Dr. med. Dirk Manski



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Retroperitoneal Lymphadenectomy (RLA) for Germ Cell Tumors

Indication for retroperitoneal lymphadenectomy

Nonseminoma Stage I:

Nerve-sparing modified RLA is a treatment option in nonseminoma stage I and an alternative to prophylactic chemotherapy or a watch-and-wait strategy.

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 6 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 xyphoid process to the lower abdomen (between the navel and symphysis) depending on the body mass index. Dissect the ligament teres hepatis and free the 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:

Seldem necessary for the removal of enlarged retrocrural lymph nodes.

Dissection Limits of Nerve-Sparing Retroperitoneal Lymphadenectomy:

To reduce the frequency of retrograde ejaculation, a (modified) dissection area for right and left testicular tumors was developed respecting the probability of lymph node metastases. In addition to observing the dissection limits, it is necessary to identify the sympathetic ganglia and to protect the exiting sympathetic nerve fibers crossing the dissection field.

The management of the removed lymph nodes regarding to the frozen section procedure is different 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.

Dissection field for left and right nerve-sparing retroperitoneal lymphadenectomy: A. phrenica inferior (1), Truncus coeliacus (2), A. mesenterica sup. (3), A. testicularis/ovarica (4), A. mesenterica inf. (5), A. sacralis mediana (6), A. iliaca communis (7). Figure modified from Gray’s Anatomy, Lea and Febinger 1918, Philadelphia, USA.
figure Dissection field for nerve-sparing retroperitoneal lymphadenectomy

Retroperitoneal Dissection Field for Right-Sided Testicular Tumors:

Retroperitoneal Dissection Field for Left-Sided Testicular Tumors:

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:

Analgesia:

Analgesics according to the WHO ladder are prescribed, e.g. a combination of metamizol and tramadol. A peridural 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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