Thyer Urology

Retro-Peritoneal Lymph Node Dissection (RPLND) is usually performed for testicular cancer. Mr Thyer has also performed RPLND for cancers originating elsewhere for example kidney, skin, pancreas, prostate and cervix.

The lymphatic system is a network of fine vessels throughout the body that transports lymph (tissue fluid) back to the heart. The lymph nodes are stationed along the lymphatic vessels where immune system cells congregate to fight infections and cancer. Testicular cancer will sometimes spread along lymphatic channels and grow within lymph nodes around the aorta and vena cava (large blood vessels in the back of the abdomen). Chemotherapy will usually remove any cancer in the lymph nodes but occasionally the lymph nodes remain enlarged raising the possibility that the cancer remains dormant within the lymph nodes. Your oncologist has referred you to Mr Thyer to have the retro-peritoneal lymph nodes removed.

Pre operation

Ten days prior to the procedure you should:

• Have your blood and urine test
• Notify Mr Thyer’s rooms if you are taking any blood thinning medication

The procedure

On arrival at hospital you will be prepared for theatre by nursing staff. Mr Thyer will see you just prior to being taken into the operating theatre. You will require a general anaesthetic of approximately 4 hours. Mr Thyer will make an incision from the breast bone to the pubic bone. The abdominal contents will be shifted aside and the aorta and vena cava exposed. The lymph nodes around these structures will be removed and sent to a pathologist for microscopic examination (you may incur a pathologist fee). The lymphatic channels that have been disrupted will be clipped to avoid lymphatic leak. The abdominal contents will be replaced in their normal position. After the operation a drain will be left in the abdomen and a catheter in the bladder. Most men spend one night in ICU then are shifted to the ward for a further 2 nights before being discharged home after Mr Thyer’s review.

Note: A vascular surgeon will be on standby to assist Mr Thyer if the lymph nodes are adherent to the aorta or vena cava

Risks

• Haemorrhage. There is minimal blood loss during most operations however the occasional operation does have bleeding complications. A vascular surgeon will always be available at the time of the operation to assist should major bleeding occur.
• Infection. Wound infection is rare but may require a course of oral antibiotics to correct.
• Nephrectomy. Occasionally the lymph nodes around the renal blood vessels or ureter can be very adherent and impossible to dissect free from these structures necessitating removal of a kidney. Large series have shown this to occur in 5% of all RPLNDs.
• Injury to surrounding structures. The bowel, liver, spleen, adrenal, pancreas, kidneys and large blood vessels are close to the area of dissection and may require repair if injured during the dissection.
• Retrograde ejaculation and reduced fertility. The nerves that cause the bladder neck to close during ejaculation pass through the area of dissection. These nerves can be injured at the time of dissection resulting in retrograde ejaculation where the semen is no longer ejaculated through the penis at the time of sexual climax. This would result in reduced fertility. If sperm banking has not already been undertaken then this should be considered prior to undertaking this operation. Erectile function is not diminished by preforming this operation.
• Chyle leak. Lymphatic channels in the abdomen transport fat from the intestines back to the heart. This fat is known as ‘chyle’. Leakage of chyle into the abdomen can cause abdominal distension and severe malnutrition. The chance of a chyle leak is approximately 13% and is minimised by placing clips on lymphatic channels at the time of surgery and also by consuming a low (or no) fat diet after the operation. Rarely a significant chyle leak may necessitate a return to theatre to close the leaking vessel.
• Bowel obstruction. There is a 1% lifetime risk of adhesions forming in the abdomen leading to bowel obstruction. This can usually be managed conservatively under the care of a general surgeon.
• Hernia. Very occasionally (1%) a hernia can develop at the wound site which requires correction with a general surgeon.
• Recurrence of cancer. It is uncommon (approximately 5%) to see cancer recur in the retro-peritoneal lymph nodes after RPLND.
• There are risks with any general anaesthetic which are very rare including blood clots, heart or lung problems and adverse drug reactions. The anaesthetist will discuss these with you at the time of the procedure.

Follow up

Mr Thyer’s rooms will contact you to arrange follow up to check your progress, wounds and pathology 3 weeks following the operation. You should consume a very low fat diet, take laxatives, wear compression stockings, drink plenty of water and avoid heavy lifting for 3 weeks following the procedure. You should not drive a motor vehicle until seen by Mr Thyer at the follow up appointment. Your oncologist will follow you up beyond this appointment.

When to contact Mr Thyer

Following the procedure, you should contact Mr Thyer if you:

• Have a fever over 38 Degrees
• Feel your abdomen is becoming increasingly bloated
• Have not received a follow up appointment
• You can contact Mr Thyer via his rooms during working hours or after hours via the after hours nurse at Hollywood Hospital on (08) 9346 6000
• You can attend the emergency department at the hospital at which you had your procedure. (Hollywood Private Emergency Department charge a fee for attendance).