Nerve Sparing Retroperitoneal Lymph Node Dissection (NS-RPLND)
Once the orchiectomy has been performed, and the pathologist has evaluated the specimen, the most important decision point in management of the testis cancer patient is whether the tumor is a pure seminoma, or a nonseminomatous germ cell tumor (NSGCT). Seminoma is most often treated with radiation therapy. If the pathology is consistent with NSGCT, and the CT scan and tumor markers are negative, surgical evaluation of the lymph nodes in the back of the abdomen (belly) is indicated. This is accomplished by performing a retroperitoneal lymph node dissection (RPLND). The RPLND allows the urologist to remove the lymph nodes in the back of the abdomen, behind the bowel, and near the big vessels of the body. If the lymph nodes are negative, than further therapy is not required. If the lymph nodes are positive, then chemotherapy is recommended.
Historically, a common side effect to an RPLND has been lack of emission, which presents as a dry ejaculate during sex and orgasm. Because of this, men who have had a RPLND may have difficulty with fertility (having children). The reason that men experience a lack of emission has to do with the fact that the nerves involved in emission run through the middle of the lymph nodes that need to be removed. A nerve sparing (NS) RPLND can be performed which leaves these nerves intact, in an attempt to preserve the emission process. This improves the patient's chances of having a wet orgasm, and ultimately improving the chance of normal fertility.
Patients who are scheduled to undergo a nerve sparing RPLND will be given preoperative instructions. The most important of these instructions is the preoperative bowel preparation. The purpose of cleaning out the bowels is to provide as much space as possible to work within the abdomen. Another reason for the bowel prep is if an inadvertent bowel injury occurs (< 1% of the time), the bowel prep limits the amount of contamination, and allows us to perform an uncomplicated repair of the bowel.
For your upcoming surgery, you will be given a form with the date and time of surgery, and the time you should arrive at the George Washington University Hospital. Many patients park at a Metro stop and take the Metro train to Foggy Bottom/GWU, which is located in from of the hospital lobby. Alternatively, there is a parking garage on I Street, less than 1 block from the hospital.
On the day of surgery your surgeon will greet you in the pre-op area and answer any last minute questions that you may have. You will meet the anesthesia team, and several peri-operative nurses. You will also meet our resident house staff. These doctors will be involved in your hospital care, and you will most likely see them several times after your surgery has finished. It is a busy time, but your family will be able to stay with you for most of the preoperative time, until you are taken back to the operating room.
As with any major operation, there are risks associated with the performance of an RPLND. The risks of these operations include but are not limited to bleeding, infection, damage to the liver, spleen, bowel, nerves, major vasculature, and complications related to anesthesia. It is important for the patient to realize that after surgery they should feel a little better every day. If you experience a dramatic turn for the worse, such as increasing belly pain, or increasing pain at one of the laparoscopic ports, nausea and vomiting, fevers (> 101°F) and chills, shortness of breath, chest pain, or unilateral leg swelling, you should return to the hospital emergency room (ER) right away for re-evaluation. On the other hand, the majority of patients do extremely well, and recover rapidly.
Postoperatively you will be given a prescription for pain pills and stool softeners. You may need to use the pain medication for several days, but we encourage you to quickly transition to Tylenol for pain control, and use the narcotic pain medication sparingly.
If you have a routine uncomplicated postoperative course, you should call the office to schedule a follow up appointment between 1 and 2 weeks following surgery. During the follow up appointment, we will evaluate how you are doing, exam your wounds, and review your pathology. Please bring your spouse or significant other to this visit. Follow up care will depend on the pathologic findings from the dissection. The surgeon will discuss the next steps in detail at this first postoperative visit.