Morbidity of retroperitoneal lymph node dissection after chemotherapy

RPLND after induction chemotherapy is a challenging operation because of the complexity of the procedure and the severe desmoplastic reaction from prior exposure to chemotherapeutic agents. The morbidity of post-chemotherapy RPLND ranges from 18% to 29% in the standard group [23,79,80] and up to 39% in the complicated RPLND group [81,82]. Perioperative complications may be subdivided into pulmonary, infectious, lymphatic, vascular, neurologic, and gastrointestinal complications.

Pulmonary-related complications occur in up to 8% of cases and include atelectasis, pneumonia, adult respiratory distress syndrome, and pulmonary embolism [23]. Aggressive chest physiotherapy, adequate analgesia, and early mobilization may reduce the incidence. Wound infections occur in 5% of cases and urinary tract infections in 0.8% of cases [23].

Injury to lymphatic channels, resulting in chylous ascites, occurs in 2% of cases [23]. Factors that predispose to this complication include suprahilar dissection, liver resection, or resection of the inferior vena cava. Dietary manipulation with medium-chain triglycerides and diuretic therapy are the mainstays of management. Lympho-celes may also result from the lymphatic injury, and percutaneous drainage is necessary if there is superimposed infection, hydronephrosis, or prolonged ileus. Injury to the inferior vena cava or aorta may necessitate primary repair or the use of interposition grafts, and injury to renal vessels may occur, resulting in renal infarction and loss of the kidney. Spinal cord ischemia is rare and is usually associated with advancing age and dissection around the anterior spinal artery near the T8 level. Small bowel obstruction is present in 2% and often responds to conservative measures [23]. Prolonged ileus may mask underlying pancreatitis, retroperitoneal hematoma, urinary extravasation, or bowel ischemia. Hemorrhage after RPLND necessitating transfusion is rare in tertiary centers, ranging from 0.3% to 1% in large studies [23,79,80]. Adjunctive procedures, including en bloc nephrectomy, inferior vena cava resection, orchiectomy, bowel resection, hepatic resection arterial graft, caval thrombectomy, adre-nalectomy, and cholecystectomy, occur in 29% to 52% of cases [23,79]. Long-term morbidity and fertility issues are covered in a separate chapter of this edition.

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