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
6.
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.
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
17.
18.
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
25.
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
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
