Retroperitoneal lymph node dissection
Retroperitoneal lymph node dissection (RPLND) is a procedure to remove abdominal lymph nodes to treat testicular cancer, as well as help establish its exact stage and type. It is usually performed using an incision that extends from the sternum to several inches below the navel. While laparoscopic methods may be used, they have been considered less effective by some surgeons.[who?]
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.
The procedure is becoming standard treatment for clinical stage I and II non-seminomatous germ cell tumors (NSGCT) because of the low mortality and relapse rate with this procedure, as compared with the alternative, which is observation. Also, NSGCT is considered more aggressive than seminomas, the "other" kind of testicular cancer. Seminomas are also much more sensitive to radiation than NSGCTs, so the noninvasive radiation treatment is often preferred over RPLND.
The potential problems in RPLND have mostly to do with nerves: sympathetic nerves running parallel to the spinal cord may be damaged or severed during the procedure, which can result in impaired ejaculation and infertility. Contrary to popular belief, erectile function is not compromised by RPLND because the nerves responsible for erection are located elsewhere (parasympathetic nerves from S2-S4). This is why most often, a nerve-sparing technique is used where possible. A less invasive form using laparoscopic techniques (L-RPLND) exists, which is more costly, time-consuming, and requires special equipment that not every hospital may have. Open RPLND (O-RPLND), which is performed by opening the abdomen to get inside, has more room for problems, but is an equally effective way to remove the lymph nodes. Disadvantages of an open RPLND include longer recovery time, sometimes with physiotherapy required to help the patient regain the ability to walk after being bed-bound. As with any major surgery, infection is a possibility, and bowel obstructions and adhesions are another possible side effect.
There are different schools of thought about the need to perform RPLND after orchiectomy, and it depends on the type of tumour, and what stage it is in. Most American doctors recommend surgery, whereas in Europe, chemotherapy is more often used. An RPLND may be performed to remove non-malignant tumour remnants which persist after chemotherapy; without further treatment these may once more become malignant, and may be resistant to the combination of chemotherapy previously used.
Chemotherapy before RPLND is considered an effective approach, because it is possible that it suffices and no relapse occurs. However, in the event that the cancer does recur, chemotherapy can complicate surgery.