For some men treated with chemotherapy, lymph nodes in the retroperitoneum will not respond to chemotherapy or slowly grow after a period of shrinkage. In these cases, the retroperitoneal mass can beviable tumor (15%) or teratoma. Teratoma in the retroperitoneum is not responsive to chemotherapy and will continue to grow until it compresses a vital structure like the inferior vena cava or intestines – a process called growing teratoma syndrome.
A post-chemotherapy RPLND is an extremely challenging surgery. Chemotherapy can cause the lymph nodes in the retroperitoneum to fuse to the important surrounding structures including the aorta, vena cava, intestines and kidneys. Safely removing the cancerous lymph nodes involves precise dissection and often removal of adjacent organs rather than risk of major vascular or bowel injury. Most post-chemotherapy RPLND are performed in a team approach, with vascular, general and thoracic surgeons available on a case-by-case basis. The surgery most often involves a large incision along the entire length of the abdomen and a hospital stay of 3-5 days. Recovery can take as long as 2-4 weeks before feeling 100%. However, post-chemotherapy RPLND can be a life-saving surgery and, when performed at expert centers, has excellent outcomes.
The complication rate for a primary RPLND is about 5% and about 15% for a post-chemotherapy RPLND. Serious complications are rare (<2%) and include:
- Serious bleeding
- Lymphatic Leak (Chylous Ascites)
The nerves that control ejaculation (expulsion of fluid from the penis during orgasm) lie in the retroperitoneum. Sympathetic nerves control ejaculation and run lateral and parallel to the great vessels before converging at the base of the aorta (where it branches to form the iliac arteries) before traveling to the seminal vesicles, vas deferens, prostate and bladder neck. With nerve-sparing techniques, the rates of anejaculation are 5-10% for both minimally-invasive and open primary RPLND. The rates of anejaculation are higher for post-chemotherapy RPLND as the nerves cannot always be spared to remove cancer.
Serious bleeding occurs in <2% of cases. However, bleeding from the aorta or vena cava can require blood transfusion and be potentially life-threatening. In cases where retroperitoneal lymph nodes appear close or adherent to the aorta or vena cava, it is often safer to surgically remove a portion of the blood vessel. Depending on the size of the tumor and complexity of the repair, a vascular surgeon may be a part of the operative team.
Lymphatic Leak (Chylous Ascites)
As the lymphatic channels in the retroperitoneum are interrupted, rarely a lymphatic leak can occur. Your surgeon will use a variety of intraoperative techniques to prevent lymphatic leak. In addition, as lymphatic fluid is “fueled” by fatty foods – a nutritionist will teach you about a low-fat diet and how to slowly resume a normal diet over the weeks following surgery.
Chylous ascites almost always resolves within a few weeks to months, but can be problematic to treat. Treatments for chylous ascites include restricted diet, placement of abdominal drains (or intermittent drainage), medications to decrease the amount of lymphatic fluids or interventional radiology procedures. Johns Hopkins is an expert center in treating refractory chylous ascites with lymphangiography and sclerotherapy. Surgery is a last resort in rare cases.