RPLND: Tips and Tricks

Transcription

1 RPLND: Tips and Tricks Andrew J. Stephenson, MD FACS FRCS(C) Director, Center for Urologic Oncology Glickman Urological & Kidney Institute Cleveland Clinic, Cleveland, OH

2 RPLND: Keys to success Knowledge of anatomy Exposure, exposure, exposure!! Meticulous split and roll technique

3 RPLND: Step by Step Exposing the retroperitoneum Setting up the RPLND Establish boundaries of dissection Identify and isolate all vital structures Lymphadenectomy

4 RPLND: Exposure Midline incision Chevron +/- midline extension (Mercedes-Benz) Midline incision with costal extension Thoracoabdominal approach Thoracoabdominal midline incision Thoracoabdominal paramedian incision

5 Exposing the Retroperitoneum Division of falciform Bookwalter retractor Transverse colon on chest with moist lap pads Mobilize small bowel and right mesentery by incising posterior peritoneum lateral to right gonadal from 4 th stage of duodenum medial to IMV base of cecum right paracolic gutter hepatic flexure 2 nd stage of duodenum (complete Kocherization) Bowel on chest beneath moist lap pads important to protect duodenum and pancreas with adequate padding

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14 Exposure of the Retroperitoneum Complete Kocherization of duodenum Expose left renal vein Important to clip all lymphatics between duodenum and left renal vein to avoid lymphatic complications

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20 Exposure of the Retroperitoneum Open the para-aortic space by incising posterior peritoneum medial to IMV Loop left ureter and left gonadal vein in this location

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24 Exposure of the Retroperitoneum Mobilize sigmoid colon off left common iliac artery Loop ureter inferior to IMA in this location Loop right ureter and right gonadal vein

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27 Lymphadenectomy Split-and-roll Left renal vein Anterior surface of IVC ligate R. gonadal vein anterior surface of R. common iliac artery lateral to IVC to the crossing of the right ureter Watch out for aberrant anatomy!

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30 Lymphadenectomy Full, bilateral template dissection Split-and-roll Left renal vein insertion of left gonadal Anterior surface of IVC ligate R. gonadal vein anterior surface of R. common iliac artery lateral to IVC to the crossing of the right ureter Watch out for aberrant anatomy! Avoid medial dissection on R. common iliac artery and anterior surface of aorta if nerve-sparing

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33 Lymphadenectomy: Strategy Start with lateral IVC (para-caval) Medial traction ligate all lumbar veins with ties Penfield neuro-dissector Medial surface of IVC Lateral traction ligate all lumbar veins with ties Nerve-sparing look for post-ganglionic sympathetics emerging from behind ligated lumbar veins Isolate nerves and plexus with vessels loops don t touch nerves dissect tissue around them!

34 Nerve Sparing RPLND Prospective identification and preservation sympathetic chains postganglionic sympathetic nerves T12- L3 hypogastric plexus

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39 Lymphadenectomy: Strategy Start with lateral IVC (para-caval) Medial traction ligate all lumbar veins with ties Penfield neuro-dissector Medial surface of IVC Lateral traction ligate all lumbar veins with ties Nerve-sparing look for post-ganglionic sympathetics emerging from behind ligated lumbar veins Isolate nerves and plexus with vessels loops don t touch nerves dissect tissue around them! Once nerves and plexus are isolated dissection on anterior surface of aorta and right common iliac artery split-and-roll on lateral and medial aorta Beware aberrant venous anatomy in inter-aortocaval space!

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43 Lymphadenectomy: Strategy Interaortocaval and Para-aortic dissection Dissection on anterior spinous ligament Row of clips across retroaortic and retrocaval tissues lateral to spine proximal ends of lumbar vein Essential to expose left and right renal artery in every case identify at origin on lateral and medial surface of aorta, respectively row of clips at cephalad extent of dissection and inferior edge of renal arteries Exposure of left and right renal hilum sponge stick inside renal pelvis with lateral traction opens this spice nicely

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46 Suprahilar or Retrocrural Mass Prefer low Chevron incision with extension to xiphoid Thompson retractor elevates and flattens diaphgram Extensive mobilization of liver or spleen with medial rotation Excellent exposure of retrocrural space, suprahilar location, intrahepatic IVC

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50 RPLND Templates: Right Full, bilateral template Modified right template

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52 RPLND Templates: Left Full, bilateral template Modified left template

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54 Rationale for Modified Templates Antegrade Ejaculation Full, bilateral < 20% Modified templates 51-85% Nerve-sparing full, bilateral (post-ganglionic T12-L3) 95%+

55 Right Modified PLND Templates Standard template Nelson Urology 1999* Foster et al. BJU Int 2004 Weissbach J Urol 1987 Janetschek J Urol 2000*

56 Left Hilar and Para-aortic Nodes Most common site for infield recurrence late relapse re-operative surgery Critical area to control for both right- and left-sided tumors

57 Left Modified PLND Templates Standard template Foster et al. BJU Int 2004 Weissbach. J Urol 1987 Nelson Urology 1999* Janetschek J Urol 2000*

58 Modified Templates: Mapping Studies Extra-Template Disease Std Indiana German TSG Innsbruck LapRPLND Hopkins LapRLND Overall 3% 11% 23% 23% 28% Right-sided 2% 19% 19% 19% 33% Left-sided 4% 4% 25% 25% 25% Extra-template teratoma 29% 18% 21% 18% Eggener et al. J Urol 2007

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