Consequences of Missed Nodes during Retroperitoneal Lymph Node Dissection and How to Avoid Them

Abstract

Abstract Context Today, the role of urologic surgery in the management of nonseminomatous germ cell tumours (NSGCT) of the testis is limited to orchiectomy and post-chemotherapy surgery for residual disease. Retroperitoneal lymph node dissection (RPLND) in low stage disease is considered an optional staging procedure and templates have been introduced to avoid the risk of postoperative loss of antegrade ejaculation. Furthermore, patients with positive nodes are given adjuvant chemotherapy. Objective To determine how best to develop templates that help surgeons to avoid missed nodes at RPLND maintaining antegrade ejaculation. Evidence acquisition Only through a thorough understanding of the lymphatic drainage of the testis can we hope to avoid missed nodes during RPLND. This paper looks at the history of research in this area of functional anatomy as well as at the current work on the management of RPLN metastases in nonseminomatous germ cell tumours (NSGCT). Evidence synthesis Templates that have been constructed to guide open or laparoscopic RPLND are fit for nerve sparing but are not able to avoid occasional missed nodes at RPLND. Critical evaluation of current templates suggests to extent RPLND templates to further zones. The consequence is that more extended templates can compromise antegrade ejaculation, which can be secured by prospective nerve sparing technique. Furthermore, RPLND alone will cure 70% of pathological stage IIA patients. Conclusions Landing zones for retroperitoneal lymph node metastases are too scattered to design a restricted template that will allow both radical RPLND and an easy nerve-sparing technique to maintain antegrade ejaculation. We also have to bear in mind that chemotherapy is not a panacea for missed or recurrent nodal metastases: radical surgery does have curative potential and prospective nerve-sparing is safer than templates.