JAMES BUCHANAN BRADY UROLOGICAL INSTITUTE LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION (RPLND)

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1 JAMES BUCHANAN BRADY UROLOGICAL INSTITUTE LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION (RPLND) OVERVIEW Laparscpic Retrperitneal Lymph Nde Dissectin (RPLND) prvides patients with a safe and effective way t remve retrperitneal lymph ndes in patients with testicular cancer. Laparscpic RPLND is a minimally invasive technique, which prvides patients with less discmfrt when cmpared t the traditinal pen surgery. Laparscpic RPLND has resulted in significantly less pst-perative pain, a shrter hspital stay, earlier return t wrk and daily activities, a mre favrable csmetic result and utcmes similar t that f pen surgery. Testicular cancer is ne f the success stries in the treatment f malignant tumrs. Advances in diagnstic x-rays, radiatin, and chemtherapy allw fr a cure in the majrity f cases. Testicular cancer usually spreads in a predictable manner, ging first t the lymph ndes, lcated behind the majr rgans in the abdmen. When testes cancer is detected, remval f the testicle (rchiectmy) is first perfrmed. This gives imprtant infrmatin regarding the type f cancer and the risk that it may have spread. Bld wrk including, AFP (Alphafetprtein), Lactic Dehydrgenase (LDH) and Quantitative HCG (Human Chrinic Gnadtrpin) are dne alng with a chest x-ray and an abdminal CT scan t determine the stage f the disease and the best treatment ptin. Treatment ptins (depending n the stage and type f cancer) include 1. Surveillance 2. RPLND 3. Chemtherapy 4. Radiatin Yur surgen has determined with yu that RPLND is the next step in the management f yur testes cancer. OUR SURGEONS Mhamad E. Allaf, MD Edward M. Schaeffer, M.D., Ph.D. Office: Appintments: Fax: mallaf@jhmi.edu Appintments: eschaef4@jhmi.edu

2 APPOINTMENTS Jhns Hpkins Hspital Patients and Jhns Hpkins Bayview Medical Center Patients please use the phne numbers listed abve. In the event f an emergency and yu need t cntact smene in the evening hurs r n the week end, please call the paging peratr at (fr Jhns Hpkins Hspital Patients) r (fr Jhns Hpkins Bayview Medical Center Patients) and ask t speak t the urlgist n call. Fr directins t Jhns Hpkins Hspital and Jhns Hpkins Bayview Medical Center please use this link PRIOR TO THE SURGERY What t expect during yu preperative cnsultatin During yur initial cnsultatin with yur surgen, he will review yur medical histry as well as any utside reprts, recrds, and utside Xray films (e.g. CT scan, MRI, sngram). A brief physical examinatin will als be perfrmed at the time f yur visit. If yur surgen determines that yu are a candidate fr surgery, yu will then meet with a Patient Service Surgery Crdinatr t arrange fr the date f yur peratin. NOTE: It is very imprtant that yu gather and bring all f yur Xray films and reprts t yur initial cnsultatin with yur surgen. What t expect prir t the surgery Since insurance cmpanies will nt permit patients t be admitted t the hspital the day befre surgery t have tests cmpleted, yu must make an appintment t have pre-perative testing dne at yur family dctr r primary care physician's ffice within 1 mnth prir t the date f surgery. These results need t be faxed by yur dctr's ffice t the Pre-perative Evaluatin Center at tw weeks prir t yur surgery. Please call The Dcumentatin Center at tw weeks befre yur surgery date t cnfirm that this infrmatin was received.. Once yur surgical date is secured, yu will receive a frm alng with a letter f explanatin t take t yur primary care physician r family dctr in rder t have the fllwing pre-perative testing dne prir t yur surgery. Physical exam EKG (electrcardigram)

3 CBC (cmplete bld cunt) PT / PTT (bld cagulatin prfile) Cmprehensive Metablic Panel (bld chemistry prfile) (AFP) Alpha-fetprtein (bld wrk) (HCG) Human Chrinic Gnadtrpin (bld wrk) (LDH) Lactic Dehydrgenase Urinalysi Chest x-ray CT scan f the abdmen Preparatin fr surgery Medicatins t Avid Prir t Surgery Aspirin, Mtrin, Ibuprfen, Advil, Alka Seltzer, Vitamin E, Ticlid, Cumadin, Lvenx, Celebrex, Vltaren, Vixx, Plavix and sme ther arthritis medicatins can cause bleeding and shuld be avided 1 week prir t the date f surgery (Please cntact yur surgen s ffice if yu are unsure abut which medicatins t stp prir t surgery. D nt stp any medicatin withut cntacting the prescribing dctr t get their apprval). Bwel Preparatin and Clear Liquid Diet D nt eat r drink anything after midnight the night befre the surgery and drink ne bttle f Magnesium Citrate (can be purchased at yur lcal pharmacy) the evening befre yur surgery. Drink nly clear fluids fr a 24-hur perid prir t the date f yur surgery. Clear liquids are liquids that yu are able t see thrugh. Please fllw the diet belw. Clear Liquid Diet Remember nt t eat r drink anything after midnight the evening befre yur surgery. Clear liquids are liquids that yu are able t see thrugh. Please fllw the diet belw. Water Clear Brths (n cream sups, meat, ndles etc.) Chicken brth Beef brth Juices (n range juice r tmat juice) Apple juice r apple cider Grape juice

