Surgery of Testicular Tumors (Chap 77 12th ed) Flashcards
What should you do if orchiectomy has been performed through the scrotum?
When an orchiectomy has been performed through the scrotum in
patients who have a low-stage seminoma, the radiation portals
should be extended to include the ipsilateral groin and scrotum; for
those with low-stage nonseminomatous germ cell tumor (NSGCT),
the scrotal scar should be excised along with the spermatic cord
remnant; and for those who have received a full cycle of platinumbased
chemotherapy, only the cord stump need be removed at the
time of RPLND.
What is the direction of contralateral lymphatic flow?
More commonly right to left
Most common site of residual suprahilar disease
Retrocrural space
How do you prevent chylous ascites?
It is extremely important, when performing a primary RPLND, to
secure all lymphatic vessels with either clips or ties, particularly in
the region of the right renal artery and diaphragmatic crus, to
minimize injury to the cisterna chyli, which could result in chylous
ascites.
What are the nerves important to preserve antegrade ejaculation?
L1-L4 ganglia
Dissection on the aorta should be performed after fibers have been identified and isolated
In stage I NSGCT, what are the factors associated with increased incidence of retroperitoneal relapse?
In clinical stage I, NSGCT lymphovascular invasion; higher T stage;
tumor involvement of the cord, capsule, or scrotum; and a high
percentage of embryonal carcinoma are associated with an increased
incidence of retroperitoneal relapse. Most relapses occur within the
first 2 years and are rare after 5 years. The absence of teratoma in the
primary tumor does not preclude its presence in the retroperitoneum.
What should you do if the aortic wall is stripped of its adventitia during RPLND.
If the aortic wall is stripped of its adventitia, it should be replaced
with a synthetic graft because delayed rupture may occur.
Involvement of which structures precludes resection?
Tumor involvement of the superior mesenteric artery, celiac axis, or
porta hepatis usually precludes resection. After chemotherapy,
resection of residual masses should be accompanied by a complete
RPLND. The standard bilateral dissection is the prudent approach.
What do you do for residual masses post chemotherapy for seminoma?
After chemotherapy for seminoma, residual masses very rarely
contain teratoma and are extremely difficult technically to remove.
Thus a residual mass less than 3 cm should be observed, patients
with masses larger than 3 cm should have PET, and if a viable
seminoma is noted, then either additional chemotherapy or RPLND
is indicated.
How does the histology of RPLND specimen predict histology of other
RPLND histology is a strong predictor of histology at thoracotomy:
if necrosis is all that is found in the retroperitoneum, 89% of the time
the chest lesions will be necrotic.
What is the lateral border of dissection for paraaortic and paracaval LN packets?
The ureters provide the anatomic landmark for the lateral border of
dissection for the para-aortic and paracaval lymph node packets.
What has constant anatomy in lumbar vasculature?
There are three paired lumbar arteries located between the renal
hilum and the aortic bifurcation in nearly all patients.
What is the most common histology seen in patients that have late relapse after chemotherapy?
Late relapse in patients with prior receipt of chemotherapy is often
composed of yolk sac tumor and tends to be relatively
chemorefractory regardless of histology. Thus primary management
of resectable disease at late relapse is surgical extirpation.
