Surgical Anatomy

The lymphatic drainage of the testis is to the retroperitoneum. The region of lymphatics draining the testicles includes that area bordered by the crus of the diaphragm superiorly, the bifurcation of the iliac arteries inferiorly, and the ureters laterally. The lymphatic drainage of the testicles is usually very predictable, and metastatic disease reliably involves the area described above. However, exceptions do occur; when metastatic disease is found in the retroperitoneum of patients with low-stage disease, it is located in an aberrant drainage area approximately 5% of the time.

Formerly, RPLND for low-stage disease included a full bilateral template, which involved the removal of all lymphatic tissue from the crus of the diaphragm to the bifurcation to iliac arteries, from ureter to ureter. This procedure universally resulted in the loss of emission and ejaculation since no effort was made to preserve sympathetic fibers. Because the aorta and the vena cava are in the field of dissection, they must be adequately mobilized in order to completely remove lymphatic tissue that is posterior to these vessels. Therefore, in the course of RPLND, lumbar arteries and veins, which attach the great vessels to the posterior body wall, must be divided. Thus, in full bilateral RPLND, complete mobilization of the great vessels, the renal artery and vein, and the ureters is performed, followed by the removal of lymphatics from the posterior body wall (Figure 10-3). Donohue has called this concept of the mobilization of structures away from the lymphatic tissue and the subsequent removal of tissue from the posterior body wall the "subtraction" concept.

In the 1970s, surgical oncologists recognized that the lymphatic drainage of the testis was unique, depending on the side of the primary. For instance, a right-sided testicular primary drains predominantly to the interaortocaval, precaval, and right paracaval lymphatics whereas a left-sided primary drains primarily to the left para-aortic and preaortic lymphatic areas. Mapping studies performed by experienced surgeons have verified this unilateralness and pre

Figure 10-3. This completed full bilateral dissection illustrates the "subtraction" concept. The ureters, aorta, vena cava, and renal arteries are dissected away from lymphatic tissue. This is followed by removal of the lymphatic tissue from the posterior body wall. In this photograph, the aorta and vena cava are retracted laterally, and the anterior spinous ligament is seen posteriorly between these two great vessels. Division of lumbar arteries and veins is necessary to fully mobilize the aorta and the vena cava.

Figure 10-3. This completed full bilateral dissection illustrates the "subtraction" concept. The ureters, aorta, vena cava, and renal arteries are dissected away from lymphatic tissue. This is followed by removal of the lymphatic tissue from the posterior body wall. In this photograph, the aorta and vena cava are retracted laterally, and the anterior spinous ligament is seen posteriorly between these two great vessels. Division of lumbar arteries and veins is necessary to fully mobilize the aorta and the vena cava.

dictability of lymphatic drainage1; that is, the lymphatic drainage is unilateral and predictable if minimal to moderate metastatic disease is present in the retroperitoneum, but it becomes relatively unpredictable with higher volumes of metastatic tumor. Therefore, based on these mapping studies and a desire to preserve unilaterally the sympathetic fibers in order to preserve emission and ejaculation, so-called modified templates were introduced. These modified templates limited the scale of the dissection and preserved emission and ejaculation in 60 to 75% of patients,2,3 thereby decreasing the morbidity of the procedure by decreasing the operative time and by limiting and decreasing the loss of emission and ejaculation (Figure 10-4).

The next step in the evolution of technique also related to anatomy. In the early 1980s, experienced surgeons who were involved in the care of patients with testicular cancer realized that the anatomy of sympathetic fibers in the retroperitoneum was not haphazard and unpredictable but was actually predictable within certain guidelines.4,5 Surgeons began developing nerve-sparing techniques whereby the prospective dissection of sympathetic efferent fibers was carried out, followed by the mobilization of the great vessels, ureter, and renal vessels from the lymphatic tissue and the subsequent template removal of

Figure 10-4. The template of dissection for a right-sided testicular primary is shown on the left. The template of dissection for a left-sided primary is shown on the right.

lymphatics from the posterior body wall. Certain surgical maneuvers allow the prospective identification and dissection of these efferent sympathetic fibers to be done in a reliable and reproducible fashion. Learning these nerve-sparing techniques is not difficult; hence, these techniques have been widely applied in surgical therapy for low-stage testicular cancer (Figure 10-5).

The "subtraction" concept has thus been refined over the last two decades. Conceptually, RPLND for low-stage disease involves, as a first step, the prospective identification and dissection of efferent

Figure 10-5. A completed right modified nerve-sparing retroperitoneal lymph node dissection as viewed from the left side of the patient. The efferent sympathetic fibers are seen in vessel loops, and there is a retro-aortic left renal vein in this particular patient. The anterior spinous ligament is seen posteriorly after the completed resection of lymphatic tissue.

Figure 10-5. A completed right modified nerve-sparing retroperitoneal lymph node dissection as viewed from the left side of the patient. The efferent sympathetic fibers are seen in vessel loops, and there is a retro-aortic left renal vein in this particular patient. The anterior spinous ligament is seen posteriorly after the completed resection of lymphatic tissue.

sympathetic fibers away from the lymphatic tissue. The second step is to mobilize the great vessels from the posterior body wall by dividing the lumbar arteries and/or veins, followed by the dissection of the ureter, the renal artery, and the renal veins from the lymphatic tissue. What then remains is to harvest the lymphatic packages from the posterior body wall since this is the only remaining attachment of the lymphatics after mobilization of the other structures. This concept and technique make RPLND a very reproducible and teachable procedure. It is not an ad hoc tour of the retroperitoneum, involving the removal of abnormal-appearing lymph nodes; rather, it is a systematic reproducible surgical procedure that is highly effective therapeutically.

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