4 Cranberry juice Tang Hawaiian punch Lemnade Kl Aid Gatr Aid Tea (yu may add sweetener, but n cream r milk) Cffee (yu may add sweetener, but n cream r milk) Clear Jell (withut fruit) Ppsicles (withut fruit r cream) Italian ices r snwball (n marshmallw) THE SURGERY The Operatin The length f the peratin is typically 3-5 hurs. The surgery is perfrmed thrugh 3-4 small (1 cm) incisins created in the midline f the abdmen. Lymph ndes are remved n the side f the testicular cancer. Using a small telescpe and ther instrumentatin, the lymph tissue that drains the testicle is remved. The number f lymph ndes t be remved can vary amng individuals and can range frm less than I 0 t ver 50 Lymph ndes are are part f the immune system, which help in fighting ff infectin. The relative number f lymph ndes remved during RPLND are nt enugh t affect yur immune system r yur bdy's ability t fight ff infectin. Alng with the remval f the lymph ndes the remainder f the bld supply t the affected testicle and spermatic crd is als remved. Open Prcedure

5 Laparscpic Prcedure

6 Ptential Risks and Cmplicatins Althugh this prcedure has prven t be very safe, as in any surgical prcedure there are risks and ptential cmplicatins. The safety and cmplicatin rates are similar when cmpared t the pen surgery. Ptential risks include: Bleeding: Bld lss during this prcedure is pssible, hwever, a bld transfusin is rarely needed. If yu are interested in autlgus bld transfusin (dnating yur wn bld) yu must make yur surgen aware. When the packet f infrmatin is mailed t yu regarding yur surgery, yu will receive an authrizatin frm fr yu t take t the Red Crss in yur area. Infectin: All patients are treated with intravenus antibitics, prir t starting surgery t decrease the chance f infectin frm ccurring after surgery. If yu develp any signs r symptms f infectin after the surgery (fever, drainage frm yur incisins, urinary frequency/discmfrt, pain r anything that yu may be cncerned abut) please cntact us at nce. Tissue / Organ Injury: Althugh uncmmn, pssible injury t surrunding tissue and rgans including bwel, vascular structures, spleen, liver, pancreas and gallbladder culd require further surgery. Injury culd ccur t nerves r muscles related t psitining. Hernia at incisin site is a pssibility. Althugh very rare, the kidney and ureter n the side that the lymph ndes are being remved culd be injured. Hernia: Hernias at incisin sites rarely ccur since all keyhle incisins are clsed carefully at the cmpletin f yur surgery. Cnversin t Open Surgery: The surgical prcedure may require cnversin t the standard pen peratin if difficulty is encuntered during the laparscpic prcedure. This culd result in a larger standard pen incisin and pssibly a lnger recuperatin perid. Sperm Banking: Patients shuld cnsider banking sperm prir t any treatment fr their testis cancer, esp. chemtherapy because chemtherapy may effect sperm prductin by yur remaining testicle. The return f sperm quality culd take ver ne year fllwing chemtherapy but may never return t nrmal levels. Retrgrade Ejaculatin/Infertility: Occasinally nerves that cntrl ejaculatin may be injured during surgery. This may result in retrgrade ejaculatin causing sperm t be expelled int the bladder instead f ut the tip f the penis. As such, ne may nt see a discharge (i.e. ejaculate) with rgasm. The fluid will mix in the bladder with urine and be eliminated with the next urinatin. This cnditin is nt dangerus and des nt affect yur ability t have erectins r an rgasm. This culd, hwever, affect future fertility. Lymphcele: Lymphatic fluid can cllect in the area where the lymph ndes were remved. This culd require drainage and further surgery. Respiratry Cmplicatin: If yu received a chemtherapy medicatin called blemycin befre yur surgery, yu are at a slightly higher risk f lung cmplicatins during and fllwing surgery. WHAT TO EXPECT AFTER SURGERY

