Retroperitoneal lymphadenectomy for testicular tumors

Testicular tumors can be divided into germ cell tumors and non-germ cell tumors. The former is more common, accounting for 95% of testicular tumors. It occurs in the seminiferous genital epithelium; the latter is rare, occurring in interstitial cells or testicular stroma. Primary germ cell tumors can be classified into seminoma, embryonic carcinoma, teratocarcinoma, teratoma and chorionic epithelial cell carcinoma according to the characteristics of histogenesis, but seminoma is the most common. Often manifested as a gradually increasing painless mass, and a few have similar inflammatory manifestations. Tumors are mostly lymphatic metastasis, while chorionic epithelial cell carcinoma is metastasized by blood. Once the diagnosis is clear, surgery must be performed immediately. The basic surgery is orchiectomy. For embryonic cancer, teratocarcinoma and teratoma, retroperitoneal lymphadenectomy should also be performed. Retroperitoneal lymphadenectomy is indicated for the treatment of non-spermatocytic testicular tumors (eg, embryonic carcinoma, teratocarcinoma), which are not sensitive to radiation therapy, and therefore undergo retroperitoneal lymphadenectomy during the same period of testicular resection or stage 2 after orchiectomy. The testicular lymphatic drainage reaches the peritoneum along the lymphatics of the spermatic vein, and goes up along the surface of the psoas muscle. It crosses the ureter at the level of the 4th lumbar vertebrae, and then branches upward and inward into the renal pedicle lymph nodes and the abdominal aorta and inferior vena cava lymph nodes. The lymphatic vessels on the left and right sides communicate with each other. The testicular tumors metastasize along the lymphatic drainage pathway and are transferred to the renal pedicle lymph nodes and the abdominal aorta, the inferior vena cava, the anterior and interparadyal lymph nodes. And the lymph on both sides communicate with each other. After these lymphoid tissues are involved, the lymphatic vessels are blocked by the tumor and can spread along the collateral or retrograde lymphatics and metastasize to the aorta, posterior vena cava, contralateral lumbar lymph nodes, and axillary lymph nodes. The retroperitoneal lymphadenectomy ranged from all lymphoid, fat, and connective tissues in the perirenal fascia of the diseased side; from the renal pedicle on the lateral side, to the spermatic vessels of the inguinal ring and lymph, fat, and connective tissue; One horizontal finger, which releases nearly one-third of the iliac vessels and the extra-orbital blood vessels, and the lymph, fat and connective tissue at the bifurcation of the contralateral common iliac artery. If necessary, the ligation of the inferior mesenteric artery is cut off. Retroperitoneal lymphadenectomy, according to the characteristics of testicular tumor lymphatic metastasis, it is more reasonable to do bilateral clearance. However, for patients without metastases (especially children), extended unilateral retroperitoneal lymphadenectomy is feasible. Treatment of diseases: testicular cancer Indication Testicular tumor retroperitoneal lymphadenectomy is applicable to: Testicular tumors of non-spermatogonia, such as embryonal cancer, teratocarcinoma and teratoma, are performed simultaneously or after the second stage of postoperative orchiectomy. Contraindications If the patient is already in advanced cachexia, the general condition is very poor. Preoperative preparation 1. Prepare blood 900~1200ml. 2. Oral antibiotics were taken 2 days before surgery. 3. Shave the pubic hair and abdominal skin 1d before surgery. 4. Clean the enema before surgery and indwell the catheter and stomach tube. 5. Explain to the patient and family that postoperative ejaculation may be affected. Surgical procedure 1. Incision: If bilateral bilateral retroperitoneal lymphadenectomy is performed, the midline incision of the abdomen is taken, and the upper xiphoid is slightly below the pubic symphysis (Fig. 7.9.5-12). Cut the skin, subcutaneous, abdominal white line and peritoneum. After incision of the peritoneum, first explore the liver and gallbladder spleen and pancreas and kidneys, pay attention to whether there is cancer metastasis; then check the retroperitoneal lymph nodes to determine whether to perform retroperitoneal lymphadenectomy. For example, only the side of the retroperitoneal lymphadenectomy, the midline of the abdomen can be taken, if necessary, can also be added as a transverse incision, from the extraperitoneal surface of the retroperitoneum. 