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.