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Retroperitoneal Lymphadenectomy (RLA) for Germ Cell Tumors
Indication for retroperitoneal lymphadenectomy
RLA is a treatment option in different stages of germ cell tumors.
Nonseminoma Stage I:
Nerve-sparing modified RLA is an option in nonseminoma stage I and an alternative to prophylactic chemotherapy or active surveillance.
Tumor Marker Negative Nonseminoma Stage IIA:
Nerve-sparing RLA at is recommended for tumor marker negative nonseminoma stage IIA. Before surgery, imaging and tumor marker should be repeated after six weeks. RLA is indicated for persistence or progression of the lymph nodes without tumor marker elevation.
Residual Mass after Chemotherapy with Normalized Tumor Markers:
Retroperitoneal lymphadenectomy should be performed for residual masses of over 1–2 cm in size (nonseminoma) and over 3 cm in size (seminoma). The dissection field depends on the extent of the metastases before chemotherapy.
Contraindications for Retroperitoneal Lymphadenectomy
Uncorrected bleeding disorders. Preoperatively, complete resection of the tumor manifestation should appear possible. No metastases in other localization.
Surgical Technique of Retroperitoneal Lymphadenectomy
Preoperative Patient Preparation:
Start with a clear liquid diet 24 hours before the planned operation, this leads to an emptying of the small bowel system from solid debris. Permitted are clear soups, plenty of sweet drinks and high-energy tube feedings without fibers. The evening before surgery, an enema is used to clean the rectum.
On the day of surgery: supine positioning with slight extension of the lumbar spine, perioperative antibiotic prophylaxis, general anesthesia with additional PDA, perioperative bladder catheter and nasogastric tube.
Transperitoneal Surgical Approach:
Midline laparotomy from the xiphoid process to the lower abdomen (between the navel and symphysis) depending on the body mass index. Dissect the ligament teres hepatis and free the liver from the diaphragm by incision of the falciforme ligament. The ascending colon and caecum are mobilized by incision of the peritoneum starting laterocolic and along the small intestinal meso to Treitz's ligament. The ascending colon and the complete mesentericum of the small intestine are detached from the retroperitoneum and displaced cranially. With the help of the Kocher maneuver, the duodenum and part of the pancreas are reflected to the left until the renal veins become visible as cranial borders of the dissection area. Careful padding of the intestinal pack, which is stored on the thorax and is regularly inspected for sufficient blood flow (ischemia due to compression/tension of the superior mesenteric vessels).
Thoracoabdominal Surgical Approach:
Seldom necessary for the removal of enlarged retrocrural lymph nodes.
Template for Nerve-Sparing Retroperitoneal Lymphadenectomy:
A nerve-sparing dissection field for right or left testicular tumor respects the probability of lymph node metastases and reduces the frequency of retrograde ejaculation. It is necessary to identify the sympathetic ganglia and to protect the exiting sympathetic nerve fibers crossing the dissection field.
Frozen section diagnosis of the removed lymph nodes differs between centers. Most open surgical centers and in a few laparoscopic centers, the lymph nodes are sent to frozen section. If lymph node metastasis are seen, the contralateral lymph nodes are removed in the contralateral dissection field (bilateral nerve-sparing lymphadenectomy). In the remaining centers intraoperative frozen section is not performed; in the case of positive lymph nodes, adjuvant chemotherapy is recommended.
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Template for Right-Sided Testicular Tumors:
- Right: lateral border of the testicular vein and ureter.
- Cranial: renal vein
- Left: left lateral border of the aorta, above the inferior mesenteric artery the interaortocaval lymph nodes are removed in addition.
- Caudal: cranial border of the iliac artery, dissection ends at the crossing of the ureter with the iliac vessels.
Template for Left-Sided Testicular Tumors:
- Left: lateral border of the testicular vein and ureter
- Cranial: renal vein
- Right: medial border of the aorta (without interaortocaval lymphe nodes).
- Caudal: cranial border of the iliac artery, dissection ends at the crossing of the ureter with the iliac vessels.
Retroperitoneal Dissection Field of Radical Lymphadenectomy:
Bilateral radical retroperitoneal lymphadenectomy is indicated in advanced germ cell cancer with initial bilateral metastases and residual tumor masses after chemotherapy. To remove all lymph nodes along the large vessels, the split-and-roll technique is used. Firstly, the lymphatic tissue is split on the aorta and on the inferior vena cava (split). Then the large vessels are rolled to the side and the lumbar arteries and lumbar veins are ligated or clipped (roll). The aorta and the inferior vena cava are now completely dissected and can be lifted with vessel loops from the retroperitoneal lymphatic tissue. The lymphatic tissue is removed, once again it is necessary to ligate or to clip the lumbar arteries and lumbar veins. If possible, the sympathetic ganglia and emerging nerve fibers are identified and spared.
Postoperative Care after Retroperitoneal Lymphadenectomy
General Measures:
- Removal of the gastric tube after surgery, clear liquid diet immediately (sips at first), advanced to regular diet as tolerated
- Heparin injections into the upper arm
- Early mobilization
- Intensive respiratory therapy
- Thrombosis prophylaxis
- Laboratory tests (hemoglobin, creatinine)
- Wound checks. Remove wound drainage after feeding with a fat-containing diet is tolerated and no fat-containing drainage (chylous leakage) is seen.
Analgesia:
Analgesics with a combination of NSAIDs and opioids. An epidural anesthesia facilitates postoperative pain management.
Complications of Retroperitoneal Lymphadenectomy
Post-chemotherapy RLA harbors significantly more complications than primary RLA in stage I–II germ cell tumor for lymph node staging (Baniel et al., 1995) (Baniel et al., 1994).
Retrograde Ejaculation After Retroperitoneal Lymphadenectomy:
In order to avoid retrograde ejaculation, it is important to respect the modified dissection field (see above) and to identify and preserve the sympathetic ganglia and emerging nerve fibers. This is often not possible in surgery after chemotherapy and a high rate of retrograde ejaculation can be expected. The results are more favorable for the primary nerve-sparing RLA with less than 5% retrograde ejaculation.
Injury to Neighboring Organs
Paralytic ileus, bowel injury, peritonitis, pancreatic tail injury with formation of a pancreatic fistula. Chylous fistula due to injury of intestinal lymphatic vessels. Injury to liver or spleen, depending on the side of surgery.
General Complications:
Bleeding, wound infection, thrombosis, pulmonary embolism, atelectasis, pneumonia, acute renal failure.
Mortality:
0.8% for RLA after chemotherapy.
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References
Deutsche Version: Retroperitoneale Lymphadenektomie