Retroperitoneal Lymph Node Dissection

Definition

Retro = behind

Peritoneal = the peritoneum is the lining of the main abdominal cavity Lymph

Nodes = small glands that filter waste from all of the main organs in the body

Dissection = freeing from surrounding tissue and often removing

Retroperitoneal lymph node dissection refers to the removal of groups of lymph node glands from either the left, right or both sides of the retroperitoneal space (the space behind the main abdominal cavity). It is an operation associated with the diagnosis of presumed-advanced or confirmed-advanced testicular cancer.

The abdomen is divided into compartments by the peritoneal lining. Organs such as the liver ,spleen, stomach, most of your small intestines, and most of your colon (large intestine) are surrounded by this cavity and are referred to as intraperitoneal. The urinary bladder in the pelvis is in front of this lining and often referred to as pre-peritoneal. The kidneys, the ureters(tubes that transport urine from the kidneys to the bladder), adrenal glands (organs above the kidneys) a small part of the small intestine, and parts of the colon are all situated in the back of your body (behind the peritoneal lining) and are termed retroperitoneal. In addition to these organs, the aorta and the vena cava (the largest artery and vein the body) as well as some of its main branches, are located in the retroperitoneum.
Lymph nodes are specialized glands that filter waste products (i.e. infection, cancer, etc.) out of the blood. There are lymph nodes everywhere and associated with virtually every organ in the body. In the retroperitoneal cavity are the lymph nodes that drain from the testicles. Their location high up in the body represents the location from where the testicles developed in the fetus prior to their descent into the scrotal sac during development. These groups of lymph nodes are situated near the kidneys and closely adjacent to the great vessels and their branches.

An RPLND is performed to document whether or not testicular cancer has spread back to the lymph nodes that drain the testicles. It is also being done for curative intent in some cases where the cancer is known to have already spread to the nodes. In this scenario, the role of the surgery in relation to other treatments (i.e. radiation or chemotherapy), will have been discussed with you in your consultation.

RPLND is subdivided into two main categories, unilateral (one side only) or bilateral (both the left and right). The left and right testicles have different drainage patterns into the lymph glands with some crossover from left to right or vice versa. In addition, the lymph nodes on each side are divided into groups according to the pattern of drainage. We often do not have to remove all of the nodes on a given side if there is very low risk that certain nodes are involved. These operations are more limited.

Whether nodes on both sides need to be removed, and whether a complete or modified dissection ought to be done on either side will have been discussed with you in your consultation. It will depend on the extent of your cancer as determined by: the type of cancer cell, specialized blood tests, x-rays or CT scans, and what is referred to as the stage of the tumor (whether the cancer cells spread out of the testicle itself).

Preparation

Retroperitoneal lymph node dissections are difficult operations. It is even more involved in patients who had prior surgery (especially a prior RPLND), or who already received chemotherapy or radiation. Because anesthesia time can be prolonged, you may be sent for an updated general physical and note of “medical clearance” from your primary physician. This is precautionary and for your own protection.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

We will ask you to clean out your small intestine and colon the night before. An empty gastrointestinal tract facilitates the surgery and may also make you far more comfortable in the postoperative period. You should plan a light lunch and early, light dinner the day prior. At6:00-7:00 p.m., you will take a laxative. For the remainder of the evening, it is important to continue to drink plenty of clear fluids, but you CANNOT eat. You may drink up until midnight but not after and not in the morning of your scheduled surgery. Particular regimens for cleaning out your system vary and will depend on the preference of your surgeon.

Procedure

Your position on the table will be supine (flat on your back) in almost all cases. In cases that require dissection higher up near the chest (thoracic cavity), you may be slightly tilted to one side (oblique position). This position facilitates what is termed a thoracoabdominal approach(one involving the chest and abdomen). You will be placed under general anesthesia (complete sleep) throughout the duration of the preparation and operation. An incision is made up and down on the abdomen extending for nearly the full length. The peritoneal cavity is entered and inspected. We then approach the retroperitoneal cavity by maneuvering the contents of the peritoneum out of the field. Once we are in the appropriate area of the retroperitoneum, the lymph nodes are inspected. Dissection is performed to remove all of the intended nodes while simultaneously preserving important blood vessels, specialized nerves, and other vital structures such as the ureters. Biopsies may even be taken from areas that are not fully dissected. Once all of the lymph nodes or other areas of tumor are removed, the abdominal wall is closed.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. An intensive care unit is rarely required, but may be necessary in longer or more involved cases. A sterile dressing will be covering your incision. You will have anintravenous (IV) line supplying you with the fluids your body requires. Your urine will becoming out through a catheter and emptying into a bag. The catheter may give you a sense of an urge to urinate even though your bladder is completely empty. You will also have boots on your legs that may inflate and deflate (an intermittent squeezing) to prevent the formation of blood clots in your veins (deep vein thrombosis or DVT). There will be a tube coming from your stomach and out of your nose (nasogastric or NG tube). The purpose of this tube is to keep your stomach and intestines empty. During the procedure, the intestine can go into spasm from having been moved and touched. If not kept empty, you could have nausea and vomiting. You will not be permitted to eat or drink in the first 12-24 hours. After that, the tube may possibly be removed (each patient is slightly different) and we may start you slowly on fluids.

*If there was dissection in the chest cavity (thoracoabdominal approach), there may be a drainage tube or “chest tube” in the lower side of your lung cavity. This may remain for a few days and is then removed.

A typical hospital stay for these operations is usually less than a week depending on your particular health status and your postoperative hospital course. It is important to get out of bed either the first or second morning and spend time in the chair. With assistance from a nurse or family member, you may walk on the first day. Drains or catheters will be removed as your surgeon sees appropriate.

Upon discharge, you may have no dressing (bandage) on your incision. You will be discharged with instructions for follow-up in our office. Other than your regular medications, you may receive other medications such as an antibiotic, a pain medication, and a stool softener so that you do not strain to have bowel movements. Other medications are rarely necessary but depend on your particular needs.

Expectations of Outcome

It is normal to feel a bit tired or weak for a few weeks. Remember, you had a big operation. We typically tell patients that they will be out of work for 4-6 weeks (up to 12 weeks is possible if your occupation requires strenuous activity) and that it may take several weeks more before you truly feel like yourself.

While we will be able to tell you about our findings during surgery, you must understand that the specimen will be evaluated by the pathologists. They carefully examine the entire specimen under the microscope. It may take a week before we have an official report to discuss with you. Of course you will be anxious, but we encourage you to be as patient as possible. Use that week to concentrate on your recovery.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Blood Loss/Transfusion: There is always some blood loss. Uncommonly, blood loss may necessitate a transfusion. This is more common with extensive tumor involvement, tumors that are adherent (scarred) to the “great vessels” or their branches, or in patients who had similar prior operations, chemotherapy or radiation.
• Anejaculation: Ejaculation is the propulsion of semen and sperm from the urethra out of the penis at the time of orgasm. This requires input from nerves that come through the abdomen (in the retroperitoneum) into the pelvis. The nerves run across the area of the operation. These nerves may be spared and ejaculation preserved in most cases. Nerve injury is more common with extensive tumor involvement, tumors that are adherent (scarred) to the “great vessels” or their branches, or in patients who had similar prior operations, chemotherapy or radiation.
• Ileus or Bowel Obstruction: As discussed, you will have a nasogastric tube. Once removed, we anticipate that your small intestine will resume its normal movement. Sometimes the small intestine may remain in spasm referred to as an “ileus.” Treatment ranges from observation to replacement of the NG tube for a day or two. Intestinal obstruction requiring repeat surgery is uncommon, and may even occur months or years after surgery.
• Wound Infection: As with any incision, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are easily managed with antibiotics and local wound care. In some instances, an area of the superficial (upper layer) incision needs to be opened for adequate drainage. An abscess is an infection collection in the body. It is more serious and is more likely to present with fevers, chills, nausea or vomiting. It would require surgical drainage, or a minimally-invasive procedure involving a small catheter.
• Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. They will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system.
• *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Inability to Remove the Lymph Nodes: While it is our intent to remove all of the targeted lymph nodes or areas of tumor, this is not always possible. Scar tissue or unexpected extensive adhesions to vital structures or large blood vessels may prohibit safe removal.
• Ureteral Injury: As mentioned previously, the ureters (tubes that drain urine from the kidneys) run in the retroperitoneum. Some of the lymph nodes are close to the ureters. In attempts to separate the lymph nodes, the ureter can be injured.
• Surgical repair and temporary placement of a stent (a thin plastic tube placed in the ureter to facilitate drainage) may be necessary.
• Lymphocele: A lymphocele is a collection of lymphatic fluid (fluid that drains through the lymph nodes) that can accumulate in patients that undergo removal of lymph nodes. It is possible for some of the fluid to persistently leak from tiny lymphatic channels. These collections can form in the abdomen or pelvis and may compress nerves (causing weakness in the leg) or blood vessels (increasing the risk of a deep veinthrombosis). Typically, the first sign of a pelvic lymphocele is ankle and foot swelling on the same side of the lymphocele. Treatment ranges from observation to a minimally invasive drainage procedure. The need for a more invasive or open procedure is uncommon.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
• Injury to the Small Intestine or Colon: The kidneys lie in close proximity to portions of the small intestine and the colon. Local extension of the cancer or inflammation may make it difficult to separate the two. Intestinal or colon injuries are a rare occurrence and can often be repaired immediately at the time of their recognition. It is uncommon to need a major procedure such as a temporary colostomy (bag for stool). A general surgeon is sometimes asked to assist with this problem.
• Liver (Hepatic) or Spleen (Splenic) Injury: Very large tumors or those associated with adhesions (scarring and inflammation) can sometimes be attached to surrounding organs–on the right, the liver, and on the left, the spleen. In an attempt to separate the two, either organ can be injured. The injury is usually small and is easily repaired. A significant injury may require a blood transfusion. Less commonly, part or all of an organ may need to be removed. A general surgeon may be asked to assist with this problem.
• Hernia: When we close an abdominal incision, we pay careful attention to the various layers of muscle and fascia (tissue lining the muscle). Nevertheless, this area may be more prone to develop hernias (weakness or bulging). Depending on the severity, it may require surgical repair.
• Chronic Pain: While quite unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.
• Death: The incidence of death during or shortly after the operation is less than 1%.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.