|The Testicular Cancer Resource Center|
Testicular cancer usually spreads via a very predictable route through the lymph nodes upwards to the lungs, and then outward to the liver, brain, and elsewhere. The affected lymph nodes are call the "retroperitoneal lymph nodes" and they are located behind all of the major organs in the belly, basically between the kidneys and along the vena cava and aorta.
In certain situations it makes sense to remove these nodes. In other situations the RPLND is simply not done. So, who might need an RPLND?
So who does not need an RPLND or is not likely to be offered an RPLND? In general, if you don't fall into one of the categories mentioned above, you should not be thinking about the RPLND. However, things may be a little more complicated, so I will try to specifically list those situations where you do not want or will not be offered an RPLND.
Enough about who should and should not have the operation. What is the operation like? Make no mistake, we're talking some serious surgery here, folks. In a nut shell, the RPLND involves an incision from just below your sternum to below the belly button (but they do go around it!). Your intestines and associated organs are literally lifted out of the way, nerves are identified and hopefully moved out of the way, and then the surgeons remove all the lymph nodes that were connected to the testicle containing the tumor.
The operation itself can take 3-6 hours, but I have spoken with doctors who have had advanced cases lasting 20+ hours! They usually check the lymph nodes on the same side as the affected testicle first, and if they find anything suspicious, they may check the other side as well for additional spreading. If you would like to see more details about the actual surgical procedure, take a look at some of the links at the bottom of this page.
This is a very well studied surgical procedure: if you come out clean, odds are pretty good that you are TC free! (not good enough to never go back to the doctor, but very good nonetheless.) If they find cancer, you've most likely got a longer (but still survivable!) path of surveillance or chemo in your future.
Is this surgery "risk free"? Absolutely not! It is a complicated and delicate procedure that is rarely done. There are far more urologists in the US than there are RPLND's in a single year. Few doctors do more than a couple of these surgeries a year. This is one time when you should be willing to hurt your urologist's feelings and look for someone who has some experience. If you need a post-chemo RPLND, I strongly suggest that you find someone who has done the procedure many times before. (I also suggest banking sperm before the surgery if you are interested in having children in the future. It is good insurance and worth the expense.)
What are some of the risks with RPLND surgery? Here's a good starter list of possible problems:
Note: these risks should not scare you away from this sometimes necessary procedure, but you do need to be aware of them and discuss them, and any other concerns with your doctor. As we have pointed out, this is serious surgery, so ask LOTS of questions.
Recent developments in the field include the laparoscopic RPLND. This is an infrequently available, very new, very difficult, time consuming operation. It does substantially reduce morbidity and recovery time. However, we do not recommend it because we do not feel that it is a curative operation. In other words, since it won't cure you, it will not eliminate the need for chemotherapy. If it doesn't do this, then why bother doing it at all? See the articles listed below for more information on this topic.
Additionally, an increasing number of doctors in Europe and a few in the United States are offering their patients 2 cycles of chemotherapy instead of an RPLND. This is popular in Europe because they appear to avoid the RPLND like the plague - basically, they simply do not have enough urologists around to do the surgery, and the surgeons they do have do not have any experience with the operation. It is becoming more popular here because there is the belief that the surgery is not valuable and can be avoided with a little chemo. I strongly disagree with this approach. The RPLND is serious surgery, but it is a proven treatment for this cancer. If there is no cancer, and the nerve sparing approach is used, then there should be no long term side effects of the surgery. You cannot say that with chemo - even two cycles of chemo can cause some lasting side effects, and it would be unfortunate to go through chemo and not even need it. Finally, the chemo is not a proven treatment and there is no long term data to support its effectiveness. Two cycles done after a properly done RPLND can virtually ensure a cure. Two cycles done without an RPLND might be too much treatment, just enough, or not enough at all...
For more information on the subject, please take a look at these links: