Difference between revisions of "Open Retroperitoneal Lymph Node Dissection"

Latest revision as of 08:56, 17 August 2023

Oncologic procedure done for management of metastatic disease, typically from testicular cancer. Many surgical teams are often involved because many retroperitoneal organ systems can be involved: typically Urology +/- GI +/- Vascular. Most notably, metastases requiring dissection often directly involve the SVC and/or Aorta, creating a serious high-volume bleed risk to this procedure.

Overview

Indications

Metastatic disease

Surgical procedure

Large ventral incision followed by exposure to retroperitoneal space. Dissection then follows in whichever organs are affected: duodenum, IVC, aorta, kidney, etc.

Preoperative management

Patient evaluation


System	Considerations
Airway
Neurologic
Cardiovascular	Expect intraoperative and postoperative tachycardia.
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

Patient preparation and premedication

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

At least 2x large bore PIV, arterial line.

Induction and airway management

GA w/ ETT, maintain complete paralysis.

Positioning

Arched back, supine, arms out.

Maintenance and surgical considerations

Emergence

Postoperative management

Disposition

ICU. Due to manipulation of the hypogastric plexus, fairly significant tachycardia is expected in the post-operative period. It is typically advised to resuscitate to the blood pressure and UOP with lesser regard to the HR because it is not their actual circulatory status that is elevating the HR, so inappropriate volume resuscitation would not be helpful. Esmolol can be useful, though.

Pain management

Epidural > Truncal block but both are valid.

Potential complications

Significant bleeding.

Procedure variants


	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Matthew Abadir and Jeremy Sieker

@@ Line 1: / Line 1: @@
+Oncologic procedure done for management of metastatic disease, typically from testicular cancer. Many surgical teams are often involved because many retroperitoneal organ systems can be involved: typically Urology +/- GI +/- Vascular. Most notably, metastases requiring dissection often directly involve the SVC and/or Aorta, creating a serious high-volume bleed risk to this procedure.
+== Overview ==
-Link to PDF including Images -- [https://drive.google.com/file/d/1EIlvIxpoZJHnKP7O1kkTxafGogMNM6i6/view?usp=share_link Open Retroperitoneal Lymph Node Dissection]
+=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===
+Metastatic disease
+=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
+Large ventral incision followed by exposure to retroperitoneal space. Dissection then follows in whichever organs are affected: duodenum, IVC, aorta, kidney, etc.
-'''Open Retroperitoneal Lymph Node Dissection (RPLND)'''
+== Preoperative management ==
-·      Objectives
+=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
+{| class="wikitable"
+|+
+!System
+!Considerations
+|-
+|Airway
+|
+|-
+|Neurologic
+|
+|-
+|Cardiovascular
+|Expect intraoperative and postoperative tachycardia.
+|-
+|Pulmonary
+|
+|-
+|Gastrointestinal
+|
+|-
+|Hematologic
+|
+|-
+|Renal
+|
+|-
+|Endocrine
+|
+|-
+|Other
+|
+|}
-.    Understand the indication for RPLND
+=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
-.    Review relevant surgical anatomy
+=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
-.    Discuss anesthetic management details specific to RPLND
+=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
+=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
-·      Indication and procedural goals
+== Intraoperative management ==
-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].
+=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
+At least 2x large bore PIV, arterial line.
+=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
+GA w/ ETT, maintain complete paralysis.
-·      Relevant Anatomy and Surgical Approach
+=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
+Arched back, supine, arms out.
-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.
+=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
-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.
+=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
-AUA Video of RPLND Surgical Approach for Trainees [4]: <nowiki>https://auau.auanet.org/content/v06-03-retroperitoneal-lymph-node-dissection-learning-module-trainees-0</nowiki>
+== Postoperative management ==
+=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
+ICU. Due to manipulation of the hypogastric plexus, fairly significant tachycardia is expected in the post-operative period. It is typically advised to resuscitate to the blood pressure and UOP with lesser regard to the HR because it is not their actual circulatory status that is elevating the HR, so inappropriate volume resuscitation would not be helpful. Esmolol can be useful, though.
+=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
+Epidural > Truncal block but both are valid.
-·      Anesthetic Management
+=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
+Significant bleeding.
-.    General
+== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
-§  Procedure is typically scheduled for the whole day.
+{| class="wikitable wikitable-horizontal-scroll"
+|+
+!
+!Variant 1
+!Variant 2
+|-
+|Unique considerations
+|
+|
+|-
+|Indications
+|
+|
+|-
+|Position
+|
+|
+|-
+|Surgical time
+|
+|
+|-
+|EBL
+|
+|
+|-
+|Postoperative disposition
+|
+|
+|-
+|Pain management
+|
+|
+|-
+|Potential complications
+|
+|
+|}
-·      For Dr. Salari, one case took 8 hours.
+== References ==
-§  These cases are almost always general anesthetics with a single-lumen endotracheal tube
+[[Category:Surgical procedures]]
-§  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).
-.    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
-.    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).
-.    Steele, GS. Retroperitoneal lymph node dissection for early-stage testicular germ cell tumors. In: UpToDate, UpToDate, Waltham, MA. (Accessed on Sept. 26, 2022.)
-.    Whitson, J.M. Retroperitoneal Lymph Node Dissection. Medscape. <nowiki>https://emedicine.medscape.com/article/449137-overview?reg=1#a9</nowiki>. Sept. 28, 2018. Accessed: Sept. 26, 2022.
-.    AUA Video of RPLND Surgical Approach for Trainees: <nowiki>https://auau.auanet.org/content/v06-03-retroperitoneal-lymph-node-dissection-learning-module-trainees-0</nowiki>
-.    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.
-.    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.
-.    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.
-.    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
-.    Brittani Bungart, MD PhD
-.    Daniel Ankeny, MD PhD