Extraperitoneal laparoscopic retroperitoneal lymph node dissection for nonseminoma germ cell testicular cancer

The description of the extraperitoneal laparoscopic retroperitoneal lymph node dissection for nonseminoma germ cell testicular cancer covers all aspects of the surgical procedure used for the management of nonseminoma germ cell testicular cancer. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: extraperitoneal approach, creation of space, left lymphadenectomy, right lymphadenectomy, end of procedure. Consequently, this operating technique is well standardized for the management of this condition.

Browse the WORLD
Virtual University
English ▼

Extraperitoneal   laparoscopic   retroperitoneal   lymph   node   dissection   for   nonseminoma   germ   cell   testicular   cancer

Authors
E Leblanc, A Villers
Abstract
The description of the extraperitoneal laparoscopic retroperitoneal lymph node dissection for nonseminoma germ cell testicular cancer covers all aspects of the surgical procedure used for the management of nonseminoma germ cell testicular cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: extraperitoneal approach, creation of space, left lymphadenectomy, right lymphadenectomy, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
Media type
Publication
2002-04
Popular
Favorites
Favorites Media
Audio
en fr tw


E-publication
WeBSurg.com, Apr 2002;2(04).
URL: http://www.websurg.com/doi-ot02en263.htm

Extraperitoneal   laparoscopic   retroperitoneal   lymph   node   dissection   for   nonseminoma   germ   cell   testicular   cancer

1. Introduction
Evaluation of the retroperitoneal lymph nodes helps determine whether adjuvant chemotherapy is indicated in patients with a stage I or stage IIA nonseminoma germ cell tumor of the testis.
The classical approach for retroperitoneal lymphadenectomy for testicular carcinoma is xiphopubic laparotomy. This procedure involves a morbidity linked to the laparotomy and to the division (more or less complete) of the postganglionic periaortic and caval sympathetic fibers, which can lead to ejaculation disorders.

Laparoscopy, with its minimally invasive approach, decreases parietal complications. Extraperitoneal laparoscopic retropubic lymph node dissection is the technique of choice as it permits real postganglionic sympathetic nerve preservation.
2. Anatomy
• Regional anatomy
Lymph node invasion in testicular cancers progresses along the gonadal vascular pedicle, along the arteries in particular, towards the para-aortic region. There is precise lateralization of this spread (Weissbach and Boedefeld, 1987), limiting the extent of the dissection that needs to be accomplished.
1. Inferior vena cava
2. Left renal vein
3. Left testicular pedicle
4. Inferior mesenteric artery
5. Ureter
6. Left common iliac vessels
7. Lymph nodes
• Sympathetic nerves
1. Left sympathetic chain
2. Right sympathetic chain
3. Principles
Extraperitoneal laparoscopic retropubic lymphadenectomy is performed in gynecology via an internal iliac approach on the patient’s affected side (Dargent, 1999).
In lymphadenectomies for tumors of the testis, the extraperitoneal approach is set up in a comparable way. The modalities of the dissection depend on the side involved. Therefore separate descriptions are required.
The schemas of Weissbach and Boedefeld (1987) are used to determine the extent of lymph node dissection in early stages. For advanced forms, following chemotherapy, dissection is limited to exeresis of the residual masses only.
Unlike retropubic lymphadenectomy for gynecologic indications, lymphadenectomies for testis tumors aim to preserve sympathetic innervation.
4. Indications
Indications
- Pathological staging for clinical stage I testicular tumors (following imaging studies and normal biological markers);
- residual retroperitoneal masses after chemotherapy.