7 During yur hspitalizatin Immediately after the surgery yu will be taken t the recvery rm and transferred t yur hspital rm nce yu are fully awake and yur vital signs are stable. Pst Operative Pain: Pain medicatin can be cntrlled and delivered by the patient via an intravenus catheter r by injectin (pain sht) administered by the nursing staff. Yu may experience sme minr transient shulder pain (1-2 days) related t the carbn dixide gas used t inflate yur abdmen during the laparscpic surgery. Nausea: Yu may experience sme nausea related t the anesthesia r pain medicatin. Medicatin is available t treat persistent nausea. Urinary Catheter: Yu can expect t have a urinary catheter draining yur bladder (which is placed in the perating rm while the patient is asleep) fr apprximately ne day after the surgery. Diet: Yu can expect t have an intravenus catheter (IV) in fr 1-2 days. (An IV is a small tube placed int yur vein s that yu can receive necessary fluids and stay well hydrated; in additin it prvides a way t receive medicatin.) Mst patients are able t tlerate ice chips and small sips f liquids the day f the surgery and regular fd the next day. Once n a regular diet, pain medicatin will be taken by muth. Fatigue: Fatigue is cmmn and shuld start t subside in a few weeks fllwing surgery. Incentive Spirmetry: Yu will be expected t d sme very simple breathing exercises t help prevent respiratry infectins thrugh using an incentive spirmetry device (these exercises will be explained t yu during yur hspital stay). Cughing and deep breathing is an imprtant part f yur recuperatin and helps prevent pneumnia and ther pulmnary cmplicatins. Ambulatin: On the day after surgery it is very imprtant t get ut f bed and begin walking with the supervisin f yur nurse r family member t help prevent bld clts frm frming in yur legs. Yu can expect t have SCD's (sequential cmpressin devices) alng with tight white stckings n yur legs t prevent bld clts frm frming in yur legs. Hspital Stay: The length f hspital stay fr mst patients is fr apprximately 1-2 days. Cnstipatin/Gas Cramps: Yu may experience sluggish bwels fr several days fllwing surgery as a result f the anesthesia. Suppsitries and stl sfteners are usually given t help with this prblem. Taking a teaspn f mineral il daily at hme will als help t prevent cnstipatin. Narctic pain medicatin can als cause cnstipatin and therefre patients are encuraged t discntinue any narctic pain medicatin as sn after surgery as tlerated. What t expect after discharge frm the hspital Pain Cntrl: Yu can expect t have sme pain that may require pain medicatin fr a few days after discharge, and then Tylenl shuld be sufficient t cntrl yur pain. Shwering: Yu may shwer after returning hme frm the hspital. Yur wund sites can get wet, but must be padded dry immediately after shwering. Tub baths are nt recmmended in the first 2 weeks after surgery as this will sak yur incisins and increase the risk f infectin. Yu will have adhesive strips acrss yur incisins. They will fall ff in apprximately 5-7 days n their wn. Sutures underneath the skin will disslve in 4-6 weeks

8 Activity: Taking walks is advised. Prlnged sitting r lying in bed shuld be avided. Climbing stairs is pssible but shuld be taken slwly. Driving shuld be avided fr at least 1-2 weeks after surgery. Abslutely n heavy lifting (greater than 20 punds) r exercising (jgging, swimming, treadmill, biking) fr six weeks r until instructed by yur dctr. Mst patients return t full activity at hme n an average f 3 weeks after surgery. Yu can expect t return t wrk in apprximately 4 weeks. Diet: There are n dietary restrictins nce yu return hme frm yur hspitalizatin. Fllw-up Appintment: If yur surgery is perfrmed at Jhns Hpkins Hspital, yu will need t call the Jhns Hpkins Out Patient Urlgy Clinic at after yur surgery date t schedule a fllw up appintment as instructed by yur surgen. If yur surgery is perfrmed at Jhns Hpkins Bayview Medical Center please call t schedule a fllw up appintment. Pathlgy Results: The pathlgy results frm yur surgery are usually available in ne week fllwing surgery. Yu may discuss these results with yur surgen by cntacting him by phne r in yur fllwup appintment in the ffice. Lng Term Fllw-up: Based n the pathlgy reprt f yur lymph ndes, yu may need additinal treatment such as chemtherapy. Yu will need a CT scan, chest x-ray and bld wrk including Alphafetprtein (AFP), Lactic Dehydrgenase (LDH) and human Chrinic Gnadtrpin (HCG) peridically. The frequency f this testing can vary frm patient t patient.