Open Retroperitoneal Lymph Node Dissection

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Open Retroperitoneal Lymph Node Dissection (RPLND)

·      Objectives

1.    Understand the indication for RPLND

2.    Review relevant surgical anatomy

3.    Discuss anesthetic management details specific to RPLND

·      Indication and procedural goals

RPLND is primarily indicated for suspected metastatic testicular cancer, especially early-stage, nonseminomatous germ cell tumors in which nodal micrometastases are currently only found via RPLND. The goal of the procedure is to provide accurate pathological staging and remove any disease from the retroperitoneal nodes [1,2].

·      Relevant Anatomy and Surgical Approach

The retroperitoneal, pelvic and inguinal nodes should be removed for pathology. The right and left testes drain into different lymphatic regions: the right to the interaortocaval nodes at the second lumbar vertebral body (full right-sided dissection area outlined in Figure 1, Left) and the left to the paraaortic area that is defined by the renal vein superiorly, inferior mesenteric artery inferiorly, ureter laterally and the aorta medially (full left-sided dissection area outlined in Figure 1, Right). The spermatic cord’s lymphatic drainage is to the retroperitoneal lymph node chain while the epididymis drains to the external iliac and pelvic nodes [2,3]. Therefore, RPLND involves the surgeon operating near major vessels and the sympathetic chain.

The RPLND laparotomy incision is long—midline laparotomy from sternum to inches below the umbilicus. This has important implications for post-operative pain management, as outlined below.

AUA Video of RPLND Surgical Approach for Trainees [4]: https://auau.auanet.org/content/v06-03-retroperitoneal-lymph-node-dissection-learning-module-trainees-0

·      Anesthetic Management

1.    General

§  Procedure is typically scheduled for the whole day.

·      For Dr. Salari, one case took 8 hours.

§  These cases are almost always general anesthetics with a single-lumen endotracheal tube

§  Preop:

·      Active type and screen without blood in the room. EBL is typically <500 cc, but possibility for large EBL exists given proximity of major vessels to target lymph nodes being resected.

·      If surgeon agrees, place thoracic epidural. Most pain is from skin incision and muscle injury, less so from deep lymph node dissection.

·      Obtain consent for: possible central and A-line access, blood products if necessary, and regional anesthesia, including post-op epidural if pre-op is not allowed by surgeon

·      Anxiolytic may be needed given patients are typically otherwise healthy, young men.

§  Access:

·      2 PIVs – at least one large bore

·      Consider central access for CVP monitoring if patient has a history of bleomycin-induced restrictive lung disease and close monitoring of fluid management is needed.

·      Consider A-line if risk of large EBL or if there are significant cardiopulmonary comorbidities

·      OGT placed after induction for stomach decompression; ask surgeon if the tube will be left for the post-operative period (rare), in which case an NG tube should be placed instead

§  Monitors:

·      Given long length of case, consider rotating the blood cuff and pulse oximeter if using clip-on pulse oximeter probes to prevent pressure damage [5].

§  Fluid management:

·      Foley will be in place intra-op and post-op. For most cases, EBL will be <500 cc and a volume neutral approach can be taken. Large insensible volume loss will be present due to large laparotomy and urine output may not be accurate if surgery applying pressure to ureters.

·      Consider having albumin in room.

§  Pain Management:

·      RCT on TEA vs rectus sheath catheters (RSCs) for midline laparotomy [6]:

o   No difference was observed for time to first food intake, first bowel movement, postoperative morbidity, catheter failure rates, time in PACU and discharge from the hospital.

o   TEA was shown to improve postoperative movement pain scores until 48hrs, at which time no difference was observed.

o   While time to first opioid dose was much shorter for RSCs, the daily opioid usage was largely indifferent, except for less opioid consumption in the RSC group on postoperative day 3.

o   Notes about study:

§  The population is not completely generalizable to this surgery as women were included and all participants were between 40-84.

§  The procedures included were major rectal and colonic resection and radical cystectomy, although the mean (SD) incision length in mm was 219.6 (68.5) for RSCs and 220 (95.6) for TEA.

§  The RSC group received fentanyl patches with morphine PCA as an alternative for visceral pain. The paper notes that the fentanyl patches are standard of care at the hospital and that similar systemic opioid is achieved with patch compared to the fentanyl in the TEA infusion.

§  The RSC group received doses of ropivacaine that were within the recommended FDA guideline of 770 mg/day. Patients received 20 cc bolus dose of 0.25% Ropivacaine on each side with intermittent blousing every 4 hrs of 20 cc of 0.2% Ropivacaine per side.

·      Cochrane review of TEA vs IV analgesia for abdominal surgery in adults [7]:

o   Pain benefit in first 24 hours with significant difference after 24 hrs. This benefit is thought to not likely be clinically important.

o   Relative risk (RR) of TEA failure was 2.48 [1.13-5.43].

o   RR of hypotension was 7.13 [2.87-17.75]. Of note, RSCs would not cause hypotension 2/2 sympathetic blockade.

o   Generalizability difficult since a very broad range of abdominal surgeries are included in this review and open RPLND is relatively uncommon.

·      As of 09/2022, Dr. Salari does not want epidural catheters due to his concern of distinguishing sympathetic blockade from epidural versus surgical resection near the sympathetic nervous system. He prefers post-op bilateral rectus sheath catheters placed. If plan for TEA, one could try to recommend epidural and wait to utilize the epidural catheter until post-op to allay surgeon concern.

·      Since majority of pain is from midline laparotomy incision, RSCs may be a good option.

·      Multimodal pain management is very important, as for any laparotomy (e.g., acetaminophen, ketorolac, ketamine and other opioid-sparing analgesics).

2.    Clinical Pearls

§  Retrograde ejaculation and infertility is common from sympathetic/parasympathetic manipulation during dissection [8].

§  Acute Respiratory Distress Syndrome or prolonged ventilatory support can occur for those with bleomycin-induced lung toxicity or needing intrathoracic dissection. Bleomycin-induced lung toxicity is a restrictive disease that is sensitive to IVF volume and high FiO2 [2,5].

§  Chemotherapy-induced cardiotoxicity, including prolonged QT interval, and peripheral neuropathy can occur with chemotherapy regimens that include cisplatin [5].

·      Resources and Links

1.    Laguna, M. P. et al. Guidelines on testicular cancer. In EAU Guidelines vol. Edn. presented a the EAU Annual Congress Amsterdam 2020 (EAU Guidelines Office, 2020).

2.    Steele, GS. Retroperitoneal lymph node dissection for early-stage testicular germ cell tumors. In: UpToDate, UpToDate, Waltham, MA. (Accessed on Sept. 26, 2022.)

3.    Whitson, J.M. Retroperitoneal Lymph Node Dissection. Medscape. https://emedicine.medscape.com/article/449137-overview?reg=1#a9. Sept. 28, 2018. Accessed: Sept. 26, 2022.

4.    AUA Video of RPLND Surgical Approach for Trainees: https://auau.auanet.org/content/v06-03-retroperitoneal-lymph-node-dissection-learning-module-trainees-0

5.    Stephens, M. & Murphy, T. & Hendry, David. (2019). Anaesthesia for retroperitoneal lymph node dissection in the treatment of testicular cancer. BJA Education. 19. 10.1016/j.bjae.2019.04.003.

6.    Krige A, Brearley SG, Mateus C, Carlson GL, Lane S. A comparison between thoracic epidural analgesia and rectus sheath catheter analgesia after open midline major abdominal surgery: randomized clinical trial. BJS Open. 2022 May 2;6(3):zrac055. doi: 10.1093/bjsopen/zrac055. PMID: 35543263; PMCID: PMC9092444.

7.    Salicath JH, Yeoh EC, Bennett MH. Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults. Cochrane Database Syst Rev. 2018 Aug 30;8(8):CD010434. doi: 10.1002/14651858.CD010434.pub2. PMID: 30161292; PMCID: PMC6513588.

8.    Heidenreich A, Albers P, Hartmann M, Kliesch S, Kohrmann KU, Krege S, Lossin P, Weissbach L; German Testicular Cancer Study Group. Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group. J Urol. 2003 May;169(5):1710-4. doi: 10.1097/01.ju.0000060960.18092.54. PMID: 12686815.

·      Contributors

1.    Brittani Bungart, MD PhD

2.    Daniel Ankeny, MD PhD