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As the testicles form and develop near the kidneys in a fetus, the blood supply, lymphatic drainage and nerves to the testicle originate near the kidney on that side. Therefore, testis cancer has a very predictable pattern of spread. The primary landing zone for metastases from testis cancer are the lymph nodes of the retroperitoneum – the area around and between the aorta and inferior vena cava at the level of the kidneys. Therefore, retroperitoneal lymph node dissection (RPLND) is an important surgical option for men with testis cancer.
Traditionally, RPLND is done through a large, midline incision (along the entire abdomen) and only performed at high-volume, centers of excellence due to the rarity of disease and technical challenges of the surgery. More recently, minimally-invasive RPLND has become an option for men with testis cancer, dramatically reducing the convalescence of the operation and offering the benefits of avoiding chemotherapy and rigorous AS.
RPLND was a mainstay of therapy for clinical stage I non-seminomatous germ cell tumors (NSGCT) as it better staged disease and offered a therapeutic benefit for many patients. However, upwards of 70% of patients will never need an RPLND and are overtreated by surgery. RPLND has fallen out of favor with many physicians and organization due to the morbidity of the procedure and high-risk of overtreatment.
Minimally-invasive RPLND changes the thought-process for CSI testis cancer, as it changes the ratio of risk to benefit as the morbidity associated with the procedure is dramatically reduced compared with the traditional, open surgery. In addition, minimally-invasive RPLND can be performed for patients with suspicion of low-burden lymph node metastases (clinical stage II) in the hopes of avoiding chemotherapy.
Many patients with lymph node metastases, especially those with seminoma, will receive chemotherapy. In some patients, the lymph nodes will shrink, but not totally disappear. In other patients, shrunken lymph nodes will slowly grow indicating that viable cancer or a teratoma may be growing in the retroperitoneum. For these patients, a post-chemotherapy RPLND is often indicated to remove cancer not adequately treated by chemotherapy.