Retroperitoneal Lymph Node Dissection (RPLND)
Testicular cancer usually spreads via a very predictable route through the lymph nodes upwards to the lungs, and then outward to the liver, brain, and elsewhere. The affected lymph nodes are call the "retroperitoneal lymph nodes" and they are located behind all of the major organs in the belly, basically between the kidneys and along the vena cava and aorta.
In certain situations it makes sense to remove these nodes. In other situations the RPLND is simply not done. So, who might need an RPLND? WE SUGGEST CONTACTING AN EXPERT IN THE FIELD OF TESTICULAR CANCER TO FIND OUT OF THE RPLND IS NECESSARY FOR YOU - CLICK HERE FOR A LIST OF EXPERTS.
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- When a patient has Stage I nonseminoma, it may make sense to remove the lymph nodes to determine whether, in fact, the cancer really is gone. If it isn't, the surgery alone may cure them or they can proactively receive a short course of chemotherapy that will essentially cure them.
- A patient with Stage II nonseminoma, meaning that the doctors think the cancer has spread to these lymph nodes, may also choose to have the surgery if the nodes are small enough. The motivation here is either 1) it might not be cancer, 2) if only a small amount of cancer is found, the surgery alone might cure it or 3) removing the lymph nodes first may reduce the amount of chemo required to cure the cancer.
- Finally, a number of people may need this surgery after chemotherapy. The chemo may kill the cancer, but one of the things left behind, teratoma, must be removed. Teratoma is a benign tumor with a tendency to grow or degenerate back into another cancer. If the stuff left after chemo is large enough (perhaps more than 1-2cm), it is likely that the doctors will want to remove it. In a few cases it is possible that the chemo did not completely kill all the cancer. In these cases, removing the lymph nodes might also be therapeutic and cure the cancer.
So who does not need an RPLND or is not likely to be offered an RPLND? In general, if you don't fall into one of the categories mentioned above, you should not be thinking about the RPLND. However, things may be a little more complicated, so I will try to specifically list those situations where you do not want or will not be offered an RPLND.
- The RPLND is almost never done for seminoma. It is more difficult to do and radiation is a preferable treatment. The most common reason to perform the surgery on a seminoma patient is to remove large, bulky masses left over after radiation or chemo that are somehow getting in the way of the normal operation of the internal organs around it.
- Patients who do not have any visible spread of their cancer, but who DO have positive and rising tumor markers after their orchiectomy should not have an RPLND. A number of studies have shown that this surgery will not cure them, and they should go directly to chemotherapy.
- Nonseminoma patients whose lymph nodes are larger than 3 cm usually are not offered an RPLND. They almost definitely have cancer and should go directly to chemotherapy. However, there are exceptions. A patient with teratoma in his testicular tumor and a 4cm lymph node stands a greater than average chance that his lymph nodes also have teratoma in them. In such a case, the RPLND alone could cure him about half the time.
- Patients with clinical stage I cancer who had their orchiectomy more than 6 weeks before the scheduled RPLND date should consider canceling the surgery. The RPLND is most beneficial if it is done soon after the orchiectomy. If you wait long enough before having an RPLND, you are essentially on surveillance and/or if they do find cancer during the surgery, it is less likely that they will have caught it before it spread outside of the surgical boundary. This is not a hard and fast rule, but unless there is a very good reason for delay, try to have the surgery done quickly.
- Finally, for good or bad, if you live in the UK or parts of Europe or Australia, you may not be offered an RPLND except possibly in the post-chemo situation. The reason for this is less medical than you think. I will attempt to explain this issue later in the article.
Enough about who should and should not have the operation. What is the operation like? Make no mistake, we're talking some serious surgery here, folks. In a nut shell, the RPLND involves an incision from just below your sternum to below the belly button (but they do go around it!). Your intestines and associated organs are literally lifted out of the way, nerves are identified and hopefully moved out of the way, and then the surgeons remove all the lymph nodes that were connected to the testicle containing the tumor.
The operation itself can take 4-6 hours, but I have spoken with doctors who have had advanced cases lasting 20+ hours! They usually check the lymph nodes on the same side as the affected testicle first, and if they find anything suspicious, they may check the other side as well for additional spreading. If you would like to see more details about the actual surgical procedure, take a look at some of the links at the bottom of this page.
This is a very well studied surgical procedure: if you come out clean, odds are pretty good that you are TC free! (not good enough to never go back to the doctor, but very good nonetheless.) If they find cancer, you've most likely got a longer (but still survivable!) path of surveillance or chemo in your future.
Is this surgery "risk free"? Absolutely not! It is a complicated and delicate procedure that is rarely done. There are far more urologists in the US than there are RPLND's in a single year. Few doctors do more than a couple of these surgeries a year. This is one time when you should be willing to hurt your urologist's feelings and look for someone who has some experience. If you need a post-chemo RPLND, I strongly suggest that you find someone who has done the procedure many times before. (I also suggest banking sperm before the surgery if you are interested in having children in the future. It is good insurance and worth the expense.)
What are some of the risks with RPLND surgery? Here's a good starter list of possible problems:
- Infertility due to retrograde ejaculation. If the doctor cuts a nerve during the surgery, and it is very easy to do this, you will lose the ability to ejaculate normally. You'll still ejaculate, but your sperm will end up in your bladder!!
- Prolonged bowel inactivity (also called "ileus")
- Bowel obstruction
- Large scar and possible infection
- Pain management issues - You will definitely be feeling the effects of the operation for 2-3 months.
- Interior damage to surrounding organs, blood vessels, etc.
- Infection from blood transfusions
- General infections
- Lymphocele - lymphatic fluid continues to collect in the removal area
Note: these risks should not scare you away from this sometimes necessary procedure, but you do need to be aware of them and discuss them, and any other concerns with your doctor. As we have pointed out, this is serious surgery, so ask LOTS of questions.
Recent developments in the field include the laparoscopic RPLND. This is an infrequently available, very new, very difficult, time consuming operation. It does substantially reduce morbidity and recovery time. However, we do not recommend it because we do not feel that it is a curative operation. In other words, since it won't cure you, it will not eliminate the need for chemotherapy. If it doesn't do this, then why bother doing it at all? See the articles listed below for more information on this topic.
Additionally, an increasing number of doctors in Europe and a few in the United States are offering their patients 2 cycles of chemotherapy instead of an RPLND. This is popular in Europe because they appear to avoid the RPLND like the plague - basically, they simply do not have enough urologists around to do the surgery, and the surgeons they do have do not have any experience with the operation. It is becoming more popular here because there is the belief that the surgery is not valuable and can be avoided with a little chemo. I strongly disagree with this approach. The RPLND is serious surgery, but it is a proven treatment for this cancer. If there is no cancer, and the nerve sparing approach is used, then there should be no long term side effects of the surgery. You cannot say that with chemo - even two cycles of chemo can cause some lasting side effects, and it would be unfortunate to go through chemo and not even need it. Finally, the chemo is not a proven treatment and there is no long term data to support its effectiveness. Two cycles done after a properly done RPLND can virtually ensure a cure. Two cycles done without an RPLND might be too much treatment, just enough, or not enough at all.
Check out Dr. Fosters article: Current Status of Retroperitoneal Lymph Node Dissection and Testicular Cancer: When to Operate