The document discusses retroperitoneal lymph node dissection (RPLND) techniques, focusing on surgical templates, rationale for treatment, and indications for different stages of non-seminomatous germ cell tumors (NSGCT). It emphasizes the importance of preserving sympathetic nerves to minimize ejaculatory dysfunction while ensuring complete lymph node removal for accurate staging and potential therapeutic benefits. Additionally, the document outlines complications associated with RPLND and the significance of modified techniques to improve patient outcomes.

1. Retroperitoneal Lymph Node Dissection
Dr Venkateshen P
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2. ANATOMIC REGIONS OF THE RETROPERITONEUM
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3. 3
PRIMARY “LANDING ZONE”
Donohue - divided the retroperitoneal nodes into specific
anatomic regions
• Right & left suprahilar
• Right paracaval, precaval, interaortocaval
• Preaortic, left para-aortic, right & left iliac, interiliac
• Gonadal vessels (right or left)
• PRIMARY “LANDING ZONE”- Right- interaortocaval
lymph nodes, precaval , paracaval nodes
• Left- left para-aortic , preaortic lymph nodes

4. 4
RATIONALE FOR TREATMENT OF RETROPERITONEAL LYMPH NODES
It is based on several factors
• Nodal spread is usually the first & often the only site of metastatic
disease ,nodes treated by RPLND increases survival rates
• 15% - 40% of patients are clinically understaged - 20% - 30%
incidence of pathologic stage II disease in clinical stage I - cause of
25% relapse during surveillance protocols in clinical stage I
• 20% incidence of teratoma /or viable carcinoma in patients with
radiographically normal CT
• Untreated nodal metastases are usually fatal
• Most common site of late recurrence of both teratoma & viable
GCT is the retroperitoneum, Late recurrences are usually
chemorefractory, decreases the survival rates

5. 5
EVOLUTION OF SURGICAL TEMPLATES AND
TECHNIQUES
• BILATERAL SUPRAHILAR DISSECTIONS
• Removal of all the nodal tissue between both ureters down
to the bifurcation of the common iliac arteries,superiorly
upto crus of diaphragm
It was associated with increased
• Pancreatic injury, Duodenal injury, Chylous ascites
• Renovascular complications
• Not routinly done
• Now, suprahilar dissections are indicated for residual hilar
or suprahilar masses after cytoreductive chemotherapy for
advanced stage NSGCT

6. 6
MODIFICATION
• RATIONALE - Suprahilar metastases are rare in low-stage
NSGCT, suprahilar dissection not necessary & high
morbidity
• To reduce surgical morbidity, suprahilar dissection is
modified to
BILATERAL INFRAHILAR RPLND
BOUNDARIES
• Sup – Renal hilum
• Lat – Ureter
• Inf – Bifurcation of common
iliac vessels
• This bilateral infrahilar RPLND also have long-term
morbidity of loss of antegrade ejaculation due to
damage of sympathetic nerve fibers

7. SURGICAL TEMPLATE -BILATERAL INFRANILAR RPLND
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8. 8
ANTEGRADE EJACULATION
It requires the coordination of three events
(1) Closure of the bladder neck
(2) Seminal emission
(3) Ejaculation
The sympathetic fibers from L1 – L4 form
the hypogastric plexus near the origin of
inferior mesenteric artery just
above the aortic bifurcation
From the hypogastric plexus, the sympathetic
fibers travel via the pelvic plexus to innervate
the seminal vesicles, vas deferens, prostate,
bladder neck

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10. 10
FURTHER MODIFICATIONS OF SURGICAL TEMPLATES
• Further modifications were developed to
reduce the incidence of ejaculatory
dysfunction by preserve the
sympathetic nerves

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GOAL OF MODIFIED TEMPLATES
(1) Resect all interaortocaval & ipsilateral lymph nodes
between the level of the renal vessels & bifurcation of
the common iliac artery
(2)To minimize contralateral dissection, particularly below the
level of IMA
• “Nerve-sparing” techniques can be utilized either in the
primary or post-chemotherapy RPLND
• Margins of resection should never be compromised in an
attempt to maintain ejaculatory function

12. 12
RT- MODIFIED RPLND
BOUNDARIES
• Sup – Rt renal vein
• Lat – Rt ureter
• Inf – Bifurcation of com.iliac art (Rt)
• Med – extends from junction of gonadal vein
to renal vein (Lt),below upto inf.mesen.art

13. TEMPLATE FOR MODIFIED RIGHT -RPLND
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14. 14
LT- MODIFIED RPLND
BOUNDARIES
• Sup – Lt renal vein
• Lat – Lt ureter
• Inf – Bifurcation of com.iliac art(Lt)
• Med – IVC,below upto inf.mesen.art

15. TEMPLATE FOR MODIFIED LEFT- RPLND
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INDICATIO
N
• Clinical stage I - PT2- T4,LV invasion
• CS IIA NSGCT (single lymph node < 2 cm)
• CS IIB NSGCT (single or multiple lymph nodes
2 to 5 cm).
• Postchemotherapy residual mass with
normal tumor markers

17. 17
INDICATIO
N
MODIFIED TEMPLATE RPLND
• Clinical stage-I
BILATERAL RPLND
• Clinical stage- IIA,IIB
• Postchemotherapy residual mass with normal
tumor markers

19. 19
TYPES OF RPLND
• STANDARD RPLND – Primary RPLND. either
unilat modified template/ Bilat RPLND in stage
I,IIA,IIB
• POSTCHEMOTHERAPY RPLND – postchemo
residual mass with normal tumor markers after
induction chemotherapy
• SALVAGE RPLND – RPLND for residual mass after
second line salvage chemotherapy with normal
tumor markers

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TYPES OF RPLND
• DESPERATION RPLND – RPLND for residual
mass after second line salvage chemotherapy
with elevated tumor markers
• REDO RPLND – RPLND for pts who had
previous RPLND with infield
recurrence
• LATE RELAPSE–RPLND Performed after
relapse >24 Months after complete
response

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ADVANTAGES OF RPLND
• Provides accurate pathological staging
• Complete excision of nodes, relapse rate is
very low
• Gives information regarding adjuvant
chemotherapy
• Remove chemoresistant teratoma
• Remove occult metastasis (15-30% in
stage I)

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SURGICAL TECHNIQUE
PREPARATION
• Explain the possibility of dry ejaculation
• Advice to have sperm for cryopreservation
• Start low fat diet for 2wks before surgery,to reduce chylous ascites
• Reservation of adequate blood
• No bowel preparation is required
• Conservative fluid management

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APPROACHES
Transabdominal approach
• Quicker & easier
• It facilitates bilateral dissection in the
contralateral suprahilar & iliac areas
Thoracoabdominal approach
• Gives better ipsilateral exposure & less
postoperative ileus
• Useful in muscular patients (or) for
bulky nodes

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TRANSABDOMINAL APPROACH
• ANESTHESIA - General anesthesia
• POSITION - Supine , arms in T position
• Bladder is catheterized
• Nasogastric tube is placed & connected to
intermittent suction
• INCISION -- midline incision is made from
the xiphisternum to couple of cm below the
umbilicus

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PROCEDURE
• Peritoneum is opened
• Falciform ligament is divided between
ligatures
• Inspect abdomen, retroperitoneum, to assess
resectability , presence of metastatic disease
• Greater omentum & transverse colon are
displaced superiorly onto the chest
• Small bowel is reflected to the right,
incision is made in the posterior peritoneum

26. Incision extends from the ligament
of Treitz along the left side of the
root of the small bowel mesentery
to the ileocecal region (1)
It may be extended superiorly
& medially to the
duodenojejunal flexure
Incision is extended around the
cecum up to the right
paracolic gutter
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27. Duodenum is kocherized &
reflected superiorly along
with the pancreas ,superior
mesenteric artery, allowing
exteriorization of small
bowel, cecum, right colon
onto the chest wall & expose
the retroperitoneal space
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LYMPHADENECTOMY
• Lat -- Ureters
• Sup -- Upper edge of the origin of renal arteries
• Inf -- Bifurcation of ipsilateral common iliac
arteries
• Post -- Psoas muscle fascia
• If possible, lumbar vessels are preserved to reduce
postoperative back pain

29. • “split and roll” technique - allows en bloc removal of nodal
tissue
• In this technique –Ant IVC split, Anterior aortic split
• Lymphatic tissue can be rolled off the IVC laterally & medially
• Lumbar veins are doubly ligated & divided
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30. Left Para- Aortic
Inter-aortocaval
Right Paracaval
Gonadal Vein
Common Iliac

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• After ,anterior aortic split, lymphatic tissue is
retracted medially & laterally, lumbar arteries are
doubly ligated & divided
• If necessary, IMV can be sacrificed
• Gonadal Vein should be ligated
• At the completion of a bilateral dissection, the aorta,
IVC, and renal vessels should be skeletonized

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Nerve-Sparing Techniques
• Highest rates of preserved ejaculation
• The sympathetic chains, the postganglionic sympathetic
fibers, and the hypogastric plexus are identified,
meticulously dissected, and preserved
• Technique can be utilised during the primary procedure
• Can be combined with standard or modifeid templates
• Can be utilised in post chemo setting
“Margins of dissection should never be compromised for
nerve preservation”

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Nerve-Sparing Techniques - requisites
1) In depth understanding of retroperitoneal
anatomy
2) Ability to recognise variations in anatomy
3) Excellent exposure of the
retroperitoneum
4) Meticulous application of “split and roll “
technique

34. 34
Prospective Nerve-Sparing Technique
• The emphasis is in identification and
preservation of relevant sympathetic nerves
– (1) The sympathetic chains bilaterally
– (2) The postganglionic sympathetic nerves arising
from the sympathetic chains
– (3) The hypogastric plexus (anastomosing network
of nerve fibers anterior to the lower aorta)

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36. 36
NERVE-SPARING TECHNIQUES
INDICATION
• Stage I NSGCT
• Stage IIA (low volume) NSGCT

37. • Sympathetic chains run parallel to
the great vessels on either side of
the spine.
• Rt side sympathetic chain lies
posterior to IVC and postganglionic
fibers emerge from medial edge of
IVC to join the hypogastric plexus
• Lt side,it lies lateral and posterior to
the lateral border of the aorta
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38. Sympathetic trunk and great vessels
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40. Relation to lumbar veins
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• Anterior “split” maneuver over the IVC does
not
damage these fibers
• But dissection along the aorta before isolating
and preserving these nerves results in
disruption of these fibres
• Proper nerve-sparing techniques result in greater
than 95% rates of antegrade ejaculation

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LAPAROSCOPIC AND ROBOTIC-ASSISTED
RPLND
INDICATIONS
• Stage I NSGCT
• Stage IIA NSGCT
• Unifocal small-volume residual mass after
chemotherapy

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ADVANTAGES
• Quicker convalescence
• More favorable cosmetic results
• Less postoperative pain & morbidity.
• Reduced blood loss & length of hospital stay
• It can be used for diagnostic/therapeutic purposes
• Patients with positive nodes should be treated
with adjuvant chemotherapy.
• Effective therapeutic impact of L-RPLND and Robotic-
assisted RPLND remains mostly with low stage
NSGCTs .

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COMPLICATIONS
• Rate of complication in primary RPLND is 10.6-24%.
• Rate of complication following PC-RPLND is 20-30%
COMPLICATIONS:
• Bleeding
• Injury to major vessels
• Injury to sympathetic nerves
• Injury to adjacent organs (duodenum, bowel, kidney, pancreas)
• Pulmonary
• Paralytic ileus
• Chylous ascites
• Peripheral Nerve injury

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RPLND AND FERTILITY
• Preserving fertility in men undergoing RPLND is more
complex than simply sparing their postganglionic
sympathetic nerves.
• When including all stages of disease, approximately 40%
to 60% of patients presenting with testicular GCT have
been reported to demonstrate abnormal parameters on
semen analysis.

47. • Before the development of unilateral
modified RPLND templates and nerve-sparing
techniques, most patients undergoing bilateral
RPLND were rendered an-ejaculatory .
• Techniques were altered in two ways: (1) changing
the boundaries of dissection and (2) prospectively
identifying postganglionic sympathetic fibers and
the superior hypogastric plexus .
• Recent studies, reported preservation of antegrade
ejaculation in 97% of men undergoing modified
unilateral template dissection
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48. 48
• Postoperative paternity can be expected in
approximately 75% of men undergoing
primary nerve-sparing RPLND.
• Fertility after PC-RPLND -not been established
[chemotherapy-induced disruption of
spermatogenesis can persist for several years
after completion of therapy].

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Pulmonary Complications
• Major pulmonary complications are extremely rare after primary
RPLND but have been reported to occur in approximately 3% to
5% of patients after PC-RPLND .
• Because most patients who undergo PC-RPLND have
received bleomycin containing induction chemotherapy,
acute respiratory distress syndrome and prolonged
postoperative ventilation account for most of these major
complications.
• The incidence of bleomycin-related perioperative pulmonary
complications can be minimized by avoiding aggressive
intraoperative and postoperative intravenous fluid
resuscitation and keeping FiO2 as low as is safely possible .

50. 50
Paralytic Ileus
• The reported rates of postoperative paralytic ileus
range widely in the primary RPLND (0% to 18%) and
PC-RPLND (2.2% to 21%) .
• In relatively low-volume PC-RPLND, an orogastric tube
is used and removed at the conclusion of the
procedure.
• In Retroperitoneal higher volume disease, the
probability of significant ileus is greater, and a
nasogastric tube should be used.

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Lymphocel
e
• The incidence of subclinical lymphocele after RPLND is unknown.
• Symptomatic retroperitoneal lymphoceles are extremely rare with
reported rates ranging from 0 % to 1.7 %.
• Symptoms can be related to ureteral compression, displacement of
abdominal viscera (if very large), or secondary infection.
• Meticulous attention to ligation of large-caliber lymphatics
during resection likely decreases the risk of developing a
symptomatic lymphocele.
• Treatment of symptomatic and/or infected lymphoceles includes
percutaneous drainage with systemic antibiotics reserved for
infected lymphoceles.

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Chylous Ascites
• Chylous ascites has been reported to occur in 0.2% to 2.1% of pts
undergoing primary RPLND and 2% to 7% of patients undergoing
PC-RPLND .
• Suprahilar resections are thought to carry a higher risk for chylous
ascites because of disruption of the cisterna chyli and its
contributing lymphatics.
• Patients with symptomatic chylous ascites should first be managed
with simple paracentesis with consideration of
low-fat/medium- chain triglyceride diet and intramuscular
octreotide.
• If Persistent high-volume chylous drainage (>100 mL/24 hr) despite
these modifications if occur, placement of a peritoneovenous
shunt, or surgical exploration with attempted ligation of the
lymphatic leak to be done.

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Venous Thromboembolism
• The rate of pulmonary embolism after primary RPLND has been
reported to be less than 1% ,After PC-RPLND, the rates range from
0.1% to 3.1%.
• All patients undergoing RPLND should have sequential
compression devices placed before induction, which should be
maintained throughout the hospital course along with early
ambulatory practice.
• Prophylactic subcutaneous low-dose unfractionated heparin or
low-molecular-weight heparin has demonstrated efficacy in
decreasing VTE rates in patients with a personal history of
VTE, obesity, known hypercoagulable condition, or older age.

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Neurologic Complication
• Peripheral nerve injury were secondary to patient
positioning and potentially retractor placement (femoral
neurapraxia).
• Careful attention to appropriate patient positioning by
the surgical and anesthesia teams is important in
minimizing peripheral nerve damage
• Patients with bulky mediastinal and retroperitoneal
disease are at an increased risk of developing paraplegia.
• The likelihood of neurologic complications increases
with the scale of para-aortic resection.

55. COMPLICATIONS OF RPLND
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SUMMARY
• RPLND is the choice for low stage NSGCT
• Modified template RPLND is choice for clinical stage I
• In Modified templates, surgical margins should never
be compromised in an effort to preserve ejaculation
• In stage IIA,B NSGCT bilateral INFRA HILAR RPLND
remains the standard

57. 57
• Major complications are rare after primary RPLND and PC-
RPLND.
• A significant proportion of major complications at PC-
RPLND are pulmonary and are related to prior bleomycin
and thoracic disease burden.

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