RETRO PERITONEAL LYMPHNODE DISSECTION CA

Retroperitoneal lymph node dissection (RPLND) is a surgical procedure to remove lymph nodes from the back of the abdomen. It's used to treat testicular cancer and to help determine the stage and type of the cancer

1. R etroperitoneal Lymph Node Dissection Dr Venkateshen P 1

2. ANATOMIC REGIONS OF THE RETROPERITONEUM 2

3. 3 PRIMARY “LANDING ZONE” Donohue - divided the retroperitoneal nodes into specific anatomic regions Right & left suprahilar Right paracaval, precaval, interaortocaval Preaortic, left para-aortic, right & left iliac, interiliac Gonadal vessels (right or left) PRIMARY “LANDING ZONE”- Right- interaortocaval lymph nodes, precaval , paracaval nodes Left- left para-aortic , preaortic lymph nodes

4. 4 RATIONALE FOR TREATMENT OF RETROPERITONEAL LYMPH NODES It is based on several factors Nodal spread is usually the first & often the only site of metastatic disease ,nodes treated by RPLND increases survival rates 15% - 40% of patients are clinically understaged - 20% - 30% incidence of pathologic stage II disease in clinical stage I - cause of 25% relapse during surveillance protocols in clinical stage I 20% incidence of teratoma /or viable carcinoma in patients with radiographically normal CT Untreated nodal metastases are usually fatal Most common site of late recurrence of both teratoma & viable GCT is the retroperitoneum, Late recurrences are usually chemorefractory, decreases the survival rates

5. 5 EVOLUTION OF SURGICAL TEMPLATES AND TECHNIQUES BILATERAL SUPRAHILAR DISSECTIONS Removal of all the nodal tissue between both ureters down to the bifurcation of the common iliac arteries,superiorly upto crus of diaphragm It was associated with increased Pancreatic injury, Duodenal injury, Chylous ascites Renovascular complications Not routinly done Now, suprahilar dissections are indicated for residual hilar or suprahilar masses after cytoreductive chemotherapy for advanced stage NSGCT

6. 6 MODIFICATION RATIONALE - Suprahilar metastases are rare in low-stage NSGCT, suprahilar dissection not necessary & high morbidity To reduce surgical morbidity, suprahilar dissection is modified to BILATERAL INFRAHILAR RPLND BOUNDARIES Sup – Renal hilum Lat – Ureter Inf – Bifurcation of common iliac vessels This bilateral infrahilar RPLND also have long-term morbidity of loss of antegrade ejaculation due to damage of sympathetic nerve fibers

7. S UR G IC AL T E M PL A T E - B I L A T E R A L IN FR A NI L AR R PL N D 7

8. 8 ANTEGRADE EJACULATION It requires the coordination of three events Closure of the bladder neck Seminal emission Ejaculation The sympathetic fibers from L1 – L 4 form the h y p o g a s t r i c p l e x u s n e ar t h e o r i g i n of i n f e r i or mesenteric artery just above the aortic bifurcation From the hypogastric plexus, the sympathetic fibers travel via the pelvic plexus to innervate the seminal vesicles, vas deferens, prostate, bladder neck

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10. 10 FURTHER MODIFICATIONS OF SURGICAL TEMPLATES Further modifications were developed to reduce the incidence of ejaculatory dysfunction by preserve the sympathetic nerves

11. 11 GOAL OF MODIFIED TEMPLATES Resect all interaortocaval & ipsilateral lymph nodes between the level of the renal vessels & bifurcation of the common iliac artery To minimize contralateral dissection, particularly below the level of IMA “Nerve-sparing” techniques can be utilized either in the primary or post-chemotherapy RPLND Margins of resection should never be compromised in an attempt to maintain ejaculatory function

12. 12 RT- MODIFIED RPLND BOUNDARIES Sup – Rt renal vein Lat – Rt ureter Inf – Bifurcation of com.iliac art (Rt) Med – extends from junction of gonadal vein to renal vein (Lt),below upto inf.mesen.art

