RPLND has an important place in the management of low and high-stage testicular cancer. It offers 2 basic benefits: accurate staging and the possibility of a surgical cure, even with metastatic disease
Approximately 80% stage II seminoma treated with chemomotherapy will present residual masses. EAU guidelines recommend biopsy or surgical resection for PET positive masses(>3cms) when feasible. PC–RPLND template depends on disease extension. According to Heidenreich criteria, unilateral modified template during PC-RPLND is suitable if the pre-chemotherapy metastases are found in the primary landing zone of the tumor-bearing testicle and if the post-chemotherapy residual masses.
Clinical case and follow-up are presented in video. PC-CT scan shows para-aortic (+0.6cms) and inter-aorto-cava (+0.4cms) lymph nodes progression with metabolic up-take on PET scan
Patient wanted to avoid significant ejaculatory morbidity and rejected bilateral template
Location (Lower incidence of cross spread disease than right tumors)
Low incidence of teratoma
Good prognosis (IGCCG)
A modified “full left” template RPLND was performed using a laparoscopic transperitoneal approach.
Inter-aorto-caval lymph nodes were included (Indiana university, Beck 2007).
Preoperative low fat diet, over 1 week continued 2 weeks postoperatively, was used. Vascular surgeon was previously advice.
Surgical time:136 min
Estimated blood loss:110ml.
No intraoperative complications.
Drain shows milky appearance. Biochemical analysis revealed chylascites. Median-chain fatty-acids rich diet and subcutaneous octeotride were used. Drainage decreases on 4th post-operative day and was removed on 7th post-operative day. Hospital stay: 8 days.
Histopathology: 2/11 lymph nodes positive for pure seminoma. <10% viable tumor Post RPLND PET scan shows a right retrocrural mass. Patient received salvage chemotherapy (TIPx2).
PC-PET scan shows no evidence of the disease.
18 months follow up: patient is recurrence free, preserves antegrade ejaculation and is asymptomatic.
Resection of residual disease was technically challenging due to desmoplastic reaction. Complications were avoided with careful dissection
Template boundary is a matter of actual debate. Experience on seminomas is limited discussed.
No infield relapse inside of modified template was detected. Follow up is a limitation.
As surgical series of limited dissections continue to mature, extent of PC-RPLND remains controversial.