Contraindications
- morphology of the patient : extreme obesity defined by a body mass index (BMI) >30;
- previous history of retroperitoneal dissection: vascular surgery involving major vessels, kidney surgery or abdominal wall hernia repair with preperitoneal dissection. In these cases, open surgery is indicated;
- anomalies in the preoperative workup: non-reduction of markers or the existence of metastatic masses is an early indication for immediate chemotherapy;
- the presence of nodal masses >4 cm that are very adherent or residual perivascular tissue is a contraindication for endoscopy. A high degree of adherence may be suspected on a CT scan that shows no interface (lighter space) between the mass and the large vessel.
5. Preop workup
The surgeon should always inform the patient of the operative modalities and the risks of converting to laparotomy (uncontrollable bleeding, ineradicable adenopathy, impossibility of complete dissection), as well as the possible postoperative complications (lymphocele, sexual dysfunction).
Sperm banking is done systematically (risk of chemotherapy, ejaculation disorders).

Preparation for the procedure
- no digestive preparation;
- complete abdominal shaving from the level of the nipples to the upper thighs;
- low molecular weight heparin at an iso-coagulant dose, and injection of broad-spectrum antibiotics when anesthesia is induced.
6. Operating room
• Patient
- general anesthesia, urinary catheter, gastric tube;
- supine position, with the side to operate on the edge of the table;
- arms spread at a right angle, legs apart (to enable conversion to transperitoneal laparoscopy if necessary);
- table flat, but lateral rotation possible.
• Team
1. The surgeon is on the side that will be operated on.
2. The assistant who handles the laparoscope is next to the surgeon, at the level of the patient’s thighs.
3. The scrub nurse (optional) is next to the assistant.
• Equipment
The laparoscopic unit and electrocautery device are opposite the surgeon.
The suction-irrigation system and instrument table are placed behind the surgeon.
1. Laparoscopic unit
2. Suction-irrigation system
7. Trocar placement
Principles
The extraperitoneal approach requires a small standard surgical kit for installation of a laparoscope. Farabeuf retractors of varying lengths and widths are sometimes needed.