13. TEMPLATE FOR MODIFIED RIGHT -RPLND 13

14. 14 LT- MODIFIED RPLND BOUNDARIES Sup – Lt renal vein Lat – Lt ureter Inf – Bifurcation of com.iliac art(Lt) Med – IVC,below upto inf.mesen.art

15. TEMPLATE FOR MODIFIED LEFT- RPLND 15

16. 16 INDIC A TIO N Clinical stage I - PT2- T4 , LV invasion CS IIA NSGCT (single lymph node < 2 cm) CS IIB NSGCT (single or multiple lymph nodes 2 to 5 cm). Postchemotherapy residual mass with normal tumor markers

17. 17 INDIC A TIO N MODIFIED TEMPLATE RPLND Clinical stage-I B I L A TE RA L R P L ND Clinical stage- IIA,IIB Postchemotherapy residual mass with normal tumor markers

18. 19 TYPES OF RPLND S T A N D A R D R P L N D – P r i m ary R P L N D . e i th e r un i l a t modified template/ Bilat RPLND in stage I,IIA,IIB POSTCHEMOTHERAPY RPLND – postchemo residual mass with normal tumor markers after induction chemotherapy SALVAGE RPLND – RPLND for residual mass after second line salvage chemotherapy with normal tumor markers

19. 20 TYPES OF RPLND DESPERATION RPLND – RPLND for residual mass after second line salvage chemotherapy with elevated tumor markers REDO RPLND – RPLND for pts who had previous RPLND with infield recurrence LATE RELAPSE – RPLND Performed after relapse >24 Months after complete response

20. 21 ADVANTAGES OF RPLND Provides accurate pathological staging Complete excision of nodes, relapse rate is very low Gives information regarding adjuvant chemotherapy Remove chemoresistant teratoma Remove occult metastasis (15-30% in stage I)

21. 22 SURGICAL TECHNIQUE PREPARATION E x p l a i n th e po ss i b ili t y o f d r y e ja cu l a t i o n Advice to have sperm for cryopreservation Start low fat diet for 2wks before surgery,to reduce chylous ascites R e s e r v a t i o n o f a d e qu a t e b l oo d No bowel preparation is required Conservative fluid management

22. 23 A P P R O A C H E S T r ansab d om i n al ap p r oa c h Quicker & easier It facilitates bilateral dissection in the contralateral suprahilar & iliac areas Tho r a c oa b d o m i n al ap p r oa c h Gives better ipsilateral exposure & less postoperative ileus Useful in muscular patients (or) for bulky nodes

23. 24 TRANSABDOMINAL APPROACH ANESTHESIA - General anesthesia POSITION - Supine , arms in T position Bladder is catheterized Nasogastric tube is placed & connected to intermittent suction INCISION -- midline incision is made from the xiphisternum to couple of cm below the umbilicus

24. 25 PROCEDURE Peritoneum is opened Falciform ligament is divided between ligatures Inspect abdomen, retroperitoneum, to assess resectability , presence of metastatic disease Greater omentum & transverse colon are displaced superiorly onto the chest S m a l l b o w e l i s r e fl e c t e d t o t h e ri g h t , i n ci s i o n is made in the posterior peritoneum

25. Incision extends from the ligament of Treitz along the left side of the root of the small bowel mesentery to the ileocecal region (1) I t m a y b e e x t e nd e d s up e r i o r l y & me d i a ll y t o th e duod e no j e j u n a l flexure Incision is extended around the cecum up to the right paracolic gutter 26

26. D uod e nu m i s k och e r i z e d & re fl e c t e d s up e r i o r l y a l on g wi t h th e p a nc re a s ,s up e r i o r mesenteric artery, allowing e x t e r i o r i z a t i o n o f s m a l l b o we l , c e c u m, r i g h t co l o n o n t o t h e chest wall & expose the re t r op e r i t on e a l s p a c e 27

