Surgery for Testis Cancer
Orchiectomy
Preoperative workup/counseling
- Labs: check baseline LDH, AFP, HCG
- Imaging: check CT chest, abdomen, and pelvis w/ IV contrast
- Potential risks: pain, bleeding, infection, injury to nearby structures, need for further treatments (chemo/RPLND/XRT), potential infertility and hypogonadism
Steps
- Shave inguinal area, prep/drape, give cefazolin for skin flora coverage
- Palpate external ring, make mark and mark ASIS, draw ~8-10cm line along langer lines from external ring laterally
- Make skin incision, divide deeper layers (can spread with hemostat), can use wheatlander as self-retaining retractor
- Identify fascia, clean off inferiorly to better define the layer for closure
- Make fascial incision with knife (not cautery) to prevent nerve injury - after making small incision, insert tenotomy scissors, spread tips along fascial fibers, spread under fascia to elevate off muscle, then cut to external ring
- Use debakeys to move cremaster fibers off overlying fascia, try to protect ilioinguinal nerve
- Can use fingers to bluntly encircle entire cord, then wrap x2 with penrose drain and clamp with tonsil clamp
- Push testicle from scrotum into inguinal region - may need to extend skin incision towards scrotum
- Divide all testicular attachments, taking care not to injure testicle or punch hole through skin, then take down cremasteric attachments until testicle and cord freed to internal inguinal ring
- Create two cord packets, clamp each packet separately proximally, then clamp entire cord distal to the clamps, and divide cord between the proximal/distal clamps (curved mayo scissors), then hand off specimen
- Tie off each packet x2 with 2-0 silk - usually use on a taper needle, can also use free tie, leave tails long to rescue if bleeding still present, leave at least one long tail to identify if RPLND needed in the future
- Check hemostasis including inside scrotum, irrigate field
- Close fascia with 2-0 or 3-0 vicryl or PDS, close scarpa layer with 3-0 vicryl, then close skin with 4-0 monocryl and dermabond
Chylous Ascites Management Algorithm, from Rose 2022
Retroperitoneal Lymph Node Dissection
Open RPLND
Chylous Ascites
- Leakage of lymph fluid into peritoneal space
- Timing: majority of patients (70%) present within 4 weeks of RPLND
- Diet: start low-fat diet to minimize lymph flow from intestines (fat can increase flow from 1ml/kg/hr to 200ml/kg/hr)
- TPN: minimizes gut stimulation, requires designated IV access, potential risks include electrolyte abnormalities, infectious risks
- Octreotide: 100-200ug subQ TID + TPN, helps reduce lymph flow
- Paracentesis: diagnostic, but relieving pressure may induce more drainage into peritoneum
- Lymphangiography and embolization: requires US-guided access to inguinal node for antegrade angiography, then closest upstream LN to leak is embolized, can consider retrograde access via thoracic duct
- Peritoneovenous shunting: similar technique for acites from cirrhosis, high complication rate (40%, PE, SVC thrombosis, DIC, shunt occlusion/malfunction)
- Surgical ligation: can be performed open or robotic, give high-fat oral bolus to optimize visualization of lymphatic leak intraoperatively
References
- Evans, James G., et al. "Chylous ascites after post-chemotherapy retroperitoneal lymph node dissection: review of the MD Anderson experience." The Journal of urology 176.4 (2006): 1463-1467.
- Leibovitch, Ilan, et al. "The diagnosis and management of postoperative chylous ascites." The Journal of urology 167.2 (2002): 449-457.
- Rose, Kyle M., et al. "Contemporary Management of Chylous Ascites after Retroperitoneal Surgery: Development of an Evidence-Based Treatment Algorithm." The Journal of Urology (2022): 10-1097.