title: Retroperitoneal Lymph Node Dissection: Anatomical and Technical Considerations from a Cadaveric Study.
abstract: Metastatic testis cancer in the retroperitoneum presents a technical challenge to urologists in the primary and post-chemotherapy settings. Where possible, bilateral nerve sparing retroperitoneal lymph node dissection should be performed in an effort to preserve ejaculatory function. However, this is often difficult to achieve, given the complex neurovascular anatomy. We performed what is to our knowledge the first comprehensive examination of the anatomical relationships between the sympathetic nerves of the aortic plexus and the lumbar vessels to facilitate navigation and nerve sparing during bilateral retroperitoneal lymph node dissection.
  
  
  
  The relative anatomy of the infrarenal vasculature (lumbar vessels, right gonadal vein and inferior mesenteric artery) was investigated in 21 embalmed human cadavers. The complex relationships between these vessels and the sympathetic nerves of the aortic plexus were examined by dissection of an additional 8 fresh human cadavers.
  
  
  
  Analysis of the infrarenal vasculature from 21 cadavers demonstrated that the position of the right gonadal vein and the inferior mesenteric artery may be useful to locate the right superior lumbar vein and the first pair of infrarenal lumbar arteries as well as the common lumbar trunk (vein) and the second pair of infrarenal lumbar arteries, respectively. Furthermore, the lumbar splanchnic nerves supplying the aortic plexus were most often positioned anteromedial to the respective lumbar vein.
  
  
  
  The current study describes the complex neurovascular relationships that are crucial to performing successful nerve sparing retroperitoneal lymph node dissection. Surgical techniques are also discussed. Collectively, these results may help surgeons decrease the rate of postoperative retrograde ejaculation and/or anejaculation.
authors.affiliation: Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Tyler S
authors.initials: TS
authors.lastname: Beveridge
authors.affiliation: Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Brian L
authors.initials: BL
authors.lastname: Allman
authors.affiliation: Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Marjorie
authors.initials: M
authors.lastname: Johnson
authors.affiliation: Vascular Surgery Division, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada.
authors.forename: Adam
authors.initials: A
authors.lastname: Power
authors.affiliation: Urology Division, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Joel
authors.initials: J
authors.lastname: Sheinfeld
authors.affiliation: Urology Division, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada; Surgical Oncology Division, Department of Oncology, London Health Sciences Centre, London, Ontario, Canada. Electronic address: nicholas.power@lhsc.on.ca.
authors.forename: Nicholas E
authors.initials: NE
authors.lastname: Power
mesh_terms: D002102:Cadaver; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008207:Lymphatic Metastasis; D008297:Male; D012187:Retroperitoneal Space; D013736:Testicular Neoplasms / Q000556:secondary* / Q000601:surgery*
keywords: anatomy; lymph node excision; nonseminomatous germ cell tumor; regional; sympathetic nervous system; testis