Boundaries of Modified Retroperitoneal Lymph Node Dissection (RPLND) Template
A modified RPLND template varies based on the side of the primary tumor, with specific anatomical boundaries that allow for preservation of ejaculatory function while maintaining oncologic efficacy. 1
Modified Template Boundaries
Right-Sided Modified Template
- Superior boundary: Crus of the diaphragm to the level of the renal arteries
- Inferior boundary: Extends to the level of the inferior mesenteric artery
- Lateral boundaries: Right ureter
- Medial boundaries: Includes interaortocaval lymph nodes
- May omit: Para-aortic lymph nodes below the inferior mesenteric artery
- Controversial: Omission of para-aortic lymph nodes above the inferior mesenteric artery 1
Left-Sided Modified Template
- Superior boundary: Crus of the diaphragm to the level of the renal arteries
- Inferior boundary: Extends to the level of the inferior mesenteric artery
- Lateral boundaries: Left ureter
- Medial boundaries: Includes interaortocaval lymph nodes
- May omit: Para-caval, precaval, and retrocaval lymph nodes
- Controversial: Omission of interaortocaval lymph nodes 1
Common Elements for Both Templates
- The ipsilateral gonadal vessels should be removed in all patients
- Nerve-sparing should be offered in select patients desiring preservation of ejaculatory function
- A complete retroaortic and/or retrocaval lymph node dissection with division of lumbar vessels should be performed when within the planned template 1
Important Considerations
Patient Selection
Modified templates are appropriate for:
- Patients with clinically negative lymph nodes
- Primary RPLND (not post-chemotherapy RPLND) 1
Limitations of Modified Templates
- Modified templates should not be used in patients with:
- Suspicious lymph nodes on CT imaging
- Suspicious lymph nodes on intraoperative assessment
- Somatic-type malignancy in the primary tumor 1
Post-Chemotherapy RPLND
- Full bilateral template RPLND should be performed in the post-chemotherapy setting
- Boundaries include renal hilar vessels (superiorly), ureters (laterally), and common iliac arteries (inferiorly) 2
- Studies show 7-32% of patients have teratoma or viable germ cell tumor outside the boundaries of modified templates in post-chemotherapy setting 3
Surgical Approach
- RPLND should be performed with curative intent in all patients
- Nerve-sparing attempts should not compromise the quality of the lymph node dissection
- Referral to an experienced surgeon at a high-volume center is recommended 1
- Minimally invasive approaches (laparoscopic or robotic) may be considered by surgeons with appropriate expertise 1
Outcomes
- Antegrade ejaculation is preserved in approximately 89% of patients after nerve-sparing RPLND compared to only 11% after modified bilateral template RPLND without nerve-sparing 4
- Modified unilateral templates have shown better perioperative outcomes compared to bilateral templates, with similar oncologic outcomes in select patients 5
The boundaries of modified RPLND templates are designed to balance oncologic control with functional preservation, particularly ejaculatory function. However, it's crucial to recognize that modified templates are not appropriate for all patients, particularly those with clinical evidence of nodal disease or in post-chemotherapy settings.