Retroperitoneal Lymph Node Dissection: Difference between revisions
Urology4all (talk | contribs) No edit summary |
Urology4all (talk | contribs) No edit summary |
||
| Line 29: | Line 29: | ||
== Anatomic principles of RPLND[https://pubmed.ncbi.nlm.nih.gov/31059667/] == | == Anatomic principles of RPLND[https://pubmed.ncbi.nlm.nih.gov/31059667/] == | ||
* '''Template''' | * '''<span style="color:#ff0000">Template</span>''' | ||
** '''Full bilateral template''' | ** '''<span style="color:#ff0000">Full bilateral template</span>''' | ||
*** '''The boundaries of a full bilateral template include''' | *** '''<span style="color:#ff0000">The boundaries of a full bilateral template include</span>''' | ||
**** '''Superiorly: the crura of the diaphragm''' and skeletonized renal vessels | **** '''<span style="color:#ff0000">Superiorly: the crura of the diaphragm</span>''' and skeletonized renal vessels | ||
**** '''Inferiorly: the bifurcation of the common iliac arteries/crossing of the ureter over the ipsilateral common iliac artery''' | **** '''<span style="color:#ff0000">Inferiorly: the bifurcation of the common iliac arteries/crossing of the ureter over the ipsilateral common iliac artery</span>''' | ||
**** '''Laterally: the ureters''' | **** '''<span style="color:#ff0000">Laterally: the ureters</span>''' | ||
**** This area includes the primary and secondary landing zones of the right (paracaval, interaortocaval) and the left (paraaortic, preaortic) testicle. | **** This area includes the primary and secondary landing zones of the right (paracaval, interaortocaval) and the left (paraaortic, preaortic) testicle. | ||
*** '''A full, bilateral template includes removal of the (10):''' | *** '''A full, bilateral template includes removal of the (10):''' | ||
| Line 47: | Line 47: | ||
***# '''Right common iliac lymph nodes''' | ***# '''Right common iliac lymph nodes''' | ||
***# '''Ipsilateral gondal vessels''' | ***# '''Ipsilateral gondal vessels''' | ||
*** '''Indications (2019 AUA Guidelines)''' | *** '''<span style="color:#ff0000">Indications (2019 AUA Guidelines)</span>''' | ||
**** '''Absolute (2):''' | **** '''<span style="color:#ff0000">Absolute (2):</span>''' | ||
****# '''Suspicious lymph nodes based on CT imaging or intraoperative assessment''' | ****# '''<span style="color:#ff0000">Suspicious lymph nodes based on CT imaging or intraoperative assessment</span>''' | ||
****# '''Somatic-type malignancy in the primary tumor.''' | ****# '''<span style="color:#ff0000">Somatic-type malignancy in the primary tumor.</span>''' | ||
****#* Malignant transformation of teratoma is defined as the transformation of a somatic teratomatous component of a germ cell tumor (GCT) to a nongerm cell malignant tumor[https://pubmed.ncbi.nlm.nih.gov/31781458/]. Most common examples of malignant transformation are sarcoma (e.g., rhabdomyosarcoma, osteosarcoma, chondrosarcoma, angiosarcoma, and liposarcoma), carcinoma (adenocarcinoma and squamous cell carcinoma), primitive neuroectodermal tumor, as well as hematologic malignancies[https://pubmed.ncbi.nlm.nih.gov/24908364/]. | ****#* Malignant transformation of teratoma is defined as the transformation of a somatic teratomatous component of a germ cell tumor (GCT) to a nongerm cell malignant tumor[https://pubmed.ncbi.nlm.nih.gov/31781458/]. Most common examples of malignant transformation are sarcoma (e.g., rhabdomyosarcoma, osteosarcoma, chondrosarcoma, angiosarcoma, and liposarcoma), carcinoma (adenocarcinoma and squamous cell carcinoma), primitive neuroectodermal tumor, as well as hematologic malignancies[https://pubmed.ncbi.nlm.nih.gov/24908364/]. | ||
**** '''Relative''' | **** '''Relative''' | ||
| Line 124: | Line 124: | ||
** Postoperative tachycardia may occur secondary to sympathetic stimulation | ** Postoperative tachycardia may occur secondary to sympathetic stimulation | ||
** Most patients can be discharged on postoperative day 1. | ** Most patients can be discharged on postoperative day 1. | ||
* '''Prospective nerve-sparing techniques''' | * '''<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. | ** 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. | ||
** '''On the right side, the postganglionic sympathetic fibers are most easily identified behind the IVC 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 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.''' | ||
** '''On the left side, the postganglionic sympathetic fibers are most easily identified at the ganglia as they leave the sympathetic chain and dissect them prospectively as they course anterior to the aorta before joining the hypogastric plexus.''' | ** '''<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 | ** Care should be taken to avoid energy sources such as electrocautery when dissecting nerve fibers | ||
* '''Complications''' | * '''<span style="color:#ff0000">Complications</span>''' | ||
** Postoperative complication rates of 9-25% | ** 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''' | ** '''Potential complications include chylous ascites, ileus, lymphocele, nerve injury, pulmonary embolus, Clostridium difficile colitis, retroperitoneal hematoma, and ureteral injury''' | ||
** '''Intraoperative bleeding is still the most commonly reported complication of the laparoscopic RPLND''' | ** '''<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%. | ** 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% | ** The rates of retrograde ejaculation have been consistently low with the laparoscopic approach and range from 0-14% | ||