Retroperitoneal lymph node dissection (RPLND)

A retroperitoneal lymph node dissection (RPLND) is surgery to remove the lymph nodes in the back of the abdomen (retroperitoneum). The lymph nodes in the back of the abdomen are called retroperitoneal lymph nodes. An RPLND is also called a retroperitoneal lymphadenectomy.

The lymph nodes in the retroperitoneum lie around the large blood vessels at the back of the abdomen. The lymph nodes are part of the lymphatic system. The lymphatic system helps fight infections and is made up of lymph vessels, lymph fluid, lymph nodes, bone marrow and the lymphatic organs (thymus, adenoid, tonsil and spleen).

Lymph vessels are very thin tubes similar to blood vessels. They collect and move lymph fluid away from tissues into the lymph nodes. Lymph nodes are small bean-shaped organs of lymphatic tissue. The lymph fluid can carry cancer cells from where the cancer started into the lymph nodes.

Lymph fluid from the testicles and some organs in the pelvis drain into the retroperitoneal lymph nodes. Lymph fluid can carry cancer cells from the testicles into the retroperitoneal lymph nodes.

An RPLND is most often used to stage and treat testicular cancer that may spread to the retroperitoneal lymph nodes. An RPLND is done to:

• find out if cancer has spread from where it started (primary site) to the retroperitoneal lymph nodes
• remove lymph nodes that may contain cancer
• reduce the chance that cancer will come back (recur)
• treat cancer that has come back

An RPLND is done under general anesthetic in a hospital operating room. An RPLND may be done using a wide cut (incision) in the middle of the abdomen (open method) or a laparoscopy( called a laparoscopic RPLND).

An RPLND is a long and difficult surgery. The surgeon will try to avoid removing the nerves and prevent damage to the nerves in the back of the abdomen (called a nerve-sparing RPLND). Removing or damaging the nerves is sometimes needed and may cause side effects such as retrograde ejaculation in men. This is a condition where semen is pushed backward into the bladder instead of out of the body.

The surgeon removes the retroperitoneal lymph nodes on the same side of the abdomen as the tumour or on both sides of the abdomen. This depends on the chance that the cancer has spread or will spread to the retroperitoneal lymph nodes.

After removing the lymph nodes, the surgeon places a small tube (drain) and closes the cut with stitches or staples. A drainage bag is attached to the end of the tube to collect fluid draining from the area. This reduces the chance of fluid building up and improves healing. The drain is left in place for a few days or until there is little or no drainage.

People who have a retroperitoneal lymph node dissection are usually sent home 3–7 days after surgery. You may be given:

• antibiotics to prevent infection
• pain-relieving medicine
• instructions on caring for and dressing the wound
• advice on how much and which types of activity you can do after surgery
• a follow-up appointment to see the surgeon in 1–2 weeks
• information about which symptoms and side effects you should report

The lymph nodes and any other tissue removed during surgery are sent to a lab to be examined by a doctor who specializes in the causes and nature of disease (a pathologist).

Side effects can happen any time during, immediately after or a few days or weeks after an RPLND. Sometimes late side effects develop months or years after an RPLND. Many side effects go away on their own or can be treated, but some may last a long time or become permanent.

During surgery, bleeding may start if there is injury to the large blood vessels. The surgeon will treat this complication immediately by repairing the injured blood vessels.

Tell the healthcare team if you have these side effects or others you think may be from an RPLND:

• pain, discomfort or tenderness in the lower abdomen
• inability to pass gas or have a bowel movement or both
• pus coming from the incision
• retrograde ejaculation (semen goes inside the body instead of coming out)
• fertility problems in men, which may be related to retrograde ejaculation
• a bulge at or near the incision (incisional hernia)

Each lymph node removed is examined to see if it contains cancer.

• A negative lymph node has no cancer cells.
• A positive lymph node has cancer cells.

The pathologist’s report includes the type of cancer, the number of lymph nodes removed and the number of lymph nodes that have cancer cells. The report may also say if the cancer has grown beyond the outer covering of the lymph node (the capsule).

Doctors use the number of positive lymph nodes to help stage the cancer. They use the stage along with other information about the type and grade of the cancer to make treatment decisions and give a prognosis.

Depending on the result, your doctor will decide if you need more tests, any treatment or follow-up care.