Laparoscopic Retroperitoneal Lymph Node Dissection (RPLND) provides
patients with a safe and effective way to remove retroperitoneal
lymph nodes in patients with testicular cancer. Laparoscopic RPLND
is a minimally invasive technique, which provides patients with
less discomfort when compared to the traditional open surgery.
Laparoscopic RPLND has resulted
in significantly less post-operative pain, a shorter hospital stay,
earlier return to work and daily activities, a more favorable cosmetic
result and outcomes similar to that of open surgery.
Testicular cancer is one
of the success stories in the treatment of malignant tumors. Advances
in diagnostic x-rays, radiation, and chemotherapy allow for a cure
in the majority of cases. Testicular cancer usually spreads in a
predictable manner, going first to the lymph nodes, located behind
the major organs in the abdomen.
When testes cancer is detected,
removal of the testicle (orchiectomy) is first performed. This gives
important information regarding the type of cancer and the risk
that it may have spread. Blood work including, AFP (Alpha-fetoprotein),
Lactic Dehydrogenase (LDH) and Quantitative HCG (Human Chorionic
Gonadotropin) are done along with a chest x-ray and an abdominal
CT scan to determine the stage of the disease and the best treatment
option. Treatment options (depending on the stage and type of cancer)
Your surgeon has determined
with you that RPLND is the next step in the management of your testes
Johns Hopkins Hospital Patients and Johns
Hopkins Bayview Medical Center Patients please
use the phone numbers listed above.
In the event of an emergency and you need to contact someone
in the evening hours or on the week end, please call the paging
operator at 410-955-6070 (for
Johns Hopkins Hospital Patients) or 410-550-0100 (for
Johns Hopkins Bayview Medical Center Patients) and ask to speak
to the urologist on call.
For directions to Johns Hopkins Hospital and
Johns Hopkins Bayview Medical Center please click
PRIOR TO THE SURGERY
What to expect during you preoperative
During your initial consultation with your
surgeon, he will review your medical history as well as any
outside reports, records, and outside Xray films (e.g. CT
scan, MRI, sonogram). A brief physical examination will also
be performed at the time of your visit. If your surgeon determines
that you are a candidate for surgery, you will then meet with
a Patient Service Surgery Coordinator to arrange for the date
of your operation.
NOTE: It is very
important that you gather and bring all of your Xray films
and reports to your initial consultation with your surgeon.
What to expect prior to the surgery
Since insurance companies will not permit patients to be admitted
to the hospital the day before surgery to have tests completed,
you must make an appointment to have pre-operative testing
done at your family doctor or primary care physician's office
within 1 month prior to the date of surgery.
These results need to be faxed by your doctor's office to
the Pre-operative Evaluation Center at 443-287-9358
two weeks prior to your surgery. Please call The Documentation
Center at 410-955-9453
two weeks before your surgery date to confirm that this information
Once your surgical date is secured, you will receive a form
along with a letter of explanation to take to your primary
care physician or family doctor in order to have the following
pre-operative testing done prior to your surgery.
- Physical exam
- EKG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood coagulation profile)
- Comprehensive Metabolic Panel (blood
- (AFP) Alpha-fetoprotein (blood work)
- (HCG) Human Chorionic Gonadotropin (blood
- (LDH) Lactic Dehydrogenase
- Chest x-ray
- CT scan of the abdomen
Medications to Avoid Prior to Surgery
Aspirin, Motrin, Ibuprofen, Advil, Alka
Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex,
Voltaren, Vioxx, Plavix and some other arthritis medications
can cause bleeding and should be avoided 1 week
prior to the date of surgery (Please contact your
surgeon’s office if you are unsure about which medications
to stop prior to surgery. Do not stop any medication without
contacting the prescribing doctor to get their approval).
Bowel Preparation and Clear Liquid
Do not eat or drink anything after midnight
the night before the surgery and drink one bottle of Magnesium
Citrate (can be purchased at your local pharmacy) the evening
before your surgery.
Drink only clear fluids for a 24-hour period prior
to the date of your surgery. Clear liquids are liquids that
you are able to see through. Please follow the diet below.
Clear Liquid Diet
Remember not to eat or drink anything after
midnight the evening before your surgery.
Clear liquids are liquids that you are able to see through.
Please follow the diet below.
- Clear Broths (no cream soups, meat,
- Juices (no orange juice or tomato
- Apple juice or apple cider
- Grape juice
- Cranberry juice
- Hawaiian punch
- Kool Aid
- Gator Aid
- Tea (you may add sweetener, but no cream
- Coffee (you may add sweetener, but no
cream or milk)
- Clear Jello (without fruit)
- Popsicles (without fruit or cream)
- Italian ices or snowball (no marshmallow)
The length of the operation is typically
3-5 hours. The surgery is performed through 3 - 4 small (1
cm) incisions created in the midline of the abdomen. Lymph
nodes are removed on the side of the testicular cancer. Using
a small telescope and other instrumentation, the lymph tissue
that drains the testicle is removed.
The number of lymph nodes to be removed
can vary among individuals and can range from less than I
0 to over 50 Lymph nodes are are part of the immune system,
which help in fighting off infection.
The relative number of lymph nodes removed
during RPLND are not enough to affect your immune system or
your body's ability to fight off infection. Along with the
removal of the lymph nodes the remainder of the blood supply
to the affected testicle and spermatic cord is also removed.
Potential Risks and Complications
Although this procedure has proven to be
very safe, as in any surgical procedure there are risks and
potential complications. The safety and complication rates
are similar when compared to the open surgery. Potential risks
Blood loss during this procedure is possible , however,
a blood transfusion is rarely needed. If you are interested
in autologous blood transfusion (donating your own blood)
you must make your surgeon aware. When the packet of information
is mailed to you regarding your surgery, you will receive
an authorization form for you to take to the Red Cross in
- Infection: All patients
are treated with intravenous antibiotics, prior to starting
surgery to decrease the chance of infection from occurring
after surgery. If you develop any signs or symptoms of infection
after the surgery (fever, drainage from your incisions,
urinary frequency/discomfort, pain or anything that you
may be concerned about) please contact us at once.
- Tissue / Organ Injury:
Although uncommon, possible injury to surrounding tissue
and organs including bowel, vascular structures, spleen,
liver, pancreas and gallbladder could require further surgery.
Injury could occur to nerves or muscles related to positioning.
Hernia at incision site is a possibility. Although very
rare, the kidney and ureter on the side that the lymph nodes
are being removed could be injured.
- Hernia: Hernias at
incision sites rarely occur since all keyhole incisions
are closed carefully at the completion of your surgery.
- Conversion to Open Surgery:
The surgical procedure may require conversion to the standard
open operation if difficulty is encountered during the laparoscopic
procedure. This could result in a larger standard open incision
and possibly a longer recuperation period.
- Sperm Banking: Patients
should consider banking sperm prior to any treatment for
their testis cancer, esp. chemotherapy because chemotherapy
may effect sperm production by your remaining testicle.
The return of sperm quality could take over one year following
chemotherapy but may never return to normal levels.
- Retrograde Ejaculation/Infertility:
Occasionally nerves that control ejaculation may be injured
during surgery. This may result in retrograde ejaculation
causing sperm to be expelled into the bladder instead of
out the tip of the penis. As such, one may not see a discharge
(i.e. ejaculate) with orgasm. The fluid will mix in the
bladder with urine and be eliminated with the next urination.
This condition is not dangerous and does not affect your
ability to have erections or an orgasm. This could, however,
affect future fertility.
- Lymphocele: Lymphatic
fluid can collect in the area where the lymph nodes were
removed. This could require drainage and further surgery.
- Respiratory Complication:
If you received a chemotherapy medication called bleomycin
before your surgery, you are at a slightly higher risk of
lung complications during and following surgery.
WHAT TO EXPECT AFTER
During your hospitalization
Immediately after the surgery you will be
taken to the recovery room and transferred to your hospital
room once you are fully awake and your vital signs are stable.
- Post Operative Pain:
Pain medication can be controlled and delivered by the patient
via an intravenous catheter or by injection (pain shot)
administered by the nursing staff. You may experience some
minor transient shoulder pain (1-2 days) related to the
carbon dioxide gas used to inflate your abdomen during the
- Nausea: You may experience
some nausea related to the anesthesia or pain medication.
Medication is available to treat persistent nausea.
- Urinary Catheter: You
can expect to have a urinary catheter draining your bladder
(which is placed in the operating room while the patient
is asleep) for approximately one day after the surgery.
- Diet: You can expect
to have an intravenous catheter (IV) in for 1-2 days. (An
IV is a small tube placed into your vein so that you can
receive necessary fluids and stay well hydrated; in addition
it provides a way to receive medication.) Most patients
are able to tolerate ice chips and small sips of liquids
the day of the surgery and regular food the next day. Once
on a regular diet, pain medication will be taken by mouth.
- Fatigue: Fatigue is
common and should start to subside in a few weeks following
- Incentive Spirometry:
You will be expected to do some very simple breathing exercises
to help prevent respiratory infections through using an
incentive spirometry device (these exercises will be explained
to you during your hospital stay). Coughing and deep breathing
is an important part of your recuperation and helps prevent
pneumonia and other pulmonary complications.
- Ambulation: On the
day after surgery it is very important to get out of bed
and begin walking with the supervision of your nurse or
family member to help prevent blood clots from forming in
your legs. You can expect to have SCD's (sequential compression
devices) along with tight white stockings on your legs to
prevent blood clots from forming in your legs.
- Hospital Stay: The
length of hospital stay for most patients is for approximately
- Constipation/Gas Cramps: You
may experience sluggish bowels for several days following
surgery as a result of the anesthesia. Suppositories and
stool softeners are usually given to help with this problem.
Taking a teaspoon of mineral oil daily at home will also
help to prevent constipation. Narcotic pain medication can
also cause constipation and therefore patients are encouraged
to discontinue any narcotic pain medication as soon after
surgery as tolerated.
What to expect after discharge
from the hospital
- Pain Control: You can
expect to have some pain that may require pain medication
for a few days after discharge, and then Tylenol should
be sufficient to control your pain.
- Showering: You may
shower after returning home from the hospital. Your wound
sites can get wet, but must be padded dry immediately after
showering. Tub baths are not recommended in the first 2
weeks after surgery as this will soak your incisions and
increase the risk of infection. You will have adhesive strips
across your incisions. They will fall off in approximately
5-7 days on their own. Sutures underneath the skin will
dissolve in 4-6 weeks
- Activity: Taking walks
is advised. Prolonged sitting or lying in bed should be
avoided. Climbing stairs is possible but should be taken
slowly. Driving should be avoided for at least 1- 2 weeks
after surgery. Absolutely no heavy lifting (greater than
20 pounds) or exercising (jogging, swimming, treadmill,
biking) for six weeks or until instructed by your doctor.
Most patients return to full activity at home on an average
of 3 weeks after surgery. You can expect to return to work
in approximately 4 weeks.
- Diet: There are no dietary
restrictions once you return home from your hospitalization.
- Follow-up Appointment:
If your surgery is performed at Johns Hopkins Hospital,
you will need to call the Johns Hopkins Out Patient Urology
Clinic at 410-955-6707 after
your surgery date to schedule a follow up appointment as
instructed by your surgeon. If your surgery is performed
at Johns Hopkins Bayview Medical Center please call 410-550-7008
to schedule a follow up appointment.
- Pathology Results:
The pathology results from your surgery are usually available
in one week following surgery. You may discuss these results
with your surgeon by contacting him by phone or in your
follow-up appointment in the office.
- Long Term Follow-up:
Based on the pathology report of your lymph nodes, you may
need additional treatment such as chemotherapy. You will
need a CT scan, chest x-ray and blood work including Alpha-fetoprotein
(AFP), Lactic Dehydrogenase (LDH) and human Chorionic Gonadotropin
(HCG) periodically. The frequency of this testing can vary
from patient to patient.