What is the role of Retroperitoneal Lymph Node Dissection (RPLND) in treating testicular cancer?

Role of Retroperitoneal Lymph Node Dissection (RPLND) in Testicular Cancer

RPLND is the standard approach to the surgical management of nonseminomatous germ cell tumor (NSGCT) in both primary and postchemotherapy settings, serving as a critical component for both diagnostic and therapeutic purposes. 1

Primary RPLND in Stage I NSGCT

Indications and Benefits

• Primary RPLND is a standard option for stage I NSGCT patients who are not candidates for surveillance
• Offers several advantages:
  • Curative in 50-80% of patients with pathologic stage II disease 2
  • Approximately 75% of clinical stage I patients avoid chemotherapy 2
  • Provides accurate pathologic staging
  • Addresses chemoresistant teratoma (present in 20-30% of pathologic stage II patients) 2

Patient Selection

• Surveillance is preferred for low-risk stage I NSGCT (absence of vascular invasion) 1
• RPLND should be considered for:
  • Patients who cannot comply with surveillance protocols
  • Those with somatic transformation in the primary tumor 1
  • Patients with contraindications to chemotherapy

Post-Chemotherapy RPLND

Critical Indications

• Post-chemotherapy RPLND is indicated in patients with metastatic NSGCT with residual retroperitoneal masses after systemic chemotherapy and normalized tumor markers 1
• Essential for:
  • Removing residual teratoma (chemoresistant)
  • Identifying and removing viable cancer (present in ~5% after chemotherapy) 2
  • Preventing late recurrences with potentially lethal consequences

Technical Considerations

• Full bilateral template RPLND should be performed in the post-chemotherapy setting 1
• Boundaries include:
  • Renal hilar vessels (superiorly)
  • Ureters (laterally)
  • Common iliac arteries (inferiorly)
• Completeness of resection is an independent predictor of clinical outcome 1

Surgical Approach and Technique

Nerve-Sparing Technique

• A nerve-sparing approach should be considered in primary RPLND to minimize ejaculatory disorders 1
• Preserves at least one paravertebral sympathetic trunk and postganglionic sympathetic fibers 3
• Retrograde ejaculation rates:
  • Primary RPLND: 2-6.7% (open) and 1.2-61% (laparoscopic) 3
  • Post-chemotherapy RPLND: 21-36% (open) and 4-7.1% (laparoscopic) 3

Template Dissection

• "Split and roll" technique allows resection of all lymphatic tissue around great vessels 1
• Modified templates may be used in primary RPLND for clinical stage I disease 1
• In post-chemotherapy setting, surgical margins should not be compromised to preserve ejaculation 1

Complications and Outcomes

Major Complications

• Grade III-IV complications occur in approximately 14.4% of post-chemotherapy RPLND cases 4
• Risk factors for complications:
  • Operation time >270 minutes
  • Vital cancer in the resected specimen
  • Left-sided resection fields 4

Oncologic Efficacy

• Excellent cure rates (>97%) when properly performed 2
• Laparoscopic RPLND has shown comparable intermediate results to open RPLND in selected patients 5

Referral Considerations

• Referral to high-volume centers should be considered for surgical resection of masses post-chemotherapy 1
• RPLND is a highly technically demanding procedure with best outcomes achieved at referral centers 3
• Academic comprehensive cancer centers perform RPLND more frequently than other facility types 6

Follow-Up After RPLND

• For pathologic N0 disease: surveillance is recommended
• For pathologic N1 disease: surveillance is preferred over chemotherapy
• For pathologic N2-3 disease: adjuvant chemotherapy (2 cycles of EP or BEP) is recommended 1

RPLND remains a cornerstone in the management of testicular cancer, particularly for NSGCT, providing both diagnostic and therapeutic benefits while preserving long-term survival and quality of life when performed by experienced surgeons at high-volume centers.