EURURO Vol. 72 No. 5

2.2.6.

Lymph node dissection

Prospective identification of the sympathetic post-ganglionic nerves is

performed first

( Fig. 2

D). Then dissection of the ipsilateral gonadal

vessels, interaortocaval dissection, and contralateral vessel exposure and

mobilization with retrocaval or paraaortic nodal dissection are carried

out in a typical fashion. A left-sided RPLND is performed in an identical

manner

( Fig. 3

A,B), with the EP plane developed from the left side. The

inferior mesenteric artery (IMA) occasionally acts as a tether for a left-

sided approach when a full bilateral template or resection of a mass

below the IMA necessitates dissection here. In this case, the IMA can

usually be skeletonized to achieve the needed mobility without

requiring ligation. Care must be taken to avoid damage to the nerves

as they coalesce into the superior hypogastric plexus in this area.

2.2.7.

Closure

The peritoneal sac is released and inspected for peritoneotomies

(

Fig. 3 C

). Peritoneotomies are closed using 3-0 vicryl or 3-0 chromic

sutures

( Fig. 3 D

In the majority of cases no drains are placed; if the mass is very large

or if warranted by concomitant extirpative procedures a closed bulb

suction drain is placed in the retroperitoneum. The incision is closed in a

typical fashion. When an epidural catheter is not present, para-incisional

[(Fig._2)TD$FIG]

Fig. 2 – (A) Ureteral identification. (B) Full mobilization of the kidney from the peritoneal sac. (C) Visualization of the great vessels. (D) Prospective

nerve-sparing step.

[(Fig._1)TD$FIG]

Fig. 1 – (A) Midline incision. (B) Incision of the posterior rectus. (C) Development of the extraperitoneal space. (D) Development of the retroperitoneal

space.

E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 8 1 4 – 8 2 0

816