Retroperitoneal Lymph Node Dissection (RPLND)
Testicular cancer spreads in a well-known pattern and the lymph nodes in the retroperitoneum are a primary landing site during spread of the disease. Examining the removed lymphatic tissue will determine the extent of spread of any malignant disease and if no malignant tissue is found, the cancer may be more accurately considered as a stage I cancer, limited to the testis.
Retroperitoneal lymph node dissection requires general anesthesia. While operating times vary greatly between individuals, the average operating time is approximately 6 hours. Your surgeon will make an extensive incision in the midline of the abdomen and push your bowels aside. Next, the lymph nodes located within the retroperitoneum on the side of the testicular cancer that drains the testicle are removed. Additionally, the remainder of the blood supply to the affected testicle and spermatic cord are removed. This can sometimes cause retrograde ejaculation. On occasion, the lymph nodes on both sides of the retroperitoneum are removed. The extent of this dissection will be discussed with you prior to surgery.
The procedure is becoming standard treatment for clinical stage I and II non-seminomatous germ cell tumors (NSGCTT) because of the low mortality and relapse rate with this procedure, as compared with the alternative, which is observation. Also, NSGCTT is considered more aggressive than seminomas, the "other" kind of testicular cancer. Seminomas are also much more sensitive to radiation than NSGCTTs, so the noninvasive radiation treatment is often preferred over RPLND.
Potential Risks and Complications
As with any major surgery, complications, although rare, may occur with the RPLND surgery. Potential risks and complications associated with this surgery include but are not limited to the following:
Bleeding: RPLND requires dissection and removal of lymph nodes that reside around the large blood vessels traveling within the abdomen, including the aorta and vena cava. Injuries to these vessels can cause major blood loss.
Infection: Although patients are given broad spectrum intravenous antibiotics immediately prior to surgery, infections of the urinary tract and skin incisions are rare but may occur.
Tissue/Organ Injury: Although uncommon, adjacent organs and tissues may be injured as a result of your surgery. This includes kidneys, colon, bowel, vascular structures, nerves, muscles, lungs, spleen, liver, pancreas and gallbladder. On rare occasions further surgery may be required to address these unexpected injuries.
Effects on Fertility: Testicular cancer patients are usually young and therefore may have an interest in preserving their fertility for the future. The treatments for testicular cancer can affect fertility in several ways. Please visit NIH National Cancer Institute.
Loss of Sperm Production: Testicular cancer patients who require chemotherapy should consider banking sperm prior to treatment (after the orchiectomy) , as chemotherapy may effect sperm production by the remaining testicle. Although sperm counts can improve following chemotherapy, there is a risk that sperm quality will not return to normal levels. For more information on sperm banking click here.
Retrograde Ejaculation: Occasionally, the delicate nerves responsible for the control of ejaculation may be damaged during the RPLND surgery. This may result in retrograde ejaculation, where the sperm is ejaculated back into the bladder rather than forward and out of the penis. Patients may notice a significant decline or complete absence of ejaculate fluid. Although this condition is not harmful to your health, it will adversely affect a man's ability to father a child by intercourse. Nevertheless, assisted reproduction techniques such as in-vitro fertilization can often be performed to achieve a successful pregnancy despite retrograde ejaculation.
Lymphocele: Lymphatic fluid can collect in the area where the lymph nodes were removed, which may require drainage of the fluid or further surgery.
Respiratory Complication: Some chemotherapy agents such as bleomycin have potential toxicity to your lungs, placing you at a higher risk of respiratory complications during and following surgery. In most cases, patients who have received such medications can still undergo successful surgery with greater attention paid to their respiratory status.