The blood supply to the testis exits the body in your inguinal area, and to meticulously stage and prevent any cancer from spreading, the cord must be taken as high toward or inside the body as possible, explaining an inguinal approach to the surgery as opposed to going through the scrotum (which is not done). Bruising and tenderness to the scrotum, which is often mild, are common for two to four weeks after surgery. Prevention with a compressive dressing, tight-fitting undergarments and/or ice packs is helpful. Ilioinguinal nerve injury can occur if the nerve is damaged during dissection of the spermatic cord, although meticulous technique spares this injury from occurring. If there is nerve injury, it is often transient, but can take several weeks or months to improve. It is important to minimize strenuous activities for two to four weeks to prevent the development of a hernia. A testicular prosthesis can be placed at the time of surgery to address any body image issues. Alternatively, many men decide to forgo this aspect for future consideration.

Nerve Sparing retroperitoneal lymphadenectomy (RPLND)

Retroperitoneal lymph node dissection, commonly referred to as RPLND, is a procedure to remove abdominal lymph nodes that are the primary location for the spread of testicular cancer. It is usually performed using an incision that extends from the sternum to just below the belly-button. While laparoscopic approaches are possible, they have not been proven to be equal in outcomes to standard surgery, and are considered to be less effective and potentially dangerous by some.

Testicular cancer spreads in a well-known predictable pattern, and the lymph nodes in the retroperitoneum ( the space behind the abdomen, next to the inner bones surrounding the spinal canal) are a primary landing site during the spread of the disease. Removing the lymphatic tissue can be curative and extremely helpful in helping patients overcome testicular cancer for clinical stage I and II non-seminomatous germ cell tumors (NSGCT). These are the two main indications for RPLND. In stage 1, there is a higher than average risk for cancer spread and after conversations with the surgeon, the patient opts to have these removed as opposed to other options of surveillance or chemotherapy. This is called a “Primary RPLND”. The second indication is for residual disease in stage 2, after chemotherapy, this would be for a “Post-chemotherapy RPLND”. In this situation, the surgeon will remove the same nodes, as they might harbour residual cancer or teratoma (a chemotherapy resistant tissue that required removal). There are more rare cases where RPLND is used, such as post chemotherapy for metastatic seminoma or for late recurrences or salvage/desperation situations.

The Procedure

The goal of the procedure is the removal of all lymph nodes in the retroperitoneum bounded by the ureters laterally, and found in between the great vessels the aorta and vena cava. These are the well-recognized ‘boundaries’ of lymph node spread. The complexity of this surgery is heightened as there are also nerves that come out of the spinal cord that passes through the area where the nodes are located, rendering them at risk of damage during the procedure. These nerves are responsible for male ejaculation, and severing all of them would render the person incapable of ejaculating during a normal sexual encounter. With meticulous technique, these nerves can be spared, but not at the cost of leaving viable cancer behind in some cases. Nerve-sparing surgery has a very high rate of success in experienced hands. Occasionally, when fertility may be an issue, sperm banking is recommended, or other assisted reproductive techniques may be needed later on in life.