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Testicular SurgeryLast updated 29 May 2026

Retroperitoneal Lymph Node Dissection (RPLND)

RPLNDtesticular cancerNSGCTnerve-sparingretroperitoneumchylous ascitessplit-and-roll

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 residual masses after chemotherapy. 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 (some centres operate even after a clinical complete response). 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 ≥24 months after complete response to primary therapy.

Pre-operative Planning

  • RPLND principles (template, limits, nerve-sparing) apply regardless of adjuvant-chemotherapy intent or approach (open vs minimally invasive). Minimally invasive RPLND may be offered by surgeons with both GCT and MIS expertise, acknowledging limited long-term oncologic data.
  • Bleomycin exposure risks postoperative respiratory distress — minimize 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 — were the significant predictors of pulmonary toxicity.)
  • Identify the renal arterial anatomy, including possible accessory branches. A high-fat meal the night before can help visualize lymphatic vessels intraoperatively.

Anatomic Principles

  • Lumbar arteries — four paired branches, regularly spaced; the 2nd–4th pairs are commonly encountered below the left renal vein.
  • Lumbar veins — variable, unpaired vessels that preferentially drain into the left-posterior IVC, spaced increasingly far apart toward the iliocaval confluence.
  • Aortic (hypogastric) plexus — supplied by at least two lumbar splanchnic nerves on each side; composed of two parallel nerve cords, each with two major ganglia.

Templates

Full bilateral template — boundaries: superiorly the diaphragmatic crura and skeletonized renal vessels; inferiorly the common iliac bifurcation / ureteric crossing of the common iliac artery; laterally the ureters. This covers the primary and secondary landing zones of both testes and removes ten structures: para-aortic, retro-aortic, pre-aortic, left common iliac, interaortocaval, pre-caval, para-caval, retro-caval, and right common iliac lymph nodes, plus the ipsilateral gonadal vessels (removed in all patients). A complete retroaortic/retrocaval dissection with division of lumbar vessels is performed when within the planned template.

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

  • Right modified — may omit para-aortic nodes below the IMA (omission above the IMA is controversial).
  • Left modified — 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 into a non-germ-cell malignancy — e.g. sarcoma, carcinoma, PNET, or hematologic malignancy).
  • Relative: clinically negative lymph nodes.

Open RPLND Technique

Position: supine. Incision: ventral midline from subxiphoid to pubis (transperitoneal).

  1. Enter the peritoneal cavity, inspect the viscera, and divide the falciform ligament to avoid hepatic retraction injury. Place a self-retaining retractor (Bookwalter, Thompson, or Wishbone).
  2. Expose the retroperitoneum. Retract small bowel superiorly, incise the line of Toldt to medialize the ascending colon, extend the posterior peritoneal incision from cecum to the ligament of Treitz, and medialize the duodenum.
  3. Split-and-roll, right side (paracaval packet). Divide tissue anterior to the IVC with cautery (clipping lymphatics) up to the superior border of the left renal vein. Reflect the right ureter laterally, roll the IVC medially, and remove all tissue from the right renal vein to the IVC bifurcation. This region is devoid of sympathetic nerves. Control the lumbar veins (usually 2–3 on the right) to fully mobilize the IVC. Ligate the right gonadal vein at its IVC insertion for right-sided disease, and excise the ipsilateral spermatic cord stump to the internal inguinal ring.
  4. Interaortocaval packet. Using split-and-roll, separate interaortocaval nodal tissue from the caval adventitia and remove retroaortic/retrocaval tissue; ligate lumbar vessels as needed (left lumbar veins often drain centrally into the left IVC, with a common lumbar trunk landmarked by the IMA).
  5. Preserve the sympathetic nerves. Postganglionic sympathetic fibers run posterior to the IVC and anterior to the aorta; identify the lumbar splanchnic nerves (usually two, ~one vertebral level apart) and dissect them free of the packet. Nerve takeoffs lie near lumbar veins — clip lumbar vessels carefully. Three pairs of lumbar arteries usually line the infrarenal aorta, the middle pair approximated by the IMA origin.
  6. Para-aortic packet. Divide tissue anterior to the aorta to the left renal vein, preserving the IMA where possible (it may be sacrificed if the marginal artery of Drummond maintains colonic supply). Reflect the left ureter laterally, roll the aorta medially, and remove all tissue from the left renal vein to the aortic bifurcation.
  7. Obtain hemostasis, return the bowel to anatomic position, and close.

Post-operative Care

Alvimopan aids ileus recovery. A low-fat diet from POD #2, maintained for 30 days, reduces the risk of chylous ascites.

Modified Template Rationale

The predictable lymphatic spread of GCTs supports modified templates in low-stage disease. Advantages: preserved antegrade ejaculation (by sparing the contralateral retroperitoneum and interiliac regions) and lower rates of chylous ascites, renovascular injury, and pancreatic complications (by omitting suprahilar regions). The Indiana templates eliminate contralateral dissection below the IMA, sparing the lumbosacral sympathetic nerves and hypogastric plexus. Suprahilar/retrocrural and interiliac resections can be safely omitted, though the need to resect contralateral tissue remains debated. Standard PC-RPLND remains resection of all macroscopic disease with a full bilateral infrahilar dissection.

Nerve-Sparing

Antegrade ejaculation requires coordinated seminal emission and prostatic secretion (smooth-muscle contraction of the vasa, seminal vesicles, prostate), bladder-neck closure, and rhythmic pelvic-floor contraction. Emission and bladder-neck closure depend on efferent L1–L4 postganglionic sympathetic fibers that coalesce in the superior hypogastric plexus. Nerve-sparing — prospectively identifying and preserving the sympathetic chains, postganglionic fibers, and hypogastric plexus — should be offered to selected patients desiring fertility and preserves antegrade ejaculation in 90–100%, but must not compromise the lymph node dissection. Avoid electrocautery near nerve fibers.

Minimally Invasive RPLND

Laparoscopic/robotic RPLND offers less blood loss, shorter stay, and faster recovery (allowing prompt chemotherapy if needed), 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 (complete retroaortic/retrocaval excision); indications match open RPLND, with the post-chemotherapy setting reserved mainly for small-volume residual disease. A transperitoneal approach is usual; most patients ambulate and take liquids the night of surgery and are discharged on POD #1.

Adverse events: complication rates of 9–25%, with intraoperative bleeding the most common (and the leading cause of open conversion). Chylous ascites should be <2% with meticulous lymphatic ligation; retrograde ejaculation ranges 0–14%; open conversion is <5% (reported up to 11.8%). Morbidity and conversion are higher after chemotherapy.

Complications & Auxiliary Procedures

  • Chylous ascites — accumulation of chylomicron-rich lymph; occurs in 0.2–2% after primary RPLND and 2–7% after PC-RPLND. Manage with paracentesis, a low-fat/medium-chain-triglyceride diet, somatostatin/octreotide, an indwelling drain, or total parenteral nutrition.
  • Auxiliary procedures — nephrectomy is the most common (usually in high-risk settings: salvage, desperation, late-relapse, or reoperative RPLND); IVC resection is generally for bulky (≥stage IIb) disease; aortic resection/reconstruction, hepatic, and pelvic resections may also be required.