Trocars and instruments
Trocar A, a 10 mm balloon-tipped trocar, is placed in the upper part of the left iliac fossa, 2 to 3 cm above and medial to the iliac spine, on the midclavicular line. The 0° laparoscope is inserted through this trocar.
Trocar B, 10 or 12 mm with a 5 mm reducer cap, is placed in the left flank on the midaxillary line. Fenestrated grasping forceps, scissors, a bipolar grasper and a clip applier are introduced through this trocar.
Trocar C, 5 mm, is placed in the left subcostal area, on the external clavicular line. Fenestrated grasping forceps, scissors, a bipolar grasper and a suction-irrigation system are introduced through this trocar.
Trocar D, 5 mm, through which fenestrated grasping forceps are introduced, is optional.
8. Instruments
A. Disposable instruments:
1. Monopolar scissors
2. Endoscopic extraction bag
3. 5 or 10 mm clip applier
B. Reusable:
4. 10 mm, 0° laparoscope
5. Two bipolar graspers: 2 mm and 5mm fenestrated graspers
6. Two atraumatic, fenestrated grasping forceps
7. Suction-irrigation system
8. Standard laparotomy kit with additional instruments for vascular surgery (should be available in the operating room).
9. Extraperitoneal approach
• Internal iliac incision
The procedure is identical irrespective of the side the patient is operated on. An incision of about 2 cm is made 2 fingerbreadths above and medial to the anterior-superior iliac spine, on the midclavicular line, strictly outside of the contours of the rectus abdominus muscle.
• Parietal passage
The anterior-lateral abdominal muscles are divided in the direction of their fibers, plane by plane, until the peritoneum is reached. The surgeon then introduces a finger into the incision.
• Peritoneal mobilization
With a finger, the parietal peritoneum is reflected laterally from the parietal muscles and deep down from the psoas major muscle. This is pursued until the surgeon can clearly perceive the muscle fibers of the psoas major muscle posteriorly, and the beating of the ipsilateral common iliac artery caudally.
1. Psoas major muscle
2. Left common iliac artery
10. Creation/space
• Trocar placement
1. Under control of the index finger maintained in the iliac incision, the 10 mm trocar is inserted into the flank facing the psoas major muscle, halfway between the iliac crest and the 11th rib, on the midaxillary line.
Insufflation to a pressure of 10-12 mm Hg is done through this trocar as soon as it is inserted.
2. The dissection space can be monitored with the laparoscope introduced through this trocar.
Under guidance of the laparoscope and the finger in the iliac incision, the 5 mm trocar is placed in the subcostal area that passes through the fleshy transverse muscle of the abdomen, at a distance from the peritoneal reflection. This trocar is placed as far as possible into the dissection space, which will facilitate the subsequent positioning of the subcostal instrument.
3. The finger in the iliac incision is replaced by the 10 mm balloon-tipped trocar. The balloon, visible in the extraperitoneal space, is then inflated with air (20 mL).
The laparoscope is then placed in the iliac trocar, and the instruments in the 2 other trocars.
• Extraperitoneal space
As the surgeon works with no retractor other than the CO2 pressure, the extraperitoneal space must be sufficiently developed.
The parietal peritoneum bearing the ureter and the testicular vessels is mobilized from the psoas major muscle posteriorly to the large vessels medially. An injury to the ureter is rare, except in cases of ureteral adenopathy. If an injury occurs, suture over a ureteral stent should be attempted, or a conversion to an open approach to repair the wound should be undertaken.
1. Psoas major muscle
2. Aorta
3. Ureter
4. Parietal peritoneum
• Difficulties
• Extraperitoneal approach
If the patient has a history of iliac surgery (a hernia repair or an appendectomy), the iliac incision should be made higher and slightly more externally than the pre-existing scars.
The psoas major muscle is perceived only after collapse of the transversalis fascia. Its exposure can be facilitated by a dissection done with the index finger, under videoscopic control.
1. Psoas major muscle
• Insufficient space
Major obesity can prevent extraperitoneal gaseous expansion.
The following steps can be taken:
- make sure that the muscle relaxation of the patient is sufficient;
- slightly accentuate the tilting of the table to the right;
- increase the maximal insufflation pressure (to no higher than 14 mm Hg).
A 5 mm trocar (trocar D) may be placed in subcostal position, behind the first 5 mm trocar, in order to lift up the kidney, the perirenal fat and the peritoneal contents that impair the view. If this does not work, the surgeon must convert to open surgery.
• Pneumoperitoneum
The creation of a pneumoperitoneum, whether it occurs by progressive diffusion of CO2 or by accidental peritoneal tearing, can make the extraperitoneal space cave in and considerably hinder the dissection. Placing a contralateral subcostal or umbilical Veress needle may be enough to improve the view in case of a moderate pneumoperitoneum caused by diffusion. If a visible peritoneal tear occurs, an attempt should be made to repair it with suture or clips. If the leak is too extensive, it is advisable to convert to transperitoneal laparoscopy to finish the operation.
1. Veress needle
11. Left lymphadenectomy
• Principles
After development of the extraperitoneal space and identification of vascular landmarks, lymphadenectomy involves several steps, the order of which is up to the surgeon. The lymph node groups resected en bloc are placed in front of the psoas major muscle until they are extracted. All suspicious lymph nodes are dissected individually and sent for frozen section during the procedure. With malignant lymph nodes, chemotherapy is clearly indicated, and it is theoretically unnecessary to continue with the procedure.

