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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

1. Shave inguinal area, prep/drape, give cefazolin for skin flora coverage
2. Palpate external ring, make mark and mark ASIS, draw ~8-10cm line along langer lines from external ring laterally
3. Make skin incision, divide deeper layers (can spread with hemostat), can use wheatlander as self-retaining retractor
4. Identify fascia, clean off inferiorly to better define the layer for closure
5. 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
6. Use debakeys to move cremaster fibers off overlying fascia, try to protect ilioinguinal nerve
7. Can use fingers to bluntly encircle entire cord, then wrap x2 with penrose drain and clamp with tonsil clamp
8. Push testicle from scrotum into inguinal region - may need to extend skin incision towards scrotum
9. 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
10. 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
11. 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
12. Check hemostasis including inside scrotum, irrigate field
13. 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

Retroperitoneal Lymph Node Dissection

Preop planning

• Open vs robot: depends on size of residual mass, prior surgery, prior chemotherapy - offer robotic approach in select patients with low threshold to convert to open
• Hilar anatomy: confirm any anatomic variants to prevent injuries to renal hilum on either side
• Bowel prep: 1/2 bottle MgCit or 1L golytely the night before surgery

Open RPLND

1. Place patient supine with arms tucked, prep entire abdomen (scrotum on field if orchiectomy required)
2. Make midline incision from xiphoid to close to pubic symphysis, enter peritoneal cavity, take down falciform ligament
3. Starting with cecum, medialize the colon towards hepatic flexure, also continue dissection inferiorly to expose the iliac vessels, take care not to transect IMA
4. Place abdominal retractors to expose IVC and aorta
5. Starting over the inferior IVC near the bifurcation, use Maryland ligasure to split the overlying tissue and roll to either side, continue this line superiorly to the level of the renal veins
6. For paracaval packet, track the tissue lateral to IVC, vessel seal or clip lumbar veins (usually clip lumbar arteries), clip gonadal vessels, take all tissue off psoas and end at R ureter
7. Split and roll off the aorta, taking care to avoid IMA insertion
8. Remove interaortocaval packet, starting at iliac bifurcation and tracking superiorly, clip/seal lumbar vessels (try to leave arteries to prevent spinal ischemia), can also clip large lymphatic channels if visualized, superior border is renal hilum
9. If performing IMA-sparing approach, reflect left colon medially and roll paraaortic tissue packet off aorta, with L ureter being lateral boundary and renal hilum being superior boundary
10. Apply hemostatic products, vistaseal recommended to prevent lymphatic leak
11. Identify gonadal vessels, track inferiorly, avoid ureteral injury, try to remove stitch if possible
12. Close fascia with #1 PDS x2 (meet in middle), use vicryl 3-0 for subQ if needed, then close skin with staples or monocryl

Robotic bilateral RPLND

1. Place patient supine with arms tucked, prep entire abdomen (scrotum on field if orchiectomy required)
2. Insufflate with veress needle
3. Place robotic trocars x4 across abdomen 2-3cm below umbilicus, place assist port on L side between left and camera arms, place patient in trendelenberg
4. Starting with cecum, medialize the colon towards hepatic flexure, also continue dissection inferiorly to expose the iliac vessels, take care not to transect IMA
5. TIP: can clip/suture the intestine up to the anterior abdominal wall to assist with retraction
6. Starting over the inferior IVC near the bifurcation, use vessel sealer in R arm to split the overlying tissue and roll to either side, continue this line superiorly to the level of the renal veins
7. For paracaval packet, track the tissue lateral to IVC, vessel seal or clip lumbar veins (usually clip lumbar arteries), clip gonadal vessels, take all tissue off psoas and end at R ureter
8. Split and roll off the aorta, taking care to avoid IMA insertion
9. Remove interaortocaval packet, starting at iliac bifurcation and tracking superiorly, clip/seal lumbar vessels (try to leave arteries to prevent spinal ischemia), can also clip large lymphatic channels if visualized, superior border is renal hilum
10. If performing IMA-sparing approach, reflect left colon medially and roll paraaortic tissue packet off aorta, with L ureter being lateral boundary and renal hilum being superior boundary
11. Apply hemostatic products, vistaseal recommended to prevent lymphatic leak
12. Identify gonadal vessels, track inferiorly, avoid ureteral injury, can consider redocking the robot to face inferiorly to reach inguinal ring
13. Undock robot, remove specimens, close all port sites

Postoperative management

• Diet: clear liquids POD#0, then can advance to medium chain triglyceride diet (low fat diet) x4 weeks, nutrition teaching prior to discharge
• IV fluids: be careful of prior bleomycin history, can lead to pulmonary edema if fluid overload
• Tachycardia: common especially if prior chemotherapy, avoid aggressive fluid or other treatment if sinus tachycardia and patient asymptomatic
• Anticoagulation: consider apixaban 2.5mg BID or enoxaparin 40mg daily x4 weeks, extrapolated from cystectomy literature (no specific data in RPLND patients)

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