2. Right retroperitoneal lymphatic dissection: The posterior peritoneum of the paracolic sulcus was cut from the colonic hepatic collateral to the outside of the cecum, and the colonic hepatic flexion to the cecum was completely freed, revealing the right renal inferior pole and the ureter. The lower end of the posterior peritoneal incision is further extended around the cecum to the medial side, across the iliac vessels, along the left side of the small mesenteric root, reaching the duodenal jejunum suspensory ligament. Free the duodenum and retract it upwards to expose the aorta, vena cava, and renal pedicle, taking care to avoid damage to the intestinal wall and its supply of blood vessels. The gastric colon ligament was incised along the right edge of the transverse colon, and the colonic hepatic flexure was freed. The peritoneal reflex covering the lateral edge of the descending part of the duodenum and the descending part of the duodenum can be used to further reveal the vena cava, renal pedicle, kidney and adrenal gland, so that the right retroperitoneal space is fully exposed. For convenience of presentation, the free right colon and small intestine can be pulled out of the abdominal wall incision, protected with wet saline gauze and placed in a soft plastic bag. After the right retroperitoneal space is revealed, lymphatic clearance can be performed: the right varicose vein is ligated and cut at the right side of the inferior vena cava anterior wall, and the right ureter is released and retracted to the outside. supply. From the upper 2 cm above the renal pedicle, the right perirenal fascia and its perirenal fat, the periorbital, inferior vena cava and abdominal aorta, lymph, fat and connective tissue Sexual and blunt dissection methods are performed from top to bottom and excised. Large lymphatic vessels should be ligated and cut, and then continue to sweep down to the common iliac vessels of the diseased side, the upper third of the external iliac vessels and the contralateral iliac bifurcation. The lateral side of the spermatic vein descends to the inner ring of the inguinal region, and the spermatic cord stump that is ligated at the high position of the original testicular is pulled out, and then the vas deferens is cut off at the back of the bladder, and the stump of the original ligature is pulled out, and the right peritoneum is pulled out. Lymphatic clearance is over. 3. Left retroperitoneal lymphatic dissection: Incision of the peritoneal reflexed part of the descending colon, and then the gastric colon ligament is cut along the left side of the transverse colon, the left colon is free, and the inner side is retracted to the tail of the pancreas. After the blunt separation, and separation of the spleen and stomach ligament, the pancreas and spleen retracted upward, the left kidney, kidney pedicle, abdominal aorta and vena cava can be revealed. Thus, the left retroperitoneal upper half has been revealed. If only the left side of the dissection, the descending colon and sigmoid colon should be pushed to the left, the peritoneum in the right inferior mesenteric artery, and the blunt dissection in the posterior mesenteric and peritoneal can reveal the left retroperitoneal Part of the abdominal aorta, inferior vena cava and iliac vessels. The procedure for the left retroperitoneal lymphadenectomy is the same as the right side. The inferior mesenteric artery should be preserved as much as possible during surgery. If there is lymphatic infiltration around the artery, it can be cut off near the aorta. 4. Drainage and suture: retroperitoneal space and intra-abdominal irrigation. The wound surface was completely hemostasis, and the retroperitoneal space was placed in a rubber tube and drained to the side of the abdominal wall to cut a small opening. Suture the incision as usual. complication 1. Bleeding: Due to the large wound surface, there is often bleeding in the operation, and the rough operation can damage the organs and blood vessels. If the hemostasis is not complete or the ligature is detached, it can cause postoperative bleeding. Therefore, attention to pulse, blood pressure and urine output after surgery. If there is bleeding, blood transfusion should be given to resist shock, severe bleeding should be surgically explored, and complete hemostasis. 2. Infection: Due to the large surgical wounds, the bleeding and exudation during operation, the poor drainage, and the damage to the intestinal tract can cause infection and even abdominal or retroperitoneal abscess. Therefore, the operation is careful, the drainage is placed, the drainage is kept smooth, and antibiotics are applied after surgery. If there is abscess formation, drainage should be performed. 3. Intestinal paralysis, intestinal adhesions and intestinal obstruction: due to large surgical wounds, long gastrointestinal exposure, not keeping the intestines moist and violently pulling the intestines, can cause postoperative intestinal paralysis, intestinal adhesions, and even intestinal obstruction. Postoperative fasting, gastrointestinal decompression, and gradually eating after the recovery of peristalsis, such as intestinal obstruction, should be surgically explored. 4. Intestinal necrosis: retroperitoneal lymphadenectomy, the inferior mesenteric artery should be preserved as much as possible. When the lymph node is severely inseparable, it can also be considered to be cut off. However, there are also very few patients who affect the blood supply to the corresponding part of the intestine and cause intestinal necrosis. If the superior mesenteric artery branch is inadvertently damaged during surgery, it can also cause the corresponding part of intestinal necrosis. Excessive traction and compression of the mesenteric vessels during the operation resulted in a corresponding part of the intestinal ischemic necrosis. Intestinal necrosis can lead to peritonitis, necrotic intestine should be removed, and intestinal anastomosis should be performed.