27. 28 LYMPHADENECTOMY Lat -- Ureters Sup -- Upper edge of the origin of renal arteries Inf -- Bifurcation of ipsilateral common iliac arteries Post -- Psoas muscle fascia If possible, lumbar vessels are preserved to reduce postoperative back pain

28. “split and roll” technique - allows en bloc removal of nodal tissue In this technique –Ant IVC split, Anterior aortic split Lymphatic tissue can be rolled off the IVC laterally & medially Lumbar veins are doubly ligated & divided 29

29. 31 After ,anterior aortic split, lymphatic tissue is retracted medially & laterally, lumbar arteries are doubly ligated & divided If necessary, IM V can be sacrificed Gonadal Vein should be ligated At the completion of a bilateral dissection, the aorta, IVC, and renal vessels should be skeletonized

30. 32 Nerve-Sparing Techniques Highest rates of preserved ejaculation The sympathetic chains, the postganglionic sympathetic fibers, and the hypogastric plexus are identified, meticulously dissected, and preserved Technique can be utilised during the primary procedure Can be combined with standard or modifeid templates Can be utilised in post chemo setting “Margins of dissection should never be compromised for nerve preservation”

31. 33 Nerve-Sparing Techniques - requisites In depth understanding of retroperitoneal anatomy Ability to recognise variations in anatomy Excellent exposure of the retroperitoneum Meticulous application of “split and roll “ technique

32. 34 Prospective Nerve-Sparing Technique The emphasis is in identification and preservation of relevant sympathetic nerves (1) The sympathetic chains bilaterally (2) The postganglionic sympathetic nerves arising from the sympathetic chains (3) The hypogastric plexus (anastomosing network of nerve fibers anterior to the lower aorta)

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34. 36 NERVE-SPARING TECHNIQUES INDICATION Stage I NSGCT Stage IIA (low volume) NSGCT

35. Sympathetic chains run parallel to the great vessels on either side of the spine. Rt side sympathetic chain lies posterior to IVC and postganglionic f i be r s e m e r g e f r o m m ed i al ed g e o f I V C to join the hypogastric plexus Lt side,it lies lateral and posterior to the lateral border of the aorta 37

36. Sympathetic trunk and great vessels 38

37. Relation to lumbar veins 40

38. 42 Anterior “split” maneuver over the IVC does not damage these fibers But dissection along the aorta before isolating and preserving these nerves results in disruption of these fibres Proper nerve-sparing techniques result in greater than 95% rates of antegrade ejaculation

39. 43 LAPAROSCOPIC AND ROBOTIC-ASSISTED RPLND INDICATIONS Stage I NSGCT Stage IIA NSGCT Unifocal small-volume residual mass after chemotherapy

40. 44 ADVANTAGES Quicker convalescence More favorable cosmetic results Less postoperative pain & morbidity. Reduced blood loss & length of hospital stay It can be used for diagnostic/therapeutic purposes Patients with positive nodes should be treated with adjuvant chemotherapy. Effective therapeutic impact of L-RPLND and Robotic- assisted RPLND remains mostly with low stage NSGCTs .

41. 45 COMPLICATIONS Rate of complication in primary RPLND is 10.6-24%. Rate of complication following PC-RPLND is 20-30% COMPLICATIONS: Bleeding Injury to major vessels Injury to sympathetic nerves Injury to adjacent organs (duodenum, bowel, kidney, pancreas) Pulmonary Paralytic ileus Chylous ascites Peripheral Nerve injury

42. 46 RPLND AND FERTILITY Preserving fertility in men undergoing RPLND is more complex than simply sparing their postganglionic sympathetic nerves. When including all stages of disease, approximately 40% to 60% of patients presenting with testicular GCT have been reported to demonstrate abnormal parameters on semen analysis.

43. Before the development of unilateral modified RPLND templates and nerve-sparing techniques, most patients undergoing bilateral RPLND were rendered an - ejaculatory . Techniques were altered in two ways: (1) changing the boundaries of dissection and (2) prospectively identifying postganglionic sympathetic fibers and the superior hypogastric plexus . Recent studies, reported preservation of antegrade ejaculation in 97% of men undergoing modified unilateral template dissection 53

44. 48 Postoperative paternity can be expected in approximately 75% of men undergoing primary nerve-sparing RPLND. Fertility after PC-RPLND - not been established [ chemotherapy-induced disruption of spermatogenesis can persist for several years after completion of therapy ] .

45. 49 Pulmonary Complications Major pulmonary complications are extremely rare after primary RPLND but have been reported to occur in approximately 3% to 5% of patients after PC-RPLND . Because most patients who undergo PC-RPLND have received bleomycin containing induction chemotherapy , acute respiratory distress syndrome and prolonged postoperative ventilation account for most of these major complications. The incidence of bleomycin-related perioperative pulmonary complications can be minimized by avoiding aggressive intraoperative and postoperative intravenous fluid resuscitation and keeping FiO2 as low as is safely possible .

46. 50 Paralytic Ileus The reported rates of postoperative paralytic ileus range widely in the primary RPLND (0% to 18%) and PC-RPLND (2.2% to 21%) . In relatively low-volume PC-RPLND, an orogastric tube is used and removed at the conclusion of the procedure. In Retroperitoneal higher volume disease, the probability of significant ileus is greater, and a nasogastric tube should be used.

47. 51 L y mph oc e l e The incidence of subclinical lymphocele after RPLND is unknown . Symptomatic retroperitoneal lymphoceles are extremely rare with reported rates ranging from 0 % to 1.7 %. Symptoms can be related to ureteral compression, displacement of abdominal viscera (if very large), or secondary infection. Meticulous attention to ligation of large-caliber lymphatics during resection likely decreases the risk of developing a symptomatic lymphocele. Treatment of symptomatic and/or infected lymphoceles includes percutaneous drainage with systemic antibiotics reserved for infected lymphoceles .

48. 52 Chylous Ascites Chylous ascites has been reported to occur in 0.2% to 2.1% of pts undergoing primary RPLND and 2% to 7% of patients undergoing PC-RPLND . Suprahilar resections are thought to carry a higher risk for chylous ascites because of disruption of the cisterna chyli and its contributing lymphatics. Patients with symptomatic chylous ascites should first be managed with simple paracentesis with consideration of low-fat/medium- chain triglyceride diet and intramuscular octreotide. If Persistent high-volume chylous drainage (>100 mL/24 hr ) despite these modifications if occur, placement of a peritoneovenous shunt, or surgical exploration with attempted ligation of the lymphatic leak to be done.

49. 53 Venous Thromboembolism The rate of pulmonary embolism after primary RPLND has been reported to be less than 1% ,After PC-RPLND, the rates range from 0.1% to 3.1%. All patients undergoing RPLND should have sequential compression devices placed before induction, which should be maintained throughout the hospital course along with early ambulatory practice. Prophylactic subcutaneous low-dose unfractionated heparin or low-molecular-weight heparin has demonstrated efficacy in decreasing VTE rates in patients with a personal history of VTE, obesity, known hypercoagulable condition, or older age.

50. 54 Neurologic Complication Peripheral nerve injury were secondary to patient positioning and potentially retractor placement (femoral neurapraxia). Careful attention to appropriate patient positioning by the surgical and anesthesia teams is important in minimizing peripheral nerve damage Patients with bulky mediastinal and retroperitoneal disease are at an increased risk of developing paraplegia. The likelihood of neurologic complications increases with the scale of para-aortic resection.

51. COMPLICATIONS OF RPLND 55

52. 56 S U M M A R Y RPLND is the choice for low stage NSGCT Modified template RPLND is choice for clinical stage I In Modified templates, surgical margins should never be compromised in an effort to preserve ejaculation In stage IIA,B NSGCT bilateral INFRA HILAR RPLND remains the standard

53. 57 Major complications are rare after primary RPLND and PC- RPLND. A significant proportion of major complications at PC-RPLND are pulmonary and are related to prior bleomycin and thoracic disease burden.

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