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LYMPH NODE
DISSECTION
Dr.S.Veda padma priya
Post graduate in general surgery
Department of surgical oncology
Clinical summary
30 year old bachelor underwent high
orchidectomy for suspected testicular cancer
CT abdomen : no evidence of
retroperitoneal lymph nodes
STAGE I NSGCT
Semen Analysis
quantity : 2.5 ml
count : 48 million/mm3
pus cells : +++
motility : 35 %
viscosity : moderate
Operative procedure
ETGA
supine position
midline incision
transabdominal approach
right sided modified template
primary retroperitoneal
dissection
split & roll technique
gonadal vein excision in toto
Split & roll technique
Rt-sided modified
template primary RPLND
IVC
Aorta
IMA
Rt gonadal vein
excised
Management of NSGCT
Post diagnostic
work -up
Sperm
Management of Stage I NSGCT
Bland-Sutton - first
RPLND
removal of all
fibrofatty/celluloadip
ose tissue in the
aortocaval area of
retroperitoneum
primary / secondary
standard / modified
Rationale for RPLND
Testicular tumors
generally spread via the
lymphatics.
Testicular descent from
retroperitoneum
First echelon-paraaortic
nodes
From retroperitoneal
nodes to the cisterna
chyli, thoracic duct,
supradiaphragmatic
nodes, and finally, to
extranodal/distant
metastasis.
Crossover of right sided
lymphatics
Indications for RPLND
• Open/laparoscopic
• Thoracoabdominal/transabdominal
• Extraperitoneal/transperitoneal
Thoracoabdominal approach
• Good exposure to the upper
retroperitoneum & renal hilum
• useful in patients with advanced
disease, with a large retroperitoneal
mass.
• a complete suprahilar dissection,
• easy access to retrocrural lymph nodes.
• extraperitoneal in patients with lower-
stage disease.
• decreases the risks of small bowel
obstruction and ileus.
Trans abdominal
approach…..
• Faster opening and
closing time.
• Exposure to the
suprahilar region at the
expense of mobilization
of the pancreas and
spleen.
Removal of
• Precaval
• Paracaval
• Interaortocaval
• Preaortic
• Paraaortic
• Common iliac nodes
bilaterally
Preservation of ejaculation
• sympathetic nerves course along
the anterolateral aspect of the
vertebral bodies of the lumbar
spine.
• ramify about the inferior
mesenteric artery & ganglion
(inferior mesenteric plexus).
• Once ramified, these fibers are
referred to as the superior
hypogastric plexus.
• control normal transport of
sperm and prevent retrograde
ejaculation by closing the bladder
neck during ejaculation.
• Nerve sparing RPLND
• Nerve dissecting RPLND
• Nerve avoiding RPLND
Nerve dissecting RPLND
• Preservation of ejaculation in 50 to
80%
• Right ureter,
• Renal veins,
• The lateral edge of the
aorta,
• IMA,
• Ipsilateral iliac artery,
where the ureter
crosses.
Interaortocaval and
retrocaval tissue is
completely removed.
Aort
a
IVC
RPLND – IMA
Limits of
Dissectio
Rt
n ureter
Left-sided modified template
primary RPLND
• Left ureter,
• Left renal vein,
• Left edge of vena cava,
• IMA,
• Ipsilateral iliac artery,
where the ureter
crosses.
• Interaortocaval tissue is
included with the
retroaortic lymphatics.
Postchemotherapy RPLND
• Ejaculatory dysfunction
• Chylous ascites - 1-3%
• Renovascular injury - 1-3%
• Small bowel obstruction - 1-3%
• Spinal cord ischemia - Less than 1%
• Wound infection – 15 %
• Urinary tract infection – 12 – 15 %
• Ileus – 15 – 16 %
Ejaculatory dysfunction-Management
• history taking,
• physical examination (including examination
of the contralateral testis),
• assessment of serum tumor markers,
• chest radiography,
• abdominal imaging.
• every 2-3 months for the first 2 years,
• every 4 months for the subsequent 2 years,
• every 6 months for the fifth year,
• and yearly thereafter.
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