Postchemotherapy (pc) retroperitoneal lymph node dissection (RPLND) can be a challenging yet curative intervention in patients with a history of metastatic testicular cancer. Recommended to be completed at high-volume centers, surgeons performing RPLNDs require an intimate understanding of the retroperitoneal vascular, nervous, and lymphatic systems as well as pathophysiology of the disease. In the postchemotherapy setting, there is an even greater emphasis on optimizing surgical planning and the approach given the higher potential morbidity of the surgery compared with a primary RPLND.¹ In our experience with pcRPLND, the following considerations have aided in surgical preparation and improving outcomes.

Patient Considerations

Seminoma vs nonseminoma considerations

Appropriate patient selection and a thorough understanding of the risk of active retroperitoneal disease after chemotherapy are essential first steps in preparation for a pcRPLND. Residual malignant disease in nonseminoma patients pursuing a pcRPLND is expected 5% to 10% of the time, while teratoma and fibrosis are both found approximately 45% of the time.² In patients with teratoma in the initial orchiectomy specimen rates of teratoma are expected to be even higher. Relapse rates in nonseminoma patients after pcRPLND are estimated to be around 10% to 15%; however, positive malignant nodes do portend a poorer prognosis and the option for adjuvant chemotherapy should be discussed.^2,3 Conversely, in seminoma patients pcRPLND is less likely to provide cure with only 23% of patients found to be disease-free after pcRPLND alone, and surgery more frequently necessitates concomitant procedures such as vascular reconstruction or nephrectomy.⁴ Thus, pcRPLND for seminoma patients is seldom performed and selection should be carefully evaluated. Given the additional complexity of pcRPLND in seminoma patients related to the diffuse desmoplastic reaction of the tumor to chemotherapy, greater attention to anatomic considerations reviewed later in this commentary are often necessary.

Preoperative optimization

While testis cancer patients often have limited comorbidities, in the postchemotherapy setting complications and ongoing side effects from the antineoplastic agents can limit patients’ resilience and increase the risk of intra- and postoperative adverse events. Review of preoperative complete blood count and complete metabolic panels to assess for persistent anemias caused by etoposide and potential renal dysfunction from cisplatin are necessary. A thorough pulmonary exam is also required to ensure limited toxicity from bleomycin, and preoperative clearance teams may perform pulmonary function tests should concerns arise.

Preoperative Planning

Staging imaging

High-quality and up-to-date (no older than 4 weeks) preoperative imaging is imperative for surgical planning. Standard abdominal imaging should include contrast-enhanced CT or MRI. Pelvic imaging should also be included if the patient has a history of scrotal surgery (ie, vasectomy, cryptorchidism repair) altering the expected lymphatic flow. On staging chest imaging progressive or residual pulmonary and/or mediastinal lymphadenopathy should be examined. The utility of positron emission tomography (PET) imaging in the evaluation of metastatic testicular cancer is limited. In the nonseminoma setting, PET imaging should not impact clinical decision-making given the poor sensitivity (59%) and the lack of fluorodeoxyglucose avidity in teratomatous disease.⁵ For seminomatous disease, National Comprehensive Cancer Network guidelines do recommend consideration of PET imaging obtained at least 6 weeks after chemotherapy for > 3 cm residual masses.⁶ However, even with these criteria, a retrospective review of 90 seminoma patients with a postchemotherapy PET-avid mass demonstrated a positive predictive value of only 23%.⁷ Given the poor reliability of PET imaging in the postchemotherapy setting, PET imaging should selectively be used and not the sole factor in proceeding with a pcRPLND.

Anatomical considerations

Imaging should be evaluated for unique patient anatomy including aberrant lumbar veins, accessory renal vasculature, duplicate inferior vena cava, and/or duplicate ureters. With regard to postchemotherapy changes, patency of vasculature should be assessed to determine if tumor thrombus or tumor invasion is present necessitating reconstruction. Vena cavography can be obtained to evaluate for collaterals if caval ligation is under consideration (Figure). Additionally, when reviewing imaging the potential need for collaborative surgical planning should be examined. These include but are not limited to the potential need for colorectal surgery to perform a bowel resection, the hepatobiliary team for complete liver mobilization, vascular surgery for arterial or venous grafting, thoracic surgery for mediastinal resection, and cardiothoracic intervention for potential bypass if tumor thrombus extends above the diaphragm.

Operative Approach Considerations

Template selection and nerve-sparing

Based on the patient and anatomic evaluation, surgeons can determine the appropriateness of offering a modified template approach. Multiple retrospective analyses have demonstrated similar disease-free survival in modified template pcRPLND patients compared with a full bilateral dissection given the patient had nonbulky initial stage II disease within the primary landing zone.^8-10 Similarly, nerve-sparing can be offered when the oncologic efficacy of the dissection will not be impacted.¹¹

Open vs robotic approach

Consideration of a minimally invasive approach should be highly selective given the limited evidence of long-term oncologic data in the postchemotherapy setting. While a number of single and multi-institutional retrospective studies have reported the safety and feasibility of robotic pcRPLND, greater rates of chylous lymphatic and vascular complications, and longer operative times have been reported.¹² A case series of abnormal out-of-field recurrences, including peritoneal carcinomatosis, pericolic, and large-volume liver recurrences, referred to our institution after robotic RPLND emphasizes reservations on widely accepting this approach.¹³ Ultimately, the data are lacking in providing greater guidance in patient selection and a robotic pcRPLND should be chosen with caution.

Extraperitoneal vs transperitoneal

As a final consideration, surgeons can weigh the option of an extraperitoneal vs transperitoneal approach. A retrospective analysis of 237 patients who underwent an extraperitoneal approach, 72% of which were in the postchemotherapy setting, demonstrated safe (4% grade III and IV complications) and acceptable oncologic outcomes (88% recurrence-free survival in nonseminoma patients).¹⁴ To date no randomized controlled trial comparing the efficacy of the extraperitoneal to transperitoneal approach has been conducted, limiting a conclusive evaluation, but current data remain encouraging.

Conclusion

While pcRPLND is based on the same surgical steps and principles as a primary RPLND, extra consideration is required in preoperative selection and surgical planning. Anticipating the potential need for additional surgical teams and collaboration as well as ensuring all necessary imaging and preoperative evaluations are conducted are critical steps to ensuring a safe and effective surgery.