Testis carcinoma- management- lymphatic drainage and rplnd

1. LYMPHATIC DRAINAGE OF TESTIS
RPLND
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH
and KMC, Chennai.
2

3. LYMPHATIC DRAINAGE OF TESTIS
• Spermatic cord has 4-8 lymphatic
channels that traverse inguinal
canal
• As spermatic vessels cross ventral
to ureter,lymphatics fan out
medially and drain into
retroperitoneal lymph node chain
from L₅-T₁₁ (weinstein et al,1999)
3
Dept of Urology, GRH
and KMC, Chennai.

4. LYMPHATIC DRAINAGE OF TESTIS
• Most et al,1899 were the first to describe
anatomically about the lymphatic drainage of
testis
• `primary echelon of drainage for
 Right side
tumor→interaortocavalnodes
 Left side tumor-left para &pre aortic
nodes
4
Dept of Urology, GRH
and KMC, Chennai.

5. LYMPHATIC DRAINAGE OF TESTIS
• Cross over of lymphatic flow is noted from right
to left (weinstein et al,1999)
• Contralateral spread
 Mc with right sided tumors
 Rare with left sided tumors
 Usually in large volume disease
5
Dept of Urology, GRH
and KMC, Chennai.

6. LYMPHATIC DRAINAGE OF TESTIS
• Retroperitoneal lymphatics continue cephalad
into cisterna chyle,via right & left lumbar trunks
• Supradiaphragmatic spread occurs via thoracic
duct leading to posterior mediastinal and left
supraclavicular lymph node involvement
6
Dept of Urology, GRH
and KMC, Chennai.

7. LYMPHATIC DRAINAGE OF TESTIS
• Rarely testicular lymphatics communicate
directly with thoracic duct bypassing
retroperitoneal nodes (distant failure -5% )
• Metastatic nodal disease to common iliac,
external iliac,inguinal nodes –in large volume
disease with retrograde spread
7
Dept of Urology, GRH
and KMC, Chennai.

8. LYMPHATIC DRAINAGE OF TESTIS
• Metastasis to pelvic & inguinal nodes occurs
 Herniorrhaphy
 Vasectomy
 Trans scrotal procedure
• Epididimal involvement leads to external iliac
nodal involvement
8
Dept of Urology, GRH
and KMC, Chennai.

9. SURGICAL MAPPING STUDIES
(DONOHUE ET AL,1982 )
9
Dept of Urology, GRH
and KMC, Chennai.

10. 10
Dept of Urology, GRH
and KMC, Chennai.

11. 11
Dept of Urology, GRH
and KMC, Chennai.

12. TNM STAGING
12
Dept of Urology, GRH
and KMC, Chennai.

13. TNM STAGING
13
Dept of Urology, GRH
and KMC, Chennai.

14. RATIONALE BEHIND RPLND
• Retroperitoneal lymph node spread is usually
the first and often the only site of metastatic
disease
• Understaging by radiologic imaging-15-40%
• Untreated retroperitoneal nodal metastasis are
usually fatal
14
Dept of Urology, GRH
and KMC, Chennai.

15. INDICATIONS FOR RPLND
• Stage I nonseminoma
• Stage II nonseminoma
• Stage III nonseminoma
15
Dept of Urology, GRH
and KMC, Chennai.

16. TYPES OF RPLND
• Bilateral suprahilar RPLND
• Bilateral infrahilar RPLND
• Modified template RPLND
• Prospective nerve sparing RPLND
• Laparoscopic RPLND
16
Dept of Urology, GRH
and KMC, Chennai.

17. SUPRAHILAR RPLND
• Practised in olden days
• Boundaries
• Complications:pancreatic &renovascular
• Current indications
17
Dept of Urology, GRH
and KMC, Chennai.

18. Bilateral infrahilar RPLND
18
Dept of Urology, GRH
and KMC, Chennai.

19. BILATERAL INFRAHILAR RPLND
• THORACO ABDOMINAL APPROACH
(COOPER )
• Advantages: easier suprahilar lymphatic
dissection and less risk of small bowel
obstruction
• Position : Torqued position
• Incision :
19
Dept of Urology, GRH
and KMC, Chennai.

20. 20
Dept of Urology, GRH
and KMC, Chennai.

21. THORACO ABDOMINAL APPROACH
• Complications: Atelectasis, Prolonged ICD,
Post operative analgesia, Small bowel
obstruction, Lymphocele, Wound dehiscence
• Overall complications -13%
• Mortality -1.3%
21
Dept of Urology, GRH
and KMC, Chennai.

22. TRANS ABDOMINAL APPROACH
22
Dept of Urology, GRH
and KMC, Chennai.

23. 23
Dept of Urology, GRH
and KMC, Chennai.

24. 24
Dept of Urology, GRH
and KMC, Chennai.

25. 25
Dept of Urology, GRH
and KMC, Chennai.

26. SPLIT AND ROLL TECHNIQUE
26
Dept of Urology, GRH
and KMC, Chennai.

27. COMPLICATIONS
• Major:
▫ Hemorrhage, Ureteral injury, Bowel obstruction,
Pulmonary embolus, Wound dehiscence
• Minor:
▫ Lymphocele, Atelectasis, Wound infection,
Prolonged ileus
• Motality rate- less than 1%
• Long term morbidity – Retrograde ejaculation
27
Dept of Urology, GRH
and KMC, Chennai.

28. ANTEGRADE EJACULATION
• Closure of bladder neck
• Seminal emission
• ejaculation
28
Dept of Urology, GRH
and KMC, Chennai.

29. Modified template PRLND
29
Dept of Urology, GRH
and KMC, Chennai.

30. NERVE SPARING RPLND
• Clinical stage I NSGCT
• Low volume stage II NSGCT
• Carefully selected subset of PCRPLND
30
Dept of Urology, GRH
and KMC, Chennai.

31. NERVE SPARING RPLND
31
Dept of Urology, GRH
and KMC, Chennai.

32. • ROLE OF INTRA OPERATIVE NEURO
STIMULATION
32
Dept of Urology, GRH
and KMC, Chennai.

33. LAPAROSCOPIC RPLND
• Since 1990
• Indications: stage I / IIA NSGCT
 Negative serum
marker
 Absence of
comorbidities
 Post chemo
unifocal small
volume residual
masses
33
Dept of Urology, GRH
and KMC, Chennai.

34. COMPLICATIONS
• Chylous ascites -20%
• Retrograde ejaculation-2-5%
• Bowel injury-1-2%
• Open conversion rate -2-5%
34
Dept of Urology, GRH
and KMC, Chennai.

35. MANAGEMENT AFTER RPLND
• Stage I
• Stage II
 Surveillance
 Adjuvant chemotheraphy
• stageIII
 Necrosis/fibrosis -45-50%
 Teratoma-35-40%
 Viable GCT-10-15%
35
Dept of Urology, GRH
and KMC, Chennai.

36. 36
Dept of Urology, GRH
and KMC, Chennai.