BETHESDA, MD USA (UroToday.com) - Dr. Michael Jewett commenced his talk with a brief history of retroperitoneal lymph node dissection. Originating at Walter Reed in the era of major open aortic surgery, RPLND classically included resection of the hypogastric nerves from the lumbar ganglia of the sympathetic chain. Radiation oncologists in the UK argued against surgery due to high incidence of postoperative “impotence”—later recognized as a loss of antegrade seminal emission—thus driving early favor for surveillance.
In 1982, Dr. Donohue (Donohue JP et al., J Urol 1982) identified the distribution of nodal metastases in nonseminomatous germ cell tumors. His group created a plastic template that anatomically mirrored the retroperitoneum. When nodes were removed, they were placed on the template in their correct anatomic orientation and taken to the pathologist. Positive versus negative nodes were mapped by location in the retroperitoneum, leading to the identification of a significant suprahilar disease prevalence, and later paving the way for dissection templates. Weissbach and colleagues (J Urol 1987) validated this work with a similarly designed study, and found that templates led to preservation of antegrade emission.
Dr. Jewett’s group expanded on this work when they identified the specific nerves to be spared for preservation of antegrade emission. In an elegant study, they intraoperatively stimulated the sympathetic nerves and simultaneously cystoscopically watched the posterior urethra emit seminal fluid. This work led to the further refinement of nerve sparing techniques.
Finally, he concluded by describing a series of 42 laparoscopic or robotic nerve-sparing RPLND cases, including 23 bilateral and 19 post chemotherapy patients. Over short-term follow-up, 86% had preservation of antegrade ejaculation.
Presented by:
Michael A. S. Jewett, MD
Princess Margaret Hospital, Toronto, Ontario Canada
Reported by:
Nikhil Waingankar, MD* from the 2014 Winter Meeting of the Society of Urologic Oncology (SUO) "Defining Excellence in Urologic Oncology" - December 3 - 5, 2014 - Bethesda, MD USA
*Fox Chase Cancer Center, Philadelphia, PA USA