A.右侧肿瘤模板解剖范围包括输尿管(外侧), 主动脉中点(内侧), 髂血管(下)和肾门(上)分叉.B. 左侧肿瘤模板剥离范围包括输尿管(外侧), 腔静脉中点(内侧), 髂血管分叉(远端)和肾门分叉(上端).

Rationale

当睾丸在胎儿肾脏附近形成和发育时, the blood supply, 通向睾丸的淋巴引流和神经起源于肾脏附近. 因此，睾丸癌有一个非常可预测的扩散模式. The primary landing zone for metastases from testis cancer is the lymph nodes of the retroperitoneum — the area around and between the aorta and inferior vena cava at the level of the kidneys. Therefore, retroperitoneal lymph node dissection (RPLND) is an important surgical option for men with testis cancer.

Indications

Traditionally, RPLND是通过一个大的, midline incision (along the entire abdomen) and only performed at high-volume centers of excellence due to the rarity of disease and technical challenges of the surgery. More recently, 微创RPLND已成为男性睾丸癌患者的一种选择, dramatically reducing the convalescence of the operation and offering the benefits of avoiding chemotherapy and rigorous AS. RPLND was a mainstay of therapy for clinical stage I non-seminomatous germ cell tumors (NSGCT) as it better staged disease and offered a therapeutic benefit for many patients. 然而，超过70%的患者永远不需要RPLND，而被手术过度治疗. RPLND has fallen out of favor with many physicians and organization due to the morbidity of the procedure and high risk of overtreatment.

微创RPLND改变了CSI睾丸癌的治疗思路, as it changes the ratio of risk to benefit as the morbidity associated with the procedure is dramatically reduced compared with traditional open surgery. In addition, minimally invasive RPLND can be performed for patients with suspicion of low-burden lymph node metastases (clinical stage II) in the hopes of avoiding chemotherapy.

Many patients with lymph node metastases, especially those with seminoma, will receive chemotherapy. 有些推荐十大正规网赌平台的淋巴结会缩小，但不会完全消失. In other patients, 萎缩的淋巴结会慢慢生长, 说明腹膜后可能正在生长癌细胞或畸胎瘤. 对于这些推荐十大正规网赌平台, a post-chemotherapy RPLND is often indicated to remove cancer not adequately treated by chemotherapy.

微创RPLND

A minimally-invasive RPLND involves the use of small incisions and instruments to perform an RPLND. 约翰霍普金斯大学是微创RPLND的先驱机构之一, 自1992年以来进行了100多次腹腔镜rplnd. 机器人技术, most minimally invasive RPLND are performed with robotic assistance as this technology allows better control and more precise dissection around important vascular structures and the nerves that control ejaculation.

Most minimally invasive RPLND are performed in men with clinical stage I non-seminomatous germ cell tumors. 这些人没有明显的淋巴结肿大. 对于这些男性，可以进行单侧(或单侧)模板解剖. 人体内的淋巴从右往左流动. Therefore men with a left-sided testicular tumor can undergo a left-sided modified template that involves dissection of lymphatic tissue on and around the aorta. 对于右侧睾丸肿瘤患者, 从腔静脉到主动脉周围的淋巴组织需要切除.

对于临床II期NSGCT的男性，可以进行微创RPLND. However, it is recommended that any patient with enlarged lymph nodes undergo a complete bilateral (both-sides) RPLND.

微创RPLND有许多理论上和实际的优势:

• Avoidance of chemotherapy: the long-term side effects of chemotherapy are not known for young men with a long life expectancy. 可能的后期副作用包括:
• 早期心血管疾病.
• 继发性恶性肿瘤发生率增加(最常见的是白血病和淋巴瘤).
• 缩短住院时间和恢复时间:大多数患者在手术后第二天出院.
• Avoidance of a post-chemotherapy RPLND: Complication rates after post-chemotherapy RPLND are higher, 住院时间和康复时间也更长.
• 低射精率:单侧后的射精率, 模板RPLND小于等于5%.

化疗后RPLND

对一些接受化疗的人来说, lymph nodes in the retroperitoneum will not respond to chemotherapy or slowly grow after a period of shrinkage. In these cases, the retroperitoneal mass can be a viable tumor (10–15%) or teratoma (40–50%). Teratoma in the retroperitoneum is not responsive to chemotherapy and will continue to grow until it compresses a vital structure like the inferior vena cava or intestines — a process called growing teratoma syndrome.

化疗后RPLND是一项极具挑战性的手术. Chemotherapy can cause lymph nodes in the retroperitoneum to fuse to important surrounding structures including the aorta, vena cava, 肠和肾. Safely removing the cancerous lymph nodes involves precise dissection and often removal of adjacent organs rather than risk of major vascular or bowel injury. 大多数化疗后rplnd采用团队方式进行, with vascular, 普通外科医生和胸外科医生根据具体情况提供服务. The surgery most often involves a large incision along the entire length of the abdomen and a hospital stay of three to five days. 恢复可能需要两到四周的时间才能完全恢复. However, 化疗后RPLND可以是挽救生命的手术, 当在专家中心执行时, 有很好的效果.

RPLND并发症

The complication rate for a primary RPLND is about 5% and about 15% for a post-chemotherapy RPLND. 严重并发症很少(少于2%)，包括:

• Anejaculation.
• 大出血需要输血.
• 淋巴渗漏(乳糜腹水).

Anejaculation

The nerves that control ejaculation (expulsion of fluid from the penis during orgasm) lie in the retroperitoneum. Sympathetic nerves control ejaculation and run lateral and parallel to the great vessels before converging at the base of the aorta (where it branches to form the iliac arteries) before traveling to the seminal vesicles, vas deferens, 前列腺和膀胱颈. 用神经保护技术, 微创和开放性原发性RPLND的射精率均为5-10%. The rates of anejaculation are higher for post-chemotherapy RPLND as the nerves cannot always be spared to remove cancer.

Serious Bleeding

不到2%的病例发生严重出血. However, bleeding from the aorta or vena cava can require blood transfusion and be potentially life-threatening. In cases where retroperitoneal lymph nodes appear close or adherent to the aorta or vena cava, 手术切除一部分血管通常更安全. 取决于肿瘤的大小和修复的复杂程度, 血管外科医生可能是手术小组的一员.

淋巴渗漏(乳糜腹水)

As the lymphatic channels in the retroperitoneum are interrupted, rarely a lymphatic leak can occur. 你的外科医生会使用各种术中技术来防止淋巴泄漏. In addition, 因为淋巴液是由高脂肪食物“补充”的, a nutritionist will teach you about a low-fat diet and how to slowly resume a normal diet over the weeks following surgery.

Chylous ascites almost always resolves within a few weeks to months, but can be problematic to treat. 乳糜腹水的治疗包括限制饮食, 放置腹部引流管(或间歇引流), medications to decrease the amount of lymphatic fluids or interventional radiology procedures. Johns Hopkins is an expert center in treating refractory chylous ascites with lymphangiography and sclerotherapy. 手术是极少数情况下的最后手段.