Overview 

Retroperitoneal Lymph Node Dissection (RPLND) is a surgical procedure to remove enlarged lymph nodes from the back of your belly (abdomen). This is performed to treat testicular cancer.¹ 

Why does testicular cancer affect the abdomen? 

Lymph nodes are clustered throughout the body and form a network of glands. Cancer can spread through the lymphatic system and invade lymph nodes and make them bigger (enlarge).²

In a fetus, the testicles develop near the kidneys and lymphatic system in the abdomen. Accordingly, testicular cancer has a very predictable pattern of spreading to the lymph nodes of the abdomen.^1,2  Therefore, RPLND is a major surgical option for men with testicular cancer. 

How is RPLND performed? 

• RPLND is a major operation for patients with lymph node metastases. This is usually performed by experienced surgeons in specialist centres. 
• Traditional RPLND involves a long cut from the top of the tummy to below the belly button, and the surgeon has to move organs aside to reach the lymph nodes in front of the spine due to technical challenges and the rarity of the disease.³ 
• The surgery is performed under general anaesthesia. 
• Post-chemotherapy RPLND may be indicated for patients with shrunken lymph nodes that slowly grow, indicating viable cancer or teratoma growth in the retroperitoneum.^1,3
• Post-chemotherapy RPLND is challenging and may involve a team of different types of surgeons (e.g. urologist, vascular surgeon) due to enlarged lymph nodes fusing to important surrounding structures (including the aorta, intestines and kidneys). 

Before your operation

Before the operation, patients who smoke may be advised by their GP to quit smoking to reduce the risk of chest problems and help in wound healing.⁴ 

Patients will need to attend a pre-operative assessment clinic where they will discuss the operation with a team of surgeons and a specialist nurse. The patients will have the chance to address any concerns they have. It is important to inform the surgical team and the anaesthetist of any history of bleomycin chemotherapy.

For a comprehensive care plan, patients should inform the medical professionals of any additional help they may need, such as requiring extra assistance during the hospital stay or recovery period. This will allow for necessary arrangements to be made. 

To offer the surgical team a comprehensive understanding of the patient's health, preceding the surgery, patients may undergo various tests, such as chest x-ray, blood tests, urine tests and electrocardiogram (ECG).^2,4

Getting the results

Following the surgery, the removed tissue is sent to the laboratory for examination. The process of analysis and examination may take several weeks. Once the results are in, the doctor along with a multidisciplinary team of medical professionals will decide on the best course of treatment for the patient.¹ 

The doctor will communicate the treatment plan to the patient, including information about any follow-up appointments that may be required. 

After Surgery 

Once the patient has undergone surgery, they may be placed in a high dependency unit (HDU) or intensive care unit (ICU)for close monitoring.^1,2 This usually lasts for 1 night before being moved back to the ward. Most patients are discharged after 3-5 days. 

The patients are encouraged to start moving as soon as possible following the surgery. Therefore, physiotherapy will start the day following the surgery. This is to reduce the risk of complications such as blood clots or chest infections. Along with movement, the patients will have to wear support stockings (TED stockings) designed to prevent blood clots in the legs.^1,5

Following the surgery, patients usually have a drip which provides them with fluids, a tube draining the bladder (catheter) which collects urine, and a tube draining the excess fluid from the wound which helps the wound heal.⁴ Patients usually can start drinking water 2-3 days after the surgery, and once bowel activity has returned, they can start eating and drinking freely.⁶ 

RPLND Complications 

octors and nurses will be monitoring patients closely for complications in order for immediate treatment to be provided. 

Common complications after the surgery include wound infection, bleeding in the wound area, chest infection, developing a blood clot, delayed normal function of the bowel, and swelling or redness in the limb.^3,5 

Another complication of RPLND is represented by ejaculation problems. This can manifest as dry ejaculation or retrograde ejaculation and is caused by semen not being able to leave the body during ejaculation, and entering the bladder instead.¹ Patients can still have an erection and reach orgasm, but will not be able to get someone pregnant without fertility treatment. Patients will be advised by the doctor if sperm banking is appropriate for them.  

Returning home 

• Surgeons use dissolvable stitches that don't need to be removed.
• Expect a long, vertical wound that will be red and swollen at first and will leave a long scar that will gradually fade.
• Full recovery may take a few months and the doctor will advise when you can lift heavy objects, start driving again or return to work.

Alternative approaches 

A less invasive approach is Keyhole surgery, sometimes called laparoscopic surgery or robotic RPLND.² This surgery is minimally invasive and usually performed when patients have not already had chemotherapy. It involves several small incisions instead of one long cut, which has a faster healing time. The operation is usually performed with robotic assistance allowing better precision. As this surgery is not very common, only highly specialised doctors can perform it, and it may not be suitable for all patients. 

Summary

Retroperitoneal lymph node dissection (RPLND) is a surgical procedure to remove enlarged lymph nodes from the back of your abdomen to treat testicular cancer. Traditional RPLND involves a long cut from the top of the tummy to below the belly button and is performed under general anaesthesia. Post-chemotherapy RPLND may be indicated for patients with shrunken lymph nodes that slowly grow, indicating viable cancer or teratoma growth in the retroperitoneum. Patients will need to attend a pre-operative assessment clinic and undergo various tests before the operation.

Following the surgery, patients may be placed in an HDU or ICU for close monitoring before being moved back to the ward. Common complications after the surgery include wound infection, bleeding in the wound area, chest infection, developing a blood clot, delayed normal function of the bowel, and swelling or redness in the limb. A less invasive approach is Keyhole surgery or minimally invasive RPLND, which involves several small incisions rather than a long cut and has a faster healing time. However, this surgery may not be suitable for all patients. Full recovery may take a few months, and the doctor will advise when patients can start lifting heavy objects, driving again, or returning to work.