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Retroperitoneal node dissection for metastasizing testicular cancer


Medical editor Bjørn Brennhovd MD
Urologist
Oslo University Hospital

General

Testicular cancer metastasizes lymphatically. Metastases are localized in the drainage area from the inner inguinal opening along the common iliac vein to lateral to the caval vein for right-sided cancer and along the aorta for left-sided cancer. Spreading stays for a long time distally to the renal vein on both sides before it metastasizes further up under the diaphragmatic curae and further to the mediastinum. The metastasis area on the right side extends along and around the caval vein and aorto-cavale area and can "jump" over to the left side in the area distal to the renal vein. On the left side, the metastasis area is located along and around the aorta and can "jump" over to the right side, also msot often distal to the renal vein.

Indication

  • Testicular cancer with spreading to the retroperitoneal space

Goal

  • The main goal is to cure the disease. However, the surgery is also of diagnostic importance for identifying tumors in the lymph nodes and deciding whether this is benign or malignant. This will be of importance for possible supplementary treatment and also for the follow-up procedure.  

Equipment

  • Abdominal tray
  • Bookwalters retractor
  • Intestinal bag
  • Stapling instrument

Instruments for vascular surgery must be available.


Preparation

The case should be discussed by a team consisting of a urologist, oncologist, and radiologist. Localization of metastases should be documented by a radiologist. The oncologist should provide the disease history, extent of the primary diagnosis and preoperative treatment. The team should agree on the indication for the operation and how comprehensive the surgery should be. This is determined by the extent of the spreading and is assessed by CT images before and after chemotherapy. The operation may be assessed for total bilateral removal of all fat tissue with lymph nodes along and behind the caval vein and aorta, as well as the aorta/caval space, possibly up and behind the diaphragmatic crurae. If the spreading is so extensive that vascular and/or thoracic surgery may be necessary, then the images must be discussed with a vascular/thoracic surgeon.

  • Inform the patient
  • Thrombosis prophylaxis 
  • Bowel emptying
  • Premedication

Implementation

The patient lies in a supine position. The incision is made from the sternum and past the navel. A Bookwalters retractor is mounted. The small intestine with the mesentery is dissected free from the ligament of Treitz to the coecum. The small intestine is packed in an intestinal bag and held out of the abdominal cavity.

Left-sided dissection

  • All fatty tissue with lymph nodes is dissected from the common iliac vein to around the crossing of the ureter. Along with the rest of the testicular vessels, the fatty tissue is freed from the posterior abdominal wall and common iliac artery up to the bifurcation by retrograde dissection.  
  • Spare the inferior mesenterial artery. If there are metastases in this area, this may be removed.
  • Dissect the ureter and secure it. 
  • All fatty tissue and nodes in front of the aorta are dissected from the aorta. It is important to secure the lumbar vessels while releasing up toward the renal vein.
  • Remove all fatty tissue along the renal vein. 
  • Ligate the testicular vessels. During the dissection, ganglion and nerves are identified. These should be spared to avoid retrograde ejaculation. 

Right-sided dissection

In principle, the procedure is the same, however, the surgeon works more toward the caval vein and in the aorto/caval space.

Total retroperitoneal node dissection

This includes both sides. The surgeon must often dissect both the caval and aorta from the posterior abdominal wall to include all of the nodes.  

The operation is concluded by securing full hemostasis and lymphostasis. A drain is installed when the surgeon decides. The small intestine is reinserted in the abdominal cavity and the peritoneum is adapted.


Follow-up

Observations

  • Postoperative intestinal paresis
  • Chyle leakage from the lymphatic duct
  • Retrograde ejaculation  

Upon discharge, the patient should confer with the oncologist for further follow-up.

The patient should have follow-up with their primary doctor.


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