Vascular landmarks
The following structures are identified:
- common iliac artery where it crosses the ureter;
1. left flank of the aorta;
2. left renal vein, following the course of the gonadal vein.
The aortic bifurcation is identified without its dissection.
The origin of the inferior mesenteric artery is distinguished by the convergence at its origin of sympathetic post-ganglionic nerve fibers. It should only be identified, because sharp dissection inevitably traumatizes the origin of the hypogastric plexus.
The anterior surface of the aorta is progressively freed caudad to cephalad, up to the duodenum.
The origin of the left gonadal artery is exposed. A bipolar coagulation-division is then done. Care must be taken to avoid tearing the gonadal artery. The left renal vein that was previously identified is fully exposed.
• Resection 1
The lateral aortic and preaortic lymph nodes must be resected.
After division at iliac level of the nodal chain, the resection is carried out en bloc, caudad to cephalad, along the vascular adventitia.
The node-bearing tissue is divided at the level of the left common iliac artery.
Lymph nodes are mobilized en bloc, with scissors and a bipolar grasper used alternately, until the left renal vein is reached. They must be simultaneously separated from the preaortic nodal group and from the posterior plane made up of the psoas major muscle, the left sympathetic chain and the vertebral plane. The post-ganglionic nerve fibers (3-4) are progressively visualized and preserved. The lymph node chain is divided at their level. The surgeon should refrain from using electrocautery as much as possible, to avoid injury to the fibers.
The lumbar vessels that course posterior to the sympathetic chain are easily identified and preserved.
The lymph node chain is divided in its upper portion, at the base of the previously dissected left renal vein. The renal artery and the posterior renal-azygos-lumbar venous network are identified.
1. Left common iliac artery
2. Node-bearing tissue
3. Aorta
4. Posterior plane
5. Sympathetic chain
6. Preserved nerve fibers
• Resection 2
The retroaortic lymph nodes are then resected. The aorta is lifted with a grasper, which is passed between the lumbar arteries that are preserved. In case of difficulty, coagulation or stapling and division of the lumbar arteries makes it possible to lift the aorta, in order to complete the resection. This step is always delicate. It may require the surgeon to add a fourth 5mm trocar.
1. Lifted aorta
2. Lumbar artery
3. Post-ganglionic nerve fibers
4. Left sympathetic chain
5. Psoas major muscle
12. Right lymphadenectomy
• Vascular landmarks
The right common iliac artery is the first structure to be identified, either directly or by following the ureter distally.
Following the iliac artery cephalad, the inferior portion of the inferior vena cava is exposed. Its lateral edge and anterior surface are then traced.
At the upper portion of this vein, the surgeon is hindered by the gonadal vessels that bar access to the renal vein. The artery is cauterized and cut while the vein is thoroughly dissected near its ending on the vena cava, clipped and divided. Care must be taken not to injure or tear out the gonadal vein at its insertion. Gentle dissection and double stapling on the caval side will prevent bleeding.
Freeing the upper portion of the vena cava allows access to the pancreaticoduodenal block and inferiorly to the left renal vein, which is the superior limit of this dissection. The anterior surface of the renal vein is exposed to the aorta.
1. Exposure of inferior vena cava
2. Right ureter
3. Latero-caval lymph nodes
4. Psoas major muscle
5. Exposure of right spermatic vein
6. Exposure of left renal vein
7. Clips on right spermatic vein
• Resections
• Step 1
The superficial prevascular and interaortico-caval lymph nodes are resected.
This resection is performed caudad to cephalad with scissors and bipolar graspers used alternately. Injuries to a small, direct lymphovenous anastomosis (especially in the lower part of the vena cava) should be avoided.
The superficial interaortico-caval lymph nodes are freed from right to left from the anterior surface of the vena cava and from the anterior surface of the supramesenteric aorta. This is done only after having identified, inferiorly to superiorly, the 2 or 3 sympathetic post-ganglionic fibers that appear as whitish strips 0.5 to 1 mm in diameter. They join the origin of the superior mesenteric artery through the interaortico-caval space to form, with the corresponding structures on the left, the superior hypogastric plexus. These fibers must not be accidentally divided or burned. The use of electricity should therefore be reduced to a minimum at this level. The preaortic dissection is limited to its inferior supramesenteric portion, without exposing the bifurcation or progressing towards its left side.
During the dissection of this space and of the aorta, the surgeon must watch out for the stump of the gonadal artery, which is identified and divided during identification of the landmarks. This stump should be cut again after bipolar cauterization at the base of the aorta.
Finally, the right renal artery can arise beneath the renal vein, in a low position. It is perceived by a pulsing at the level of the highest interaortico-caval lymph nodes. Dissection must therefore be carried out with extreme caution.
a. Exposure of a sympathetic post-ganglionic fiber
b. Interaortico-caval dissection
1. Stump of right spermatic vein
2. Vena cava
3. Sympathetic post-ganglionic fiber
4. Lymph node
• Step 2
The deep interaortico-caval lymph nodes are resected.
Retrocaval dissection facilitates the resection by enabling the surgeon to lift these lymph nodes situated in the prevertebral plane, without risking injury to the lumbar veins or the sympathetic nerve fibers.
The vena cava is progressively lifted with a subcostal atraumatic grasper. Its deep surface is delicately freed with scissors. The 2 or 3 right lumbar veins that join the posterior surface of the inferior vena cava are identified. Unlike the arteries, the right and left lumbar veins are not symmetrical. Because of their laxity and their size, they are generally not cut. If there are difficulties in exposure, they can be safely divided using the technique described for division of the gonadal vein.
This retrocaval freeing is pursued until the dissected interaortico-caval space is reached. It is terminated when the aorta appears below the inferior vena cava.
It is then extended cephalad to the left renal vein and caudad to the level of the origin of the inferior mesenteric artery.
The inferior vena cava is mobilized. The deep lymph nodes are grasped with the forceps that lift up the inferior vena cava at the same time. They are then mobilized from the prevertebral aponeurotic plane. They are recovered in an anterior position in the aortico-caval space. Care must be taken to avoid dividing the sympathetic post-ganglionic fibers. The retrocaval right sympathetic chain is buried beneath the lymph nodes. The previously identified post-ganglionic fibers are followed in retrocaval position and are thereby preserved.
During freeing of the lymph nodes, the right lumbar arteries (1-2) situated against the vertebral plane are exposed. They must not be injured. If they get in the way of the exposure, they should be cauterized and divided.
1. Inferior vena cava
2. Right renal vein
3. Lumbar vein
4. Post-ganglionic sympathetic fibers
• Step 3
The retrocaval lymph nodes are resected.
This step follows the previous step, during which the retrocaval lymph nodes were extensively mobilized. The lymph nodes must be identified and separated from the sympathetic ganglia.
1. Inferior vena cava
2. Right renal vein
3. Aorta
4. Post-ganglionic sympathetic fibers
• Step 4
The latero-caval lymph nodes are resected.
The dissection ends with this resection, which should not be difficult, since all potentially dangerous structures have been previously identified and freed. The cephalic limit of the resection is the origin of the right renal vein, and the caudal limit is the right common iliac artery.
1. Inferior vena cava
2. Psoas major muscle
3. Cephalically situated latero-caval lymph node
4. Right common iliac artery
5. Caudally situated latero-caval lymph node
6. Left renal vein
7. Sympathetic post-ganglionic fibers
8. Aorta
9. Aortic bifurcation
a. Final cephalic aspect
b. Final caudal aspect
13. End of procedure
• Gonadal vessels
The gonadal vessels must be resected.
The upper tip of the vascular pedicle, mobilized during the previous steps of the lymphadenectomy, is grasped with atraumatic forceps. This tip is progressively wound around the forceps to keep the vessels taut, making it easier to free them from the posterior parietal peritoneum. The small afferent veins are progressively cauterized and divided.
At the junction of the vascular pedicle with the ureter, the laparoscope is introduced through the trocar positioned in the flank. The grasping forceps are inserted into the iliac trocar. The exposure, freeing and bipolar coagulation-division of the distal tip of the pedicle, in contact with the internal inguinal ring, are facilitated. The ductus deferens is often visible.
Insufflation of the scrotum by CO2 is a possible secondary effect. If this happens, the CO2 must be evacuated by puncture before the patient emerges from anesthesia.
1. Clips on the upper tip of the gonadal pedicle
2. Freeing of the distal tip of the gonadal pedicle
• Extraction
The operative specimens are extracted in an endoscopic bag through the iliac incision under guidance of the laparoscope introduced through the trocar in the flank.
Hemostasis and lymphostasis are performed with a bipolar grasper.
Lavage of the operative area and trocar wounds is done with warm saline.
• Closure
The fascia of the incisions =>10 mm are closed. This is followed by skin closure.
14. Postop management
- the gastric tube and urinary catheter are removed at the end of the operation;
- systematic antibiotic therapy is not administered;
- normal diet is resumed on the evening of the operation or on the next day;
- the patient may return home on POD1 or POD2;
- anticoagulant therapy is continued with the administration of low molecular weight heparin for about 10 days.
15. Complications
Penoscrotal lymphedema
Penoscrotal lymphedema has not yet been observed for this limited form of surgery. It occurs only in cases of complete bilateral lymph node dissection. It disappears spontaneously.

Lymphoceles
Lymphocele formation is the most likely complication of this extraperitoneal dissection. Lymphoceles should be evaluated by CT scan (size, anatomical relationships and effects on the ipsilateral excretory paths). Only symptomatic lymphoceles are treated. The usual treatment is an evacuating puncture. Recurrence is managed by external drainage that is placed either surgically or under radiologic guidance. Internal drainage by laparoscopic marsupialization can be indicated in case of multiple recurrences. In cases of chylous lymphocele, a low fat diet for a few weeks is systematically prescribed.
Prevention of lymphoceles is based on respecting the limits of dissection and on preventative lymphostasis by performing bipolar cauterization on all of the small vessels associated with the lymph nodes. At the end of the procedure, marsupialization is done to prevent postoperative lymphoceles. The pelvic peritoneum is opened widely via an extraperitoneal approach. Care must be taken to prevent the small intestine from getting trapped in the opening, by slow exsufflation of the retropneumoperitoneum.

Sexual disorders
In the staging of early testicular carcinoma, the limited lymph node dissection areas associated with the precautionary measures described for nerve preservation will guarantee that no delayed onset sexual disorders occur.
In cases of the removal of residual post-chemotherapy masses in which nerve fibers are often found, it is not always possible to guarantee that the patient will have no resulting ejaculation disorders. The patient should be clearly informed of this risk.
In all cases, it is mandatory to bank the patient’s sperm prior to surgery.
a. Pelvic peritoneal marsupialization
b. Direct lympho-venous anastomosis
1. Open parietal peritoneum
2. Small intestinal loops
3. Right spermatic duct
4. Right external iliac artery
5. Direct lympho-venous anastomosis
6. Inferior vena cava
16. Reference
Dargent D. Retroperitoneal approach for lymph node sampling and dissection. In: D. Querleu, D.
Dargent, J. Childers, editors. Laparoscopic surgery in gynaecological oncology. Oxford London
Edinburgh: Blackwell Science, 1999. p. 34-46.
Leblanc E, Caty A, Dargent D, Querleu D, Mazeman E. Le curage lombo-aortique laparoscopique
dans les tumeurs germinales non seminomateuses (TGNS) du testicule aux stades precoces:
pourquoi? Comment? Prog Urol 2000;10:379-87.
LeBlanc E, Caty A, Dargent D, Querleu D, Mazeman E. Extraperitoneal laparoscopic para-aortic
lymph node dissection for early stage nonseminomatous germ cell tumors of the testis with
introduction of a nerve sparing technique: description and results. J Urol 2001;165:89-92.
Weissbach L, Boedefeld EA. Localization of solitary and multiple metastases in stage II
nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I. J Urol
1987;138:77-82.