Nerve-preserving bilateral retroperitoneal lymphadenectomy: anatomical study and operative approach

In a study of the sympathetic trunk in 18 cadavers a new anatomical approach for modified bilateral retroperitoneal lymphadenectomy was developed, which is characterized by unilateral preservation of the L3 ganglion and the fibers arising from this ganglion. Furthermore, the sympathetic trunk and its lumbar branches were dissected, including the connections between the right and left sympathetic trunks arising from the L3 and L4 ganglia. On the right side the fibers were found dorsal to the inferior vena cava from where they pass into the aortocaval zone. Caudal to the inferior mesenteric artery these fibers communicate with the left para-aortic fibers. The precise topographic inter-relationship between the L2 and L3 ganglia was studied; the lower margin of the L3 ganglion was located 1 cm. cranial to the origin of the inferior mesenteric artery. Based on these findings a modified operative technique was developed for stages B1 and B2 testicular tumors. With the help of this modification it should be possible to preserve ejaculatory function in 50% of the patients who undergo an operation for small retroperitoneal tumors. However, this modification can be justified only if the recurrence rate is not higher than that with radical bilateral lymphadenectomy.