Urology

Retroperitoneal Lymph Node Dissection

IU School of Medicine has been the world’s leading institution in pioneering the surgical technique of retroperitoneal lymph node dissection since the 1960s when John Donohue, MD began performing this operation in attempts to cure men with metastatic testicular cancer.

This interest in retroperitoneal lymph node dissection led to the development of a number of modifications to the technique over the decades, which have helped standardize the procedure and lower patient morbidity. One of these accomplishments was the development of the nerve-sparing retroperitoneal lymph node dissection procedure, which preserves ejaculatory function and as a result fertility in young men who require this operation.

Expertise through High Patient Volume

IU School of Medicine Department of Urology faculty physicians have performed more than 6,000 retroperitoneal lymph node dissection procedures since the late 1960s. Through the school’s partnership with IU Health, faculty perform approximately 150 RPLND procedures each year.

Two-thirds of these cases are performed after chemotherapy in what is called a postchemotherapy retroperitoneal lymph node dissection (PCRPLND). The remaining one-third are primary retroperitoneal lymph node dissections performed for clinical stage I or low volume stage II disease.

Nationwide Patient Population

The majority of patients who come to IU School of Medicine faculty experts to receive this surgery are from outside the state of Indiana. The heat map below displays geographical location of patients who have traveled to IU School of Medicine for surgical care.

Heat Map

Patient Requirements

Patients with clinical stage I or low volume stage II disease have the option of electing to undergo this procedure as both a diagnostic and therapeutic treatment option. If cancer is found in the retroperitoneal lymph nodes, a properly performed retroperitoneal lymph node dissection can be curative with surgery alone in up to 80 percent of cases. This eliminates the need or risk of chemotherapy and its subsequent acute and long-term side effects.

Patients who present with bulkier metastatic disease and/or elevated AFP or HCG receive chemotherapy and then undergo follow-up imaging in the form of a CT scan. If residual disease in the retroperitoneum is greater than one centimeter in size, a postchemotherapy, retroperitoneal lymph node dissection is recommended. The rationale for this is to remove either teratoma or residual active germ cell tumor elements.

The spread of testicular cancer to the retroperitoneal lymph nodes follows a predictable pattern. A properly performed retroperitoneal lymph node dissection requires removing the lymphatic tissue/nodes from around the vena cava and/or aorta. This occurs from the renal blood vessels superiorly to where the ureters cross over the iliac blood vessels inferiorly. This also includes removing the lymphatic tissue from behind the vena cava and/or aorta.

Testicular Cancer Illustration

The nerves that control ejaculation and, as a result, fertility course through the retroperitoneum where the lymph nodes are located that need to be removed. Depending on each individual case, these nerves can be preserved and separated from the lymphatic tissue. Performing a nerve-sparing procedure maintains ejaculation following surgery and the potential fertility remains intact. If it is not technically possible to save or spare these nerves, then retrograde ejaculation occurs at the time of an orgasm. This is where the semen and sperm go into the bladder instead of out through the penis and can also be referred to as a ‘dry ejaculate.’ This is not harmful, but obviously limits the ability to maintain normal fertility.