Editing Retroperitoneal Lymph Node Dissection (section)

== Minimally Invasive RPLND ==

*'''Rationale and Evolution'''
** Potential advantages of MIS approach vs. open RPLND: decreased blood loss, shorter hospital stays, and faster return to normal activity
*** The reduced recovery allows patients who are candidates to receive chemotherapy with minimal delay.
** MIS approach can allow preservation of antegrade ejaculation in > 95% of patients, similar to nerve-sparing open RPLND
* '''Staging Laparoscopic RPLND and controversy'''
** Previously, L-RPLND was used as a staging procedure; if staging found absence of occult metastases, those patients were spared exposure to chemotherapy without undergoing open RPLND. When used for staging, a limited dissection was performed with the use of restrictive templates and omission of the retrocaval or retroaortic lymph nodes.
** Use of L-RPLND has been abandoned and has evolved into a therapeutic procedure duplicating the open approach (wide templates and complete excision of retroaortic and retrocaval tissue) in its intent
* '''Surgical technique'''
** Indications for primary L-RPLND are identical to the indications for open RPLND. In the post-chemotherapeutic setting, L-RPLND has been limited mainly to small-volume residual disease; however, experienced surgeons have excised bulky tumors
** Preoperative patient preparation and technical considerations
*** All patients considered candidates for L-RPLND must be fully informed of all treatment options, including open RPLND, chemotherapy, and surveillance.
*** Potential complications include bleeding requiring blood transfusion; injury to adjacent organs (liver, bowel, gallbladder, kidney, ureter, pancreas, major vascular structures); and orthopedic, neurologic, or pulmonary complications as well as conversion to open surgery because of complications or incomplete resection
*** Patients interested in future fertility are educated regarding preoperative sperm banking
*** Patients undergo a mechanical bowel preparation the afternoon before surgery and take only clear liquids until midnight to decompress the bowels.
** Approach
*** Most prefer a transperitoneal approach
* '''Postoperative care'''
** The patient may ambulate and resume a liquid diet the night of surgery.
** Postoperative tachycardia may occur secondary to sympathetic stimulation
** Most patients can be discharged on postoperative day 1.
* '''<span style="color:#ff0000">Prospective nerve-sparing techniques</span>'''
** As in open RPLND, nerve-sparing techniques involve prospectively identifying, dissecting, and preserving the sympathetic chains, hypogastric plexus, and postganglionic fibers. With experience, these tissues can be readily identified as more fibrous compared with lymphatic tissue.
** '''<span style="color:#ff0000">On the right side, the postganglionic sympathetic fibers are most easily identified behind the IVC</span> as they cross anterior to the aorta to insert in the hypogastric plexus. Their takeoff from the sympathetic chains is always near lumbar veins, so great care should be taken in clipping lumbar vessels.'''
** '''<span style="color:#ff0000">On the left side, the postganglionic sympathetic fibers are most easily identified at the ganglia as they leave the sympathetic chain</span> and dissect them prospectively as they course anterior to the aorta before joining the hypogastric plexus.'''
** Care should be taken to avoid energy sources such as electrocautery when dissecting nerve fibers
* '''<span style="color:#ff0000">Adverse Events</span>'''
** Postoperative complication rates of 9-25%
** '''Potential complications include chylous ascites, ileus, lymphocele, nerve injury, pulmonary embolus, Clostridium difficile colitis, retroperitoneal hematoma, and ureteral injury'''
** '''<span style="color:#ff0000">Intraoperative bleeding is still the most commonly reported complication of the laparoscopic RPLND</span>'''
** With meticulous ligation of lymphatic channels, the incidence of chylous ascites should be < 2%.
** The rates of retrograde ejaculation have been consistently low with the laparoscopic approach and range from 0-14%
** Open conversion rate is < 5%, but it has been reported as high as 11.8%; '''the most common reason for conversion to an open procedure is bleeding'''
** Injury to major abdominal viscera also has been reported but appears to be a rare event
** The morbidity and open conversion rate of L-RPLND after chemotherapy is higher
* '''Results and current status'''
** Laparoscopic RPLND for clinical stage I disease
*** Published reports of L-RPLND with long-term follow-up suggest that it is an effective treatment option for patients with low-stage NSGCTs
*** Reports omitting chemotherapy for patients with N1 disease who underwent L-RPLND support its therapeutic efficacy, but more studies and follow-up are required
** Laparoscopic RPLND for clinical stage II disease
*** Fewer reports exist examining the role of L-RPLND for patients with clinical stage II NSGCTs as a primary modality or in the postchemotherapeutic setting