This information describes the operation to remove the residual lymph nodes at the back of the abdomen as part of your treatment for testicular cancer.
What are lymph nodes?
The lymphatic system is a part of the body’s immune system which helps to fight infection. It also helps to remove excess fluid from the body. The lymphatic system is made up of vessels similar to veins which carry the lymph around the body. Along its course are groups of nodes or glands.
After passing through various nodes, the lymph is finally delivered into the blood stream. Cancer cells can be carried in the lymph fluid to the lymph nodes where they can grow as ‘secondary deposits’ of cancer. This is what happens with testicular cancer that has spread outside the testicle.
Agreeing to treatment
Consent
We will ask you to sign a consent form agreeing to accept the treatment you are being offered. The basis of the agreement is that you have had The Christie’s written description of the proposed treatment and that you have been given the opportunity to discuss any concerns. You are entitled to request a second opinion from another doctor who specialises in treating this cancer. You can ask your own consultant or your GP to refer you.
Your consent may be withdrawn at any time before or during this treatment. Should you decide to withdraw your consent, a member of the treating team will discuss the possible consequences with you.
What are the benefits of the operation?
The CT scan you had after your chemotherapy treatment showed some enlarged lymph nodes in your abdomen. As these nodes are more than 1cm in size we recommend that the nodes are removed.
Although the chemotherapy will kill most of the aggressive cancer cells, about 2 in 5 patients with enlarged nodes will have a less aggressive form of the cancer remaining, and a smaller proportion, about 1 in 10, will have a more aggressive form of cancer. The CT scan you had after your chemotherapy treatment showed some enlarged lymph nodes in your abdomen. As these nodes are more than 1cm in size we recommend that the nodes are removed.
The lymph nodes in the abdomen are most likely to be benign (not cancer). However, there is a chance that if they are left there they will either begin to grow or change into another cancer which occurs in about 1 in 5 people.
What are the risks of the operation?
There are some risks that are common to all types of major surgery and some that are more specific to this operation.
General risks of surgery include:
- bleeding at the operation site
- infection in the wound or chest
- heart irregularities due to the anaesthetic and surgery
- blood clots in the legs (deep vein thrombosis, also known as DVT) or lungs (pulmonary embolus, also known as PE)
- poor wound healing or weakness in the wound site
- bleeding and the need for a blood transfusion
- injury to nearby nerves and tissues
Stopping smoking
If you continue to smoke, this will reduce the chance of the treatment being successful. It also increases the risk of serious late side effects as well as the risk of further cancers. We strongly advise you not to smoke. There is a free smoking cessation service at The Christie. Please ring them on 0161 956 1215 or 07392 278408. You can also contact the Smokefree National Helpline on 0300 123 1044.
What are the risks of RPLND?
Removing the lymph nodes from the abdomen can cause infertility in some patients because of an effect called retrograde ejaculation. Retrograde ejaculation means that during sexual intercourse when you ejaculate or have an orgasm, the fluid (semen) that usually comes out of your penis goes backwards into your bladder instead. The semen is then passed out harmlessly the next time you pass urine. But it means that it is highly unlikely you would be able to get somebody pregnant without having some medical help including storing sperm before you have the operation.
The surgeon may be able to lessen the risk of damaging the nerves by reducing the size of the operation site. However, it is not always possible to do this after chemotherapy as the lymph nodes may be close to the nerve pathways. In some cases trying to preserve the nerves would increase the chances of leaving behind some of the lymph nodes. This would increase the possibility of the cancer coming back.
If, in the future, you feel that your sex life has been affected by the surgery, please discuss this with your doctor or nurse.
The affected lymph glands are usually stuck to the major blood vessels in the abdomen (the aorta or main artery and the vena cava or main vein). The blood vessels near to the kidney may also be closely involved with the lymph glands. If this is the case then there is a risk to the blood vessels and kidney and on rare occasions it may be necessary to repair or replace the major blood vessels with an artificial graft. In 1 in 10 to 1 in 20 patients, it may be necessary to remove a kidney.
If either of these procedures is necessary, it will not worsen your overall health once you have recovered from the operation.
Are there any alternatives to the operation?
The other treatment for testicular cancer is chemotherapy and you have already received this type of treatment.
It may be possible to delay the operation and keep you under regular review using CT scans. The disadvantage of this is that in many cases it is impossible to tell whether there is active tumour present in the lump (lymph node) that we can see. Also, lymph nodes may become larger and more complicated to operate on in the future.
What will happen if I do not have this operation?
If you do not have the operation to remove the lymph nodes there is the possibility that the cancer will continue to grow and this may make any future chance of surgery more difficult or impossible.
More seriously, there is a 1 in 5 chance that the lymph nodes change into another cancer. If they do, this may be life-threatening.
What does the operation involve?
A cut (incision) is made along the middle of the abdomen extending from the bottom of the breastbone to the pubic region. Sometimes, we may need to extend the incision up on to the ribcage on the right or the left side. This will heal completely but it will leave a long scar. If the incision goes on to the chest there may be tenderness in the lower rib area after the operation. This is where the ribs have to heal.
Before the operation
We will ask you to attend The Christie for assessment at the pre-admission clinic. At this clinic a healthcare professional will:
- ask questions about your medical history
- assess your heart and lung function
- take a sample of blood for analysis
- take swabs from your skin to make sure that you do not have an existing infection
- ask you if you have any questions about the operation
The date of your operation will have been given to you by the time you come to the pre-admission clinic.
You will be admitted to the ward the day before, or on the day of your operation when you will meet the other members of the team looking after you such as the anaesthetist, the ward nurses and ward doctor.
Your stay in hospital will usually be about 7 to 10 days.
After the operation
- After you come out of theatre, staff will transfer you to the recovery area for up to 2 hours, you will then be moved to the oncology critical care unit (OCCU). Your stay in the OCCU will probably last for 48 hours until you are ready to return to the main The purpose of your stay in the OCCU is to monitor your blood pressure, heart rate and fluid levels.
- To reduce the pain in your abdomen after the operation ward staff will give you painkillers. The anaesthetist will discuss the options with you:
- a painkiller device that you control, that releases painkillers into your blood stream via a drip (patient controlled analgesia), or
- an epidural by which painkillers and local anaesthetic given directly into the spinal nerve This involves inserting a very fine plastic tube into your back through which these drugs are given.
- After about 2 days the need for these types of painkiller is greatly reduced, and you will be able to have the systems removed. The ward staff will then give you painkilling tablets or injections instead. Please tell the staff looking after you if you are still in pain or discomfort as it may be that your medication needs to be altered.
- You will have a drip running into a vein in your neck to give you fluids until you are able to drink normally (about 3 to 4 days after the operation). When you are able to drink you will then be allowed to start to eat again (about 4 to 6 days after surgery).
Physiotherapy
After the operation the physiotherapists will visit you to teach you deep breathing and leg exercises. It is important that you carry out these exercises regularly as they will help to prevent a chest infection and blood clots in the legs that can occur while you are not as mobile as you would be normally.
Drain
If your operation has involved a cut that goes into your chest, the surgeon may need to put a drain into the side of your chest during the operation. This drain allows the lung, which would collapse during the surgery, to re-inflate. The drain normally stays in place for up to 3 days. A chest X-ray will be carried out to make sure that the lung has re-inflated before the drain is removed.
A dressing will be put over the wound. The wound usually has stitches which are dissolvable.
As well as a dressing on your wound, you will also have a drain (a small plastic tube) from your abdomen which drains away fluid from inside your wound. This will normally stay in place for 4 to 5 days.
Occasionally you will be discharged with the drain in place. If you are sent home with a drain still in place, a district nurse will visit you at home to monitor and care for the drain.
The amount of fluids that you can drink immediately after the operation will be restricted. This is to prevent you from being sick. You will gradually be able to drink and eat normally – usually about 4 days after the operation.
Going home
Most people stay in hospital for between 7 to 10 days after this operation. By the time you are ready to go home you will be looking after yourself without the need for help from others.
However, you will feel tired when you get home and it is important that you rest as well as take gentle exercise such as walking. For a few weeks after surgery you will appreciate some time to recuperate and gradually get back to normal. This may take between 6 and 12 weeks.
We will give you a letter to take for the district nurses and necessary tablets, such as painkillers, to take home.
General advice after the operation
Getting back to work
This depends on the type of work that you do but as a general rule you will probably need about 6 weeks off work. If your job involves manual work such as lifting then you will need about 12 weeks off work. If you are unsure about your return to work, ask the team looking after you. You can get a fit note for the time that you are in hospital from the ward staff. Your GP can give a fit note for the rest of the time you need to have off.
Lifting
Be careful about what you lift, such as during sport or carrying bags and small children. For the first 6 weeks, try not to lift anything.
Driving
Until you can safely carry out an emergency stop without it causing you pain you should not attempt to drive. This will take about 4 to 6 weeks.
Follow up
We will give you an appointment to attend the outpatient department to see the surgeon about 6 weeks after the operation. At this appointment we will be able to give you the results of the findings from the laboratory from the lymph nodes that were removed at the time of the operation.
Further follow up will be under the care of the consultant that gave you your chemotherapy.
Contacting The Christie
For health queries about your operation, contact your Christie urology specialist nurse keyworker - ask for their contact number.
Out of hours, contact The Christie Hotline for urgent support and specialist advice on 0161 446 3658, 24 hours a day, 7 days a week.
For further information
Macmillan Cancer Support
Provides emotional and practical support to people affected by cancer and for general information about cancer, treatments and booklets as well as benefits information. You can ask to talk to a cancer
information nurse specialist who can answer questions about cancer and treatments and what to expect.
Freephone: 0808 808 0000 (8am to 8pm, 7 days a week)
Textphone: 0808 808 0121
Or visit www.macmillan.org.uk
Maggie’s centres
The centres provide a full programme of practical and emotional support including psychological support, benefits advice, nutrition and headcare workshops, relaxation and stress management. No appointment needed. Support is free. Drop-in Monday to Friday, 9am to 5pm.
Maggie’s Manchester
Contact Maggie’s on 0161 641 4848 or email manchester@maggies.org
The Robert Parfett Building, 15 Kinnaird Road, Manchester M20 4QL
Maggie’s Oldham
Contact Maggie’s on 0161 989 0550 or email oldham@maggies.org
The Sir Normal Stoller Building, The Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH