Retroperitoneal lymph node dissection (RPLND) is a surgical procedure used to treat testicular cancer. It involves removing lymph nodes in the retroperitoneum which are the first draining sites of metastasis from testicular cancer. Over time, the procedure has evolved from open approaches to minimally invasive techniques. Key developments included mapping of lymphatic drainage patterns, adoption of nerve-sparing approaches to preserve ejaculation, and use of modified or extended templates based on tumor staging. While RPLND remains an important treatment option, ongoing debates include its role compared to surveillance for very small residual masses after chemotherapy and optimal surgical extent. Complication rates also vary based on whether performed for primary staging or post-

1. RETROPERITONEAL
LYMPH NODE
DISSECTION
Dr Kaushal Yadav

2. ANATOMY
Breakthrough in science of surgery
What we know today

4. Primary lymphatic drainage of testis – area of embryologic
origin – retroperitoneum adjacent to great vessels
First echelon draining lymph nodes –
Right testis : interaortocaval area, followed by
precaval and preaortic nodes
Left testis : para-aortic and preaortic lymph nodes,
followed by the interaortocaval nodes

5. Contralateral spread-
Right-sided tumors more commom
Left-sided rare
Paracaval Midline of IVC to
right ureter
Interaortocaval Midline of IVC to
midline of Aorta
Paraaortic Midline of Aorta to
left ureter

7. Breakthroughs
• John Hunter first described Testicular descend
• Jamiesen, Most, and Cuneo (early 1900s)- independently
described lymphatic drainage
• Bland-Sutton(early 1900) -first RPLND
• Cuneo and Chevassu, suggested performing resection of
retroperitoneal masses in conjunction with orchiectomy in
the treatment of testis cancer

8. • Hinman (1914)- published first case series of
retroperitoneal lymph node dissection (RPLND)
• Cooper (1950s)- thoracoabdominal approach
• Donohue(1977)- first described extended bilateral
suprarenal RPLND

9. • Sayegh (1960), Weissbach(1987), and Donohue(1982) -
lymphangiographic surgical mapping studies
• predilection for unilateral involvement by metastases
• suprahilar spread rare
Sum of templates in Donohue and Weissbach and Boedefeld Stage IIA

10. Donohue et al(1982, 1993)- bilateral standard infrahilar
RPLND
Popularized split and roll technique
• Narayan and colleagues (1982)- first reported Modified
Template
• Jewett et al, 1988; Donohueet al, 1990- reported on
nerve sparing techniques.

11. CLASSIFICATION
 EXTENDED (SUPRAHILAR) RPLND-
reserved for residual hilar or suprahilar mass
following CT
most common site retrocrural
more pancreatic, lymphatic, and renovascular
complications.

13.  BILATERAL STANDARD INFRAHILAR RPLND

14.  MODIFIED TEMPLATE RPLND:
RIGHT LEFT

16. NERVE SPARING
RPLND:
can be incorporated with
any template
identification and preservation
of- 1) sympaetic chain B/L
2)postganglionic
sympathetic nerves
3)hypogastric plexus

19.  POSTCHEMOTHERAPY RPLND
 DESPERATION RPLND:
Patients with rising serum tumor markers+
resectable disease esp single site

20. INDICATIONS
 RATIONALE FOR STAGE I NSGCT:
• In high risk patients - +ve LVI/ EC predominance
• JCO 2005-
The 22% incidence of retroperitoneal teratoma and the low
rate of systemic progression support RPLND as the
preferred primary intervention for patients with CS I to IIA
disease and normal postorchiectomy AFP and HCG

21. Br J Urol. 1993 Nerve-sparing retroperitoneal
lymphadenectomy for low stage testicular cancer.
de Bruin MJ, Oosterhof GO, Debruyne FM
Nerve sparing RPLND preffered
A full, bilateral template dissection
lowest risk of abdominopelvic recurrence (<2%) and
the highest rate of antegrade ejaculation (>90%)
with nerve-sparing techniques

22.  RATIONALE FOR CS IIA &IIB NSGCT:
Candidates best suited for RPLND include
• patients with single focus of retroperitoneal disease
measuring less than or equal to 3 cm at the primary
landing zone
• normal postorchiectomy markers
• without signs of tumor-related back pain.

23. JCO 2007
• Chemotherapy is preferred for
• elevated postorchiectomy serum tumor markers
• retroperitoneal adenopathy greater than 2 cm
• outside primary landing zone
• involving multiple nodes given the high risk
• RPLND is preferred modality for-
• normal postorchiectomy serum tumor markers
• with a solitary retroperitoneal mass less than 2cmin
size limited to the primary landing zone.

24.  RATIONALE FOR CS IIc & III:
residual radiographic mass + normalized tumor
markers
• Resection of residual tumors after first-line
chemotherapy remains essential in the treatment of
metastatic testicular cancer. Undifferentiated tumor may
still be found in 20% Necrosis is found in only 50% of
marker normalized patients after first-line and
approximately 30% after second-line chemotherapy

26.  HIGH RISK RPLND FOR NSGCT
Donohue and associates identified surgical
scenarios wherepatients are at higher risk of relapse and
experience lower survival rates:
(1) PC-RPLND after salvage or second-line chemotherapy
(2) redo RPLND
(3) desperation RPLND
(4) RPLND with viable cancer in resected specimen

27. • Reoperative retroperitoneal surgery for nonseminomatous
germcelltumor: clinical presentation, patterns of
recurrence, and outcome: McKiernan JM, Urology 2003
• lower rates of complete resection
• higher histologic proportions of viable cancer
• overall 5-year survival rate for patients who underwent redo
PC RPLND was 56%, thus underscoring importance of initial
complete resection
• patients who undergo incomplete initial resection and require
redo RPLND are at a severe disadvantage

28. BJUI 2007
Pathologic findings and therapeutic outcome of
desperation post-chemotherapy retroperitoneal lymph
node dissection in advanced germ cell cancer: Stephen
Urol Onco 2007

29. 200
• JCO 2003 identified 3 independent prognostic variables
for survival:
(1) complete resection
(2) good risk IGCCCGT classification
(3) less than 10% viable malignant cells

30. RATIONALE FOR SEMINOMA:
• For advanced stage residual masses greater than 3 cm
should be evaluated further with FDG-PET
• PET positive should undergo PCS.
• Observation is justified in patients with a negative
FDGPET scan after primary chemotherapy, particularly
for those with residual masses less than 3 cm.

31. • Surgery can be omitted safely if PET is negative for
Seminoma > 3cm

32. • PET CT is better than PET and CECT for followup and
evaluation

33. CONTROVERSIES

34. SUBCENTIMETER RESIDUAL
MASS AFTER PC RPLND
• Recommend surgery for ≤
2cm

35. JCO 2010
Recommend surveillance for favourable responders with
CR ( ≤ 1cm )

36. Unilateral Modified
Template RPLND
• Both from MSKCC (n> 400)
• high incidence of extra template
• more extensive, nerve-sparing bilateral RPLND templates
optimize oncologic outcomes while preserving antegrade
ejaculation

37. • Prospective trial of modified (168 men) vs bilateral (67 men)
RPLND
• RP relapse rates (2.4% vs 1.5%), overall relapse rates (17% vs
15%) and complications (12% vs 10%) were similar at a
median follow-up of 30 months.
• Antegrade ejaculation was improved with the modified
RPLND (74% vs 34%).
• Only assessed pathological stage I patients
• Did not incorporate nerve-sparing
• 40 different centres, had recurrence rates higher than expected
in both arms

38. Laparoscopic RPLND
• Steiner and colleagues reported a small series of 42
patients with NSGCT, 23 primary L-RPLND, and 19 PC-
L-RPLND, treated with bilateral nerve-sparing RPLND
with therapeutic intent
• preservation of antegrade ejaculation in 85.7%
• relapse rate of 2.3%
• no retroperitoneal recurrences.
• Follow-up was limited 17.2 months
• RPLND is technically feasible in patients with CS I and,
more recently, CS II patients;
• it is technically difficult
• Associated with a steep learning curve

39. NUMBER
• N=255
• underwent primary RPLND at MSKCC
• a median node count of 48 lymph nodes

40. Advocate: An adequate PRPLND should yield 40 to
50 lymph nodes

41. COMPLICATIONS:
• overall complication rates for primary RPLND - 10.6%
• PC-RPLND -20% to 35%
• Chylous ascites - 2% to 7%
• pulmonary complications
• renovascular injury
• superficial wound infection
• retrograde ejaculation
• Prolonged ileus

42. CHALLENGES IN RPLND