph nodes.

Open RPLND Technique

Position: supine, with a Foley catheter. Incision: ventral midline (transperitoneal); the historic thoracoabdominal approach is now rarely used, and a low retrocrural mass can be reached transabdominally through the diaphragm.

1. Enter the peritoneal cavity, inspect and palpate the viscera, divide the falciform ligament (to avoid a hepatic retraction injury), and place a self-retaining retractor.
2. Access the retroperitoneum. Incise the root of the small-bowel mesentery from the cecum to the ligament of Treitz (stopping before the inferior mesenteric vein) for CS I or small paracaval/interaortocaval tumours; for larger tumours, extend around the cecum up the white line of Toldt to the foramen of Winslow and place the right colon and small bowel on the chest. For a large left para-aortic mass, additionally ligate the IMV and IMA to retract the left mesocolon; a left modified template is reached by mobilising the left colon medially along the white line of Toldt. Identify the gonadal vein and stay on its anterior surface (the correct plane); sweep the duodenum off the IVC and left renal vein.
3. Split-and-roll. Begin over the left renal vein (ligate its superior-surface lymphatics to reduce chylous leak), then the anterior aorta at 12 o'clock just below the left-renal-vein crossover, carried caudally to the IMA origin — preserve the IMA for a right modified template; ligate and divide it for a bilateral template (the postganglionic nerves coalesce just distal to the IMA). Roll the lymphatic tissue off the aorta to ligate the six lumbar arteries (3 medial + 3 lateral), then split-and-roll the IVC from the renal veins to the iliac bifurcation, ligating the right gonadal vein and the variable lumbar veins.
4. Paracaval packet. Protect the right ureter/kidney behind a retractor; a Gil-Vernet retractor holds the IVC medially. Roll the packet superiorly off the right common iliac vein, body wall, and psoas — preserving the right sympathetic trunk and genitofemoral nerve — up to the right renal hilum and crus.
5. Interaortocaval packet. Hold both great vessels laterally with Gil-Vernet retractors and harvest off the anterior spinous ligament (caudal → cranial), controlling the divided lumbar vessels; identify the right renal artery, roll the packet off it, and ligate the retrocrural lymphatics to prevent a chylous leak.
6. Para-aortic packet. After dividing the three left lumbar arteries, retract the aorta medially; roll the packet off the left common iliac artery, body wall, and psoas (avoiding the left sympathetic chain), ligate the left gonadal vein at its renal-vein origin, and ligate the retrocrural lymphatics at the crus.
7. Gonadal vein specimen. Resect the entire ipsilateral gonadal vein to the internal inguinal ring (from the IVC on the right, from the left renal vein on the left) and send it separately.

Nerve-Sparing

Antegrade ejaculation depends on efferent L1–L4 postganglionic sympathetic fibres driving seminal emission and bladder-neck closure via the superior hypogastric plexus. Prospectively identify and preserve the sympathetic chains and postganglionic fibres — the right nerves by rolling the lymphatic tissue medially off the IVC (the chain lies posterior to it), the left nerves distal to the IMA as they cross the left common iliac artery. A Kittner sponge sweeps away overlying tissue and vessel loops place the nerves on gentle traction; avoid electrocautery near them. Nerve-sparing preserves antegrade ejaculation in 90–100% but must not compromise the node dissection.

Modified Template Rationale

The predictable lymphatic spread of GCTs supports modified templates in low-stage disease: preserved antegrade ejaculation (by sparing the contralateral retroperitoneum and interiliac regions) and lower rates of chylous ascites and renovascular/pancreatic injury (by omitting suprahilar regions). The Indiana templates eliminate contralateral dissection below the IMA. Standard PC-RPLND remains resection of all macroscopic disease with a full bilateral infrahilar dissection.

Minimally Invasive RPLND

Laparoscopic/robotic RPLND offers less blood loss, shorter stay, and faster recovery, with antegrade ejaculation preserved in > 95% — comparable to open nerve-sparing. Staging L-RPLND has been abandoned in favour of a therapeutic procedure that duplicates the open templates; indications match open RPLND. Adverse-event rates are 9–25%, with intraoperative bleeding the commonest (and the leading cause of open conversion, which is < 5%, reported up to 11.8%); morbidity and conversion are higher after chemotherapy.

Closure and Post-operative Care

• Reapproximate the small-bowel mesenteric root with running 2-0 chromic (to prevent scarring to the great vessels); if the right colon was fully mobilised, tack the cecum to the right lower quadrant with interrupted 2-0 chromic to prevent a volvulus.
• Keep fluids conservative after bleomycin. Pain control with a one-shot intrathecal opioid/local anaesthetic plus a PCA pump. Alvimopan aids ileus recovery; a low-fat diet from POD 2 for 30 days reduces chylous ascites.
• Clear liquids on POD 1, regular diet by POD 2, early ambulation. Length of stay ~2–3 days for a primary RPLND, 3–5 days for PC-RPLND (longer with larger resections/aortic grafts).

Complications and Auxiliary Procedures

• Chylous ascites — chylomicron-rich lymph; 0.2–2% after primary and 2–7% after PC-RPLND. Manage with a low-fat/medium-chain-triglyceride diet, paracentesis or a drain, somatostatin/octreotide, or TPN.
• Retrograde ejaculation ranges 0–14% (least with a nerve-sparing modified template).
• Auxiliary procedures — nephrectomy is the commonest (usually salvage, desperation, late-relapse, or reoperative settings); IVC resection is generally for bulky (≥ stage IIb) disease; aortic, hepatic, and pelvic resections may also be required.