Centralization tendencies of retroperitoneal lymph node dissection for testicular cancer in Germany? A total population-based analysis from 2006 to 2015

Regionalization of Testis Cancer Care-Is It Necessary?

Testicular germ cell tumors are rare genitourinary malignancies, but they represent the most common malignancies in men aged 15 to 30 years. Whereas the initial steps of management such as staging imaging studies, inguinal orchiectomy, and tumor marker can be performed elsewhere, the surgical and cytotoxic therapy needs to be done at reference centers. Regionalization of testis care has been shown to result in superior oncological outcome.

Lymph Node Dissection in Testicular Cancer: The State of the Art and Future Perspectives

PURPOSE OF REVIEW

This narrative review provides a comprehensive overview of the evolving role of retroperitoneal lymph node dissection (RPLND) in the management of testicular cancer (TC). It explores the significance of RPLND as both a diagnostic and therapeutic tool, highlighting its contribution to accurate staging, its impact on oncological outcomes, and its influence on subsequent treatment decisions.

RECENT FINDINGS

RPLND serves as an essential diagnostic procedure, aiding in the precise assessment of lymph node involvement and guiding personalized treatment strategies. It has demonstrated therapeutic value, particularly in patients with specific risk factors and disease stages, contributing to improved oncological outcomes and survival rates. Recent studies have emphasized the importance of meticulous patient selection and nerve-sparing techniques to mitigate complications while optimizing outcomes. Additionally, modern imaging and surgical approaches have expanded the potential applications of RPLND. In the context of TC management, RPLND remains a valuable and evolving tool. Its dual role in staging and therapy underscores its relevance in contemporary urological practice. This review highlights the critical role of RPLND in enhancing patient care and shaping treatment strategies, emphasizing the need for further research to refine patient selection and surgical techniques.

The prognostic impact of treatment centralization in patients with testicular germ cell tumors: analysis of hospital-based cancer registry data in Japan

BACKGROUND

To identify the prognostic impact of treatment centralization in patients with testicular germ cell tumors (TGCT).

METHODS

We used a hospital-based cancer registry data in Japan to extract seminoma and non-seminoma cases that were diagnosed in 2013, histologically confirmed, and received the first course of treatment. To compare the 5-years overall survival (OS) rates of patients stratified by institutional care volume, we performed a Cox proportional hazards regression analysis using inverse probability of treatment weighting (IPTW) method to adjust patient backgrounds.

RESULTS

A total of 1767 TGCT patients were identified. The 5-years OS rates for stage II and III TGCT patients treated at low-volume institutions (< 7 cases) were significantly worse than high-volume institutions (≥ 7 cases) (91.2% vs. 83.4%, p = 0.012). Histological stratification revealed that 5-year OS rates for stage II and III seminoma patients in the low-volume group were significantly worse than the high-volume group (93.5% vs. 84.5%, p = 0.041). Multivariate OS analysis using an IPTW-matched cohort showed that institutional care volume was an independent prognostic factor (hazard ratio 2.13 [95% confidence interval: 1.23-3.71], p = 0.0072).

CONCLUSION

Our results indicate that stage II and III TGCT patients experience lower survival rates at low-volume institutions and would benefit from treatment centralization.

Retroperitoneal lymph node dissection for testicular cancer is a demanding procedure: detailed real-life data of complications and additional surgical procedures in 295 cases

PURPOSE

Retroperitoneal lymph node dissection (RPLND) for germ cell tumours is a challenging procedure that may present relevant complications. The purpose was to analyse postoperative complications and identify risk factors for major complications.

METHODS

This is a retrospective unicentric analysis of a large cohort of 295 RPLNDs from 1992 to 2020. Early complications (30 days) and late complications (31-180 days) were classified according to the Clavien‒Dindo classification. The influence of surgical, patient-specific, and tumour-specific parameters on grade III-V complications was analysed in univariate and multivariate logistic regression models.

RESULTS

A total of 232 were postchemotherapy RPLNDs, and 63 were primary RPLNDs. Early postoperative complications were found to be grades I-II in 58.6% (173/295), grades III-IV in 9.8% (29/295), and grade V in 0.3% (1/295). In 20% (58/295), additional surgical procedures were needed. Grade III-V complications were associated with ≥ 4 cycles of preoperative chemotherapy (OR 3.7 (1.5-8.9); p = 0.004), RPLND specimen (nonseminoma or immature teratoma) (OR 3.1 (1.4-6.6); p = 0.005), transfusions (OR 2.4 (1.1-5.4); p = 0.03), salvage RPLND (OR 4.1 (1.8-9.3); p < 0.001), and preoperatively elevated AFP (OR 5 (2.2-11.7); p < 0.001). In multivariate analysis, the only independent predictor for grade III-V complications was preoperative AFP elevation (OR 3.3 (1.2-9.2); p = 0.02). Limitations include the retrospective study design.

CONCLUSIONS

Our results demonstrate that RPLND is a demanding surgical procedure. Patients with a complex tumour history have a higher risk of complications. We recommend treatment of these complex cases in high-volume centres.

[Cancer registries in Germany: what does the future hold for urology?]

Cancer registries are defined as systematically collected information in the form of a database on tumour diseases. They can provide information about the quality of oncological care or progress in the treatment of individual cancers over time. Since 1995, all German federal states have been required by law to establish and maintain a cancer registry. The Center for Cancer Registry Data (ZfKD) at Robert Koch Institute has collected this nationwide data since 2009 and compiled it into an annually audited dataset available for research purposes. By virtue of the Cancer Early Detection and Registry Act (KFRG), which was passed in 2013, the cancer registries were given a new perspective. Since then, they have made a central contribution to the quality assurance of oncological care. The cancer registries are mainly financed by the health insurance funds. An upcoming expansion of the dataset including clinical variables and earlier provision by the ZfKD starting next year offers new opportunities for the scientific use of cancer registry data. In particular, the course of the disease will now be mapped in considerable detail. Apart from the cancer registries, there are not many useful supplemental datasets in Germany for the assessment of the nationwide healthcare situation and treatment reality on a national level. The DRG database (case-based hospital statistics) of the Federal Statistics Office records all billing data of all German hospitals with few exceptions. Another interesting supplement to the cancer registry data are the datasets of the structured quality reports, which have been mandatory for hospitals since 2003. In the future, the scientific role of cancer registries is to be further enhanced by the Act on the Pooling of Cancer Registry Data, which was passed in 2021.

Development of Incidence and Surgical Treatment of Penile Cancer in Germany from 2006 to 2016: Potential Implications for Future Management

BACKGROUND

Penile cancer is a rare disease and surgical treatment often entails a significant impact on quality of life. The aim of this study was to analyze trends in surgical treatment patterns in Germany.

METHODS

We analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2016. All penile cancer cases with penile surgery or lymph node dissection (LND) were included. We also analyzed the distribution of cases, extent of surgery, and length of hospital stay, stratified for annual caseload. The geographical distribution of centers for 2016 was presented.

RESULTS

During the investigated timespan, tumor incidences increased from 748 to 971 (p = 0.001). We identified 11,353 penile surgery cases, increasing from 886 to 1196 (p < 0.001), and 5173 cases of LND, increasing from 332 to 590 (p < 0.001). Cases of partial amputation increased from 45.8 to 53.8% (p < 0.001), while total amputation remained stable at 11.2%. Caseload in high-volume hospitals increased from 9.0 to 18.8% for penile surgery (p < 0.001) and from 0 to 13.1% for LND (p < 0.001). The increase in LND caseload was caused by an increase in inguinal LND, from 297 to 505 (p < 0.001), with increasing sentinel LND, from 14.2 to 21.9% (p = 0.098). The assessment of geographical distribution of cases in Germany revealed extensive areas without sufficient coverage by experienced centers.

CONCLUSIONS

We saw consistent increases in penile surgery and LND, with a growing number of cases in high-volume hospitals, and, accordingly, an increase in tumor incidence. The increasing use of inguinal LND and organ-preserving surgery reflect the adaptation of current guidelines; however, geographical distribution of experienced centers could be improved.

[Health care reality of selected pediatric urologic surgeries in Germany from 2006 to 2019]

BACKGROUND

The conservative and surgical treatment of children is a fundamental pillar of the urological specialist training program and represents one of the core competencies within urological healthcare. The loss of this expertise has been a reoccurring topic within urologic occupational policy. The aim of this study is to analyse actual case numbers and to compare the distribution and dynamics of pediatric urologic surgeries between the specialist departments of urology and pediatric surgery in Germany.

MATERIALS AND METHODS

We defined the surgical treatments of maldecensus testis, hypospadias, and vesicoureteral reflux (VUR) as index interventions. Using the tool reimbursement.INFO (RI Innovation GmbH, Hürth, Germany) we analysed publicly available quality report data of German hospitals between 2006 and 2019.

RESULTS

While orchidopexy was more commonly performed in the field of urology, the correction of hypospadias and the surgical treatment of VUR showed higher case numbers in the field of pediatric surgery. Proportionally, there was no relevant shift between urologic and pediatric surgical clinics for orchidopexy and surgical VUR therapy during the study period. For hypospadias corrections, the proportion of surgeries performed in pediatric surgical units is increasing (p < 0.0001). In pediatric surgery 84-93% of the analyzed procedures are performed in high-volume units, while this proportion is 56-73% in urology. In particular, a high proportion of VUR therapy in urology is performed as an occasional procedure (30% very low volume).

CONCLUSIONS

The quality report data enable the compilation of case numbers and the analysis of the distribution between urology and pediatric surgery in Germany. Merely the correction of hypospadias has shown a relevant shift towards pediatric surgery. The causes and possible consequences for professional policy of this preliminary investigation are complex and require further analysis.

[Trends in uro-oncological surgery in Germany-comparative analyses from population-based data]

Although urologic cancer represents a relevant health economic burden with about 100,000 new cases per year, hardly any knowledge exists about the structure and development of the corresponding uro-oncological interventions at the more than 400 urological surgical hospitals in Germany. Thus, we identified all cases of 5 major tumor surgery procedures in Germany from the DRG (diagnosis-related group) database of the Federal Statistical Office (prostatectomy, cystectomy, renal tumor surgery, retroperitoneal lymphadenectomy, penis surgery) from 2006-2013 (or 2016) by database query and investigated the influences of technical innovations, as well as guideline changes on the developments of case numbers. In addition, we analyzed the correlations between annual case numbers and perioperative outcomes. The results showed a clear correlation between case volume (and thus expertise) of a hospital and an improved perioperative outcome. Nevertheless, there is hardly any tendency towards centralization in these uro-oncological interventions. The development in the number of cases seems to depend more on the effect of advertising by means of technical innovations or the regional relation of the patients to a certain clinic. In the past, centrally controlled attempts to introduce minimum case numbers or voluntary certification of centers had little influence on the distribution of case numbers.

Clinical outcome of robot-assisted residual mass resection in metastatic nonseminomatous germ cell tumor

PURPOSE

To evaluate the outcome of robot-assisted residual mass resection (RA-RMR) in nonseminomatous germ cell tumor (NSGCT) patients with residual tumor following chemotherapy.

PATIENTS AND METHODS

Retrospective medical chart analysis of all patients with NSGCT undergoing RA-RMR at two tertiary referral centers between January 2007 and April 2019. Patients were considered for RA-RMR in case of a residual tumor between 10 and 50 mm at cross-sectional computed tomography (CT) imaging located ventrally or laterally from the aorta or vena cava, with normalized tumor markers following completion of chemotherapy, and no history of retroperitoneal surgery.

RESULTS

A total of 45 patients were included in the analysis. The Royal Marsden stage before chemotherapy was IIA in 13 (28.9%), IIB in 16 (35.6%), IIC in 3 (6.7%) and IV in 13 patients (28.9%). The median residual tumor size was 1.9 cm (interquartile range [IQR] 1.4-2.8; range 1.0-5.0). Five procedures (11.1%) were converted to an open procedure due to a vascular injury (n = 2), technical difficulty (n = 2) or tumor debris leakage (n = 1). A postoperative adverse event occurred in two patients (4.4%). Histopathology showed teratoma, necrosis and viable cancer in 29 (64.4%), 14 (31.1%), and two patients (4.4%), respectively. After a median follow-up of 41 months (IQR 22-70), one patient (2.2%) relapsed in the retroperitoneum. The one- and 2-year recurrence-free survival rate was 98%.

CONCLUSION

RA-RMR is an appropriate treatment option in selected patients, potentially providing excellent cure rates with minimal morbidity. Long-term outcome data are needed to further support this strategy and determine inclusion and exclusion criteria.

Additional surgical procedures and perioperative morbidity in post-chemotherapy retroperitoneal lymph node dissection for metastatic testicular cancer in two intermediate volume hospitals

Purpose

To evaluate the perioperative morbidity of PC-RPLND in two intermediate volume centers and to identify predictors of high morbidity.

Methods

Retrospective analysis of 124 patients treated with open PC-RPLND at two tertiary referral centers between 2001 and 2018. Perioperative morbidity was determined by analyzing additional surgical procedures, intra-operative blood loss, and postoperative complications.

Results

An additional procedure was necessary for 33 patients (26.6%). The risk was higher in patients with IGCCCG intermediate/poor prognosis (OR 3.56; 95% CI 1.33–9.52) and residual tumor size > 5 cm (OR 3.53; 95% CI 1.39–8.93). Blood loss was higher in patients with IGCCCG intermediate/poor prognosis (β = 0.177; p = 0.029), large residual tumor (β = 0.570; p < 0.001), an additional intervention (β = 0.342; p < 0.001) and teratoma on retroperitoneal histