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Retroperitoneal Lymph Node Dissection


Retroperitoneal lymph node dissection (RPLND) has a diagnostic and therapeutic role in many urologic malignancies. Testicular carcinoma is the most common urologic indication for RPLND, followed by renal cell carcinoma and upper urinary tract urothelial carcinoma.

In the setting of testicular tumors, RPLND may be used as a primary treatment modality for low-volume nonseminomatous germ cell tumors (NSGCTs) localized to the retroperitoneum. In addition, RPLND may be used as a salvage therapy for residual masses following chemotherapy in NSGCTs and in seminomatous tumors that are refractory to chemoradiotherapy.

RPLND was initially a component of all radical nephrectomy procedures, as outlined by Robson.
RPLND subsequently evolved mainly into a staging procedure, believed to confer limited therapeutic benefit in most circumstances. In 1999, a randomized trial conducted by the European Organisation for Research and Treatment of Cancer (EORTC) evaluated whether RPLND conferred a benefit in the management of renal cell cancer. The patients studied were randomized to undergo either radical nephrectomy alone or in conjunction with RPLND. Among the patients who underwent RPLND, only 3.3% were found to have positive lymph nodes, and the addition of RPLND did not change 5-year progression-free survival or overall survival rates.

However, new adjuvant therapies, as well as laparoscopic RPLND (L-RPLND), have renewed interest in the topic. One study demonstrated a nodal yield of 12.1 toward the end of their series of 50 patients with clinically node-negative renal cell carcinoma undergoing laparoscopic nephrectomy and L-RPLND.
In another study, a very experienced laparoscopist found laparoscopic nephrectomy with hilar lymph node dissection to be feasible and safe in patients with clinically node-positive disease.

Similarly, RPLND has not had a traditional role in the management of upper urinary tract urothelial carcinoma. A provocative retrospective report recently showed that RPLND conferred a significant survival advantage in univariate analysis, although, in multivariate analysis, the improved overall survival occurred without improvement in local recurrence or disease-specific survival rates, suggesting selection bias or unexplained confounding factors.

This article focuses primarily on RPLND in the setting of testicular tumors. For additional information on testicular cancer, see Medscape’s Testicular Cancer Resource Center.

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