Retroperitoneal lymph node dissection (RPLND)

RPLND removes the lymph nodes at the back of the belly, around the aorta and vena cava, where testicular cancer spreads first. It is done to treat cancer in those nodes or to remove masses left behind after chemotherapy.

Also called RPLND, Retroperitoneal lymph node dissection, Retroperitoneal lymphadenectomy, Nerve-sparing RPLND, Robotic RPLND, R-RPLND, Primary RPLND, Post-chemotherapy RPLND

Where: Hospital operating room, ideally at a center that does many of these operations
Anesthesia: General anesthesia, often with an epidural or nerve block for pain after open surgery
Time in the room: 3 to 6 hours; often longer after chemotherapy
Hospital stay: Open surgery: usually 3 to 7 days. Robotic surgery: usually 1 to 2 days
Back to normal: Open surgery: 4 to 6 weeks. Robotic surgery: 2 to 4 weeks
Back to work: Open surgery: 4 to 6 weeks; robotic surgery: 2 to 3 weeks for desk work

See the steps

AortaVena cavaLymph nodesEjaculation nerves

Where it happens. The highlighted part is what this procedure treats.

Overview

Testicular cancer spreads in a predictable way. Before it goes anywhere else, it usually travels to lymph nodes deep in the back of the belly, along the two largest blood vessels in the body: the aorta and the vena cava. This area is called the retroperitoneum. An RPLND removes the lymph nodes there.

RPLND is done in two main situations. A primary RPLND is done before any chemotherapy, usually for a type of testicular cancer called nonseminoma that has spread to a few small nodes or is at higher risk of spreading. It can cure some men without chemotherapy and shows exactly how far the cancer has gone. A post-chemotherapy RPLND is done when a node mass is still visible on scans after chemotherapy. That leftover tissue may be dead scar, active cancer, or teratoma, a type of tumor that chemotherapy cannot kill, and the only way to know is to remove it.

The operation is done either through a long cut down the middle of the belly (open surgery) or, at some experienced centers and for selected men, with a robot through small keyhole cuts. Surgeons follow maps called templates that define which nodes to remove, based on which testicle had the cancer and what the scans show.

The nerves that control ejaculation run right through the same area. When the cancer allows, your surgeon finds and protects them, which is called nerve sparing. In experienced hands, most men keep normal ejaculation after a nerve-sparing primary RPLND. Because experience matters so much, RPLND is best done at centers that perform it often.

The parts of your body involved

The retroperitoneum is the space at the back of the belly, behind the bowel and in front of the spine. The aorta and the vena cava run down its middle, with the kidneys on either side and the ureters (the tubes from the kidneys to the bladder) running down along the edges. Lymph nodes cluster around the two big vessels, from the level of the kidney veins down to where the vessels split toward the legs. The testicles form near the kidneys before birth, so their lymph drains here: the right testicle mainly to nodes around and between the vessels on the right, and the left testicle mainly to nodes beside the aorta on the left. Thin nerves for ejaculation leave the spine on each side, cross over and between the nodes, and join in a web in front of the lower aorta. They control the release of semen into the urethra.

Aorta
The main artery carrying blood from the heart down through the belly.
Vena cava
The main vein carrying blood from the legs and belly back to the heart.
Retroperitoneal lymph nodes
Small glands along the aorta and vena cava where testicular cancer spreads first.
Ejaculation nerves
Thin nerves from the spine that cross the node area and control the release of semen. They are protected when possible.
Kidneys and ureters
Sit beside the node area and mark its edges. The surgeon protects their blood vessels and drainage tubes.
Testicular vein
The remaining stump of the testicle's vein, left from the orchiectomy. It is removed with the nodes.

Why it’s done

RPLND treats and stages testicular cancer in the place it spreads first. Your team recommends it based on the type of cancer, the tumor markers and the scans.

Removing cancer in the nodes
For small-volume spread, surgery alone cures many men, and some avoid chemotherapy entirely.
Removing teratoma
Teratoma does not respond to chemotherapy or radiation. Left in place, it can grow and press on organs, or rarely turn into a more aggressive cancer. Surgery is the only cure.
Checking leftover masses after chemotherapy
Scans cannot tell scar from living tumor. Removing the mass gives the answer and removes any tumor that remains.
Accurate staging
Examining the nodes shows exactly whether cancer has spread, which helps decide whether more treatment is needed.
Avoiding chemotherapy's long-term effects
For some men, surgery instead of chemotherapy avoids later risks such as hearing loss, nerve damage and heart disease.

Other options

Surveillance
For cancer confined to the testicle, regular scans and blood tests can catch any spread early, when it is still highly curable. Many men never need further treatment.
Chemotherapy
Chemotherapy, usually a combination called BEP or EP, is the standard treatment for more extensive spread, and one cycle is an option for some higher-risk stage I cancers. It treats cancer anywhere in the body but has short- and long-term side effects.
Radiation
Radiation to the node area is an option for seminoma with small lymph node spread. It is not used for nonseminoma.
Watching a small leftover mass
After chemotherapy for seminoma, small leftover masses are often watched with scans rather than removed. After chemotherapy for nonseminoma, masses larger than about 1 centimeter are usually removed.
Robotic or open surgery
Both remove the same nodes. Robotic surgery means smaller cuts and a faster recovery, and is offered at some centers for selected men, mostly before chemotherapy. Open surgery remains standard for large or complex masses after chemotherapy.

In the operating room, step by step

Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.

Anesthesia teamYouSurgeon

1 / 9

1. Going to sleep

You lie on your back on the operating table. For open surgery, the anesthesia team usually places an epidural, a thin tube in the back for pain relief, before you go to sleep. A catheter is placed in the bladder once you are asleep. For robotic surgery, the robot is brought to the table after the keyhole cuts are made.

More detail

If you had bleomycin chemotherapy, the anesthesia team keeps the oxygen level as low as is safe and is careful with IV fluids to protect your lungs.

You lie on your back on the operating table. For open surgery, the anesthesia team usually places an epidural, a thin tube in the back for pain relief, before you go to sleep. A catheter is placed in the bladder once you are asleep. For robotic surgery, the robot is brought to the table after the keyhole cuts are made.
More detail
If you had bleomycin chemotherapy, the anesthesia team keeps the oxygen level as low as is safe and is careful with IV fluids to protect your lungs.
For open surgery, your surgeon makes a long up-and-down cut in the middle of the belly, usually from just below the breastbone to below the belly button. For robotic surgery, four to six small keyhole cuts are made instead.
The colon and small bowel are gently lifted and moved out of the way to open up the back of the belly. The aorta, vena cava and the lymph nodes around them come into view.
Your surgeon marks out the area to be cleared: from the kidney veins at the top, to the ureters at the sides, to where the big vessels split toward the legs at the bottom. A one-sided template is often used before chemotherapy. A full, both-sided template is more often used after chemotherapy or when there is more disease.
More detail
Modified one-sided templates were designed from studies of where testicular cancer spreads from each side. They leave the nerves on the opposite side untouched, which helps protect ejaculation even without formal nerve sparing.
Before removing the nodes, your surgeon finds the thin nerves for ejaculation as they leave the spine and cross the area. Each is gently freed and held aside, often with a small rubber loop, so it can be protected.
The fatty tissue holding the lymph nodes is opened along the top of the aorta and vena cava and rolled off the vessels. Small branch vessels to the spine are tied or clipped. Lymph channels are sealed with clips to prevent leaks. The nodes are removed in labeled packets for the pathologist.
More detail
This is called the split-and-roll technique. Sealing the lymph channels carefully, especially near the top of the template, lowers the chance of a milky lymph fluid leak into the belly afterward.
The leftover testicular vein from your orchiectomy is removed along its full length, up to where it joins the main vein. The marking stitch left during the orchiectomy helps the surgeon find its lower end.
With the nodes gone, the clean vessels are checked for bleeding and the area for lymph leaks. When nerve sparing was possible, the ejaculation nerves are seen lying intact across the field.
The bowel is returned to its normal place. The belly wall is closed with strong stitches, and the skin with staples or dissolving stitches. A drain is not usually needed.

Your surgeon is in control the whole time

The surgeon sits at a console a few steps from you and moves every instrument with hand controls and foot pedals. The robot cannot move on its own or make decisions.

A magnified 3D view

A camera on one arm gives the surgeon a bright, three-dimensional picture magnified about ten times, which helps them see small nerves and vessels.

Wristed instruments through keyholes

The instruments are about the width of a pencil and bend like a wrist inside your body, so the surgeon can stitch and dissect through small openings.

A team at your side

A bedside assistant and a scrub nurse stay at the table, and the anesthesia team watches your breathing and blood pressure throughout. Most U.S. hospitals use the da Vinci system made by Intuitive.

After the operation

In the hospital

Pain control
After open surgery, the epidural usually stays in for 2 to 3 days, then you switch to pills. After robotic surgery, pills are usually enough from the start.
Getting up
Nurses help you sit up and walk the same evening or the next morning. Walking several times a day speeds recovery and prevents clots and pneumonia.
Eating
You start with sips of liquid and move to food as your bowels wake up. Some surgeons recommend a low-fat diet for a few weeks to lower the risk of a lymph fluid leak.
The catheter
The bladder catheter is usually removed within 1 to 2 days.
Clot prevention
You may get blood-thinning injections and wear squeezing leg sleeves while in bed.
Breathing exercises
A small breathing device helps keep your lungs open. Use it often while awake.
Going home
You go home when you are walking, eating, passing gas and your pain is controlled with pills.

At home

Pain
Incision pain improves steadily over 2 to 3 weeks after open surgery. Use acetaminophen and anti-inflammatory medicine as directed, and stronger medicine only as needed.
The incision
Keep it clean and dry. Staples, if used, are removed in about 10 to 14 days. A pillow pressed over the incision helps when you cough or laugh.
Showering
Usually allowed after 24 to 48 hours. Let water run over the incision and pat dry. No baths or swimming until it is fully healed.
Diet
Small, frequent meals at first. Follow a low-fat diet if your surgeon advised it, and report new belly swelling.
Bowels
Constipation is common, especially with pain pills. Use a stool softener and drink plenty of fluids.
Activity
Walk several times a day and build up gradually. Expect to tire easily for a few weeks.
Lifting
After open surgery, no lifting more than about 10 to 15 pounds for 6 weeks to protect the belly wall. After robotic surgery, usually for 2 to 4 weeks.
Driving
Once you are off strong pain medicine and can turn and brake comfortably, usually 2 to 3 weeks after open surgery and about 1 week after robotic surgery.
Sex and ejaculation
Sex is usually fine once you feel ready, often after 2 to 4 weeks. Erections are not affected by this surgery. If your orgasm is dry, tell your surgeon; sometimes ejaculation returns over the first months.
Work
Desk work after about 4 to 6 weeks for open surgery, or 2 to 3 weeks for robotic surgery. Physical jobs may take longer.

Recovery timeline

Day 0
Surgery
You wake up in the recovery room with an epidural or pain medicine, a bladder catheter and an IV.
Days 1 to 2
Up and walking
Walking in the hallway, sipping liquids, and the catheter comes out. Robotic patients often go home now.
Days 3 to 7
Home after open surgery
Your bowels wake up, you eat, and you go home once pain is controlled with pills.
Weeks 1 to 2
Pathology and follow-up
The pathology report shows what was in the nodes. Your team explains whether you need anything more.
Weeks 2 to 6
Getting stronger
Energy returns gradually. Most men walk farther each day and return to light activity.
About 6 weeks
Back to full activity
After open surgery, lifting and exercise usually resume. Robotic patients usually get there sooner.
First months
Any further treatment
If cancer was found, your team may suggest surveillance or a short course of chemotherapy, depending on how much.
Years 1 to 5 and beyond
Follow-up
Regular blood tests and scans, more often at first. Long-term care includes heart health and other checks.

What it feels like

RPLND is a big operation, and many men come to it already tired from an orchiectomy and sometimes chemotherapy. The first week is the hardest. Most men say they felt noticeably better each week after that.

Before surgery
Many men feel worn down by treatment so far and anxious about a large operation and about losing ejaculation or fertility.
What helpsAsk your surgeon for honest numbers about ejaculation in your situation, and bank sperm if you have not. Bring a list of questions and someone to help you remember the answers.
Waking up
Groggy, with a sore belly, an IV and a catheter. With an epidural, your belly and legs may feel numb or heavy.
What helpsTell the nurses if pain is not controlled. The epidural can be adjusted.
The first walk
Getting out of bed hurts and you may feel dizzy. It can seem impossible on the first day.
What helpsHug a pillow against your belly, roll to your side, and push up with your arms. Each walk gets easier, and walking is one of the best things for recovery.
Waiting for the bowels
Bloating, gas pains and a poor appetite are common for the first several days.
What helpsWalk, chew gum if allowed, and eat small amounts. Passing gas is a real milestone.
The first weeks at home
Fatigue is often the biggest surprise. Naps are normal, and so is feeling low some days.
What helpsAccept help, walk a little more each day, and expect steady but uneven progress.
The first ejaculation
Many men are anxious to find out whether ejaculation works. A dry orgasm, if it happens, can be upsetting.
What helpsOrgasm still feels pleasurable without fluid. Talk with your surgeon, since ejaculation sometimes returns over months and there are ways to help with fertility.
The pathology results
Waiting for the results brings back the fear of the first diagnosis.
What helpsAsk when and how results will be shared. Many men learn that no active cancer was found, or that it was fully removed.

How well it works

Success means the nodes and any tumor in them are fully removed, the cancer does not come back in the operated area, and ejaculation is preserved when possible.

The pathology report
It describes what was in the nodes: no cancer, active cancer, teratoma, or scar and dead tissue after chemotherapy, and how many nodes were involved.
What happens next
If no cancer was found, follow-up alone is usual. If cancer was found, your team discusses surveillance or a short course of chemotherapy, depending on how much.
Control in the operated area
When RPLND is done thoroughly at an experienced center, cancer coming back in the operated area is uncommon. Overall cure rates for testicular cancer are very high.
Ejaculation
After a nerve-sparing primary RPLND at an experienced center, more than 9 in 10 men keep normal ejaculation. The chance is lower after chemotherapy or when nerves must be removed with the tumor.
Follow-up
Tumor markers and scans continue on a schedule for at least 5 years.

Risks

Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.

Common

Pain

Incision pain for several weeks after open surgery, less after robotic surgery.

Slow bowels (ileus)

The bowel can take several days to wake up, causing bloating, nausea and a slow return to eating.

Fatigue

Tiredness for several weeks, especially after open surgery or chemotherapy.

Less common

Loss of ejaculation (dry orgasm)

If the nerves are injured or must be removed, semen no longer comes out at orgasm. Orgasm and erections are not affected. Sperm can often still be collected for fertility treatment. The chance depends on the template, whether nerve sparing was possible, and prior chemotherapy.

Lymph fluid leak (chylous ascites)

Milky lymph fluid can build up in the belly, causing swelling. It is usually treated with a low-fat diet and sometimes draining. More common after chemotherapy.

Bleeding and transfusion

Bleeding that needs a blood transfusion is more common after chemotherapy, when tissue is scarred.

Wound problems

Infection or opening of the incision, usually treated with wound care and antibiotics.

Blood clots

Clots in the legs or lungs. Walking, leg sleeves and blood-thinning injections lower the risk.

Rare

Injury to nearby organs

Injury to a major blood vessel, the bowel, a ureter or a kidney is rare and is usually repaired during surgery.

Removal of a kidney or other structure

Occasionally, mostly after chemotherapy, a mass is stuck to a kidney or a major vessel and part of it must be removed with the tumor.

Bowel blockage later

Scar tissue can cause a blockage months or years later.

Incisional hernia

A bulge at the incision from a weak spot in the belly wall after open surgery.

Serious lung problems

Rare, but more likely in men who had bleomycin chemotherapy.

Call your care team or go to the emergency room if

Fever of 101°F (38.3°C) or higher, or shaking chills
Belly swelling that keeps growing, or belly pain that keeps getting worse
Vomiting, or no gas or bowel movement for 3 days with bloating
Redness, pus, or the incision opening up
Swelling, warmth or pain in one calf
Chest pain or sudden shortness of breath: call 911
You cannot pass urine, or you see a lot of blood in your urine

Questions to ask your surgeon

Why do you recommend RPLND for me instead of surveillance, chemotherapy or radiation?
Will my surgery be open or robotic, and why?
How many RPLNDs do you do each year?
Which template will you use, one-sided or full?
How likely am I to keep normal ejaculation?
Should I bank sperm before surgery?
How long will I be in the hospital?
Will I need a low-fat diet afterward, and for how long?
I had bleomycin. How will that change my anesthesia care?
What is the chance you will need to remove a kidney or part of a blood vessel?
When will the pathology results be ready, and what happens if cancer is found?
What will my follow-up schedule look like?

Words you may hear

RPLND: Retroperitoneal lymph node dissection: surgery to remove the lymph nodes at the back of the belly.
Retroperitoneum: The space at the back of the belly, behind the bowel and in front of the spine.
Lymph nodes: Small glands that filter lymph fluid. Cancer can spread to them.
Aorta: The body's main artery, running down through the belly.
Vena cava: The body's main vein, returning blood from the legs and belly to the heart.
Template: A map of which lymph nodes the surgeon removes, based on where the cancer is likely to have spread.
Nerve sparing: Finding and protecting the nerves for ejaculation while removing the nodes.
Dry orgasm: Orgasm without semen coming out, from injury to the ejaculation nerves. Also called anejaculation.
Retrograde ejaculation: Semen flowing backward into the bladder instead of out through the penis.
Teratoma: A type of germ cell tumor that does not respond to chemotherapy and must be removed with surgery.
Primary RPLND: RPLND done before any chemotherapy.
Post-chemotherapy RPLND: RPLND done to remove masses that remain after chemotherapy.
Chylous ascites: A buildup of milky lymph fluid in the belly after lymph node surgery.
Ileus: A temporary slowdown of the bowel after surgery.
Bleomycin: A chemotherapy drug used for testicular cancer that can make the lungs sensitive to high oxygen levels.

Common questions

Will I still be able to ejaculate and have children?

After a nerve-sparing primary RPLND at an experienced center, most men keep normal ejaculation. If ejaculation is lost, orgasm still happens, and sperm can often be collected from urine, with a special stimulation procedure, or directly from the testicle for fertility treatment. Banking sperm beforehand is the simplest safeguard.

Will my erections be affected?

Usually not. The nerves for erections run deep in the pelvis, away from the area of this surgery, so erections and the feeling of orgasm are normally unchanged.

Why remove nodes that may not have cancer?

Scans cannot reliably tell whether small nodes contain cancer. Removing them gives a definite answer and, if cancer is present, can cure it.

My markers are normal after chemotherapy. Why do I need surgery?

Normal markers do not rule out teratoma, which makes no markers and does not respond to chemotherapy. A leftover mass after chemotherapy for nonseminoma is usually removed for that reason.

Is robotic surgery as good as open surgery?

In experienced hands and for selected men, mostly before chemotherapy, robotic RPLND removes the same nodes with a faster recovery. Open surgery remains the standard for large or complex masses, especially after chemotherapy. Ask your surgeon which suits your situation.

Why does it matter where I have this done?

RPLND is uncommon and technically demanding. Surgeons and centers that do many have better results for removing all the disease and preserving ejaculation.

Will I need chemotherapy afterward?

Often not. It depends on what the pathologist finds. Many men need only follow-up.

Sources this page draws on

American Urological Association, Diagnosis and Treatment of Early Stage Testicular Cancer: AUA Guideline (amended 2023) (2019)
European Association of Urology, EAU Guidelines on Testicular Cancer
American Cancer Society, Testicular Cancer: Surgery for Testicular Cancer
Journal of Urology, Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation (Donohue and colleagues) (1990)
Urology Care Foundation, Testicular Cancer

Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.

Retroperitoneal lymph node dissection (RPLND)

Overview

The parts of your body involved

Why it’s done

Other options

Getting ready

Weeks before

Getting your body ready

The week before

The day before and the morning of surgery

In the operating room, step by step

1. Going to sleep

After the operation

In the hospital

At home

Recovery timeline

What it feels like

Before surgery

Waking up

The first walk

Waiting for the bowels

The first weeks at home

The first ejaculation

The pathology results