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RPLND

Common indications:

  • Residual > 1 cm mass post chemo NSGCT
  • Primary RPLND for stage 1 NSGCT
  • Marker negative stage 2 NSGCT
  • Growing mass with normalisation of markers – concern for teratoma
  • Late relapse – 2+ years after completion of chemo
  • “Desperation” RPLND – growing mass or rising markers despite salvage chemotherapy
  • Sex cord stromal tumours with nodes

Pre-operative assessment:

  • Up to date imaging mandatory – recent high quality CT
    • Vasculature – renal vessels, caval involvement
    • Adjacent organs / possibility of auxiliary procedures – appropriate teams aware
  • Up to date tumour markers
  • Risk factors for more difficult procedure
    • Post chemo (particularly seminoma)
    • Post radiation
    • Previous surgery
    • Larger mass
  • Fertility assessment and counselling, sperm banking if appropriate
  • Respiratory assessment if previous bleomycin
    • Low FiO2, potentially avoid preoxygenation, less fluids
  • Ensure normalisation of blood counts if post chemo
  • Pre-op fatty meal night before
  • Consider tranexamic acid, spinal morphine, NGT, experienced anaesthetist

 

Technique:

  • Transverse incision 2 finger breadths above umbilicus
  • Incise anterior sheath, divide rectus and control superior epigastrics, open posterior sheath and peritoneum. Divide falciform ligament.
  • Omnitract fixed table retraction
  • Cattell-Braasch manoeuvre (right medial visceral rotation) – mobilising right colon along Toldt, and posterior peritoneum from caecum tip up to Ligament of Treitz, no further than IMV – displacing small bowel and right colon on to chest – Kocherising duodenum during this
    • If left sided mass, can ligate IMA/IMV to further left sided exposure
  • Split and roll technique for LND
    • Starting at left renal vein crossing aorta
    • Aortic dissection – watching for accessory renal vessels
  • Medial aortic / aortocaval dissection
    • Division of 3 x lumbar arteries below level of renal vessels, which arise posteromedially on aorta – allowing lateral rotation of aorta and exposure of interaortocaval packet
  • Para-aortic dissection
    • Division of 3 x lumbar arteries arising from posterolateral side of aorta – allowing medial rotation of aorta and left sided para-aortic packet to be taken
    • Now have total aortic exposure between renal vessels and bifurcation
  • Para-caval dissection
    • Origin of right gonadal vein identified and divided
    • Lumbar veins exiting posteriorly – variable number
  • Harvesting of lymph node packets
    • Paracaval
      • Protect right ureter and kidney
      • Watch for right sympathetic trunk and genitofemoral nerve
    • Interaortocaval
      • Lateral retraction of both cava and aorta, harvesting packet off anterior longitudinal ligament
      • Watch for right renal artery origin cranially
      • Ligate lymphatics heading up to crura
    • Para-aortic
      • Ligation of IMA (alternate is medialising left colon)
      • Protect left ureter and kidney
      • Watch for left sympathetic trunk
      • Ligate lymphatics heading up to crura
    • Gonadal vein
      • Excise and sent entire gonadal vein of ipsilateral tumour side from origin (cava or left renal vein) to deep ring
    • Sympathetic nerves
      • Originate from T10 – L2, exiting sympathetic chain at L1 – L4 and coalescing as superior hypogastric plexus anterior to aorta just distal to IMA, near aortic bifurcation
      • Right and left sympathetic trunks then course on either side of vertebral column
      • Right side is posterior to cava
      • Left side is posterolateral to aorta / lateral margin of aorta
      • Lumbar vessels are posterior to sympathetic trunk
    • Close over drain after confirmation of haemostasis, ligation of large lymphatic leaking channels, and exclusion of bowel injury

Templates

  • Bilateral template
    • Borders are renal vessels, ureters, common iliacs, ALL of spine (inter-iliac region is rarely involved)
  • Left template
    • Para-aortic nodes including preaortic tissue – only left lumbar arteries divided, lumbar veins may not be divided, can be approached with left rotation preserving IMA and tissue below
  • Right template
    • Interaortocaval and paracaval nodes, including all precaval and retrocaval tissue, IMA may be preserved and only nodes above taken

Exam answer = bilateral template never wrong.

Heidenreich criteria for post chemo RPLND – well defined lesion < 5 cm in primary landing zone can be considered for unilateral template.

 

AUA guidelines

  • Full bilateral template in patients with clinically involved nodes (CT or palpable during procedure)
  • Full bilateral template in somatic type malignant or transformed teratoma in testis
  • Modified template or full template in clinically negative nodes
  • Right side modified template spares para-aortic nodes below IMA, sparing para-aortic above IMA is controversial
  • Left side modified template spares paracaval and retrocaval nodes, sparing interaortocaval is controversial
  • Nerve sparing should be offered to select patients desiring preservation of ejaculatory function – but should not compromise the dissection
  • Complete template should involve complete retroaortic and retrocaval dissection

Auxiliary procedures

Rarely required in primary RPLND – may be needed in post chemo RPLND.

Most commonly nephrectomy, followed by vascular resection, grafting or replacement.

Risk factors for needing nephrectomy:

  • Post chemo
  • > 10 cm post chemo mass
  • Left side
  • Desperation and repeat RPLND
  • Concern is may need further platinum chemo which requires good kidney function

Vascular interventions:

  • Caval resection
    • Primary repair if lumen not narrowed by > 50 %
    • Patch repair with graft i.e., bovine pericardium
    • Reconstruction with PTFE or dacron grafts
    • Ligation (especially if chronically obstructed with collateralisation)
  • Aortic
    • Dissection into subintimal plane due to fibrosis -> aortic dissection which requires replacement with PTFE or dacron graft
    • Aortoduodenal fistula possible if either organ injured
  • Hepatic metastasis resection
  • Retrocrural disease – may need thoracoabdominal incision and hepatic mobilisation

 

Minimally invasive RPLND

Benefits for length of stay, with low blood loss.

No long term oncological data available but initial results seem comparable.

 

Post-operative

DVT prophylaxis, extended for 4 weeks total

Dietitian involvement to reduce risk of chylous ascites

 

Complications

Intra-operative:

  • Anaesthetic – pulmonary complications due to bleomycin, positioning, anaphylaxis
  • Vascular injury – aorta, cava, iliacs, renal vessels, lumbars
  • Duodenal injury

Early:

  • Chylous ascites
  • Lymphocele
  • Ileus / SBO
  • DVT/PE
  • Delayed bleed, aortoduodenal fistula
  • Pneumonia
  • Mild pancreatitis

Late:

  • Ejaculatory dysfunction (failure of emission and retrograde ejaculation)
  • SBO

 

Management of chylous ascites:

  • Declares itself after commencement of eating
  • Check drain fluid triglycerides
  • Dietary measures first line – low salt, medium chain triglycerides, high protein
  • Second line – somatostatin / octreotide, +/- TPN
  • Locate site of leak with lymphoscintigraphy
  • Percutaneous embolisation described – not often done – usually requires surgery with fatty meal prior and oversewing or ligation of leaking lymphatics

Ejaculatory dysfunction:

  • Well over 90 % preservation in high volume centres for unilateral or bilateral template and nerve spare – although some delay due to neuropraxia
  • Post chemo > 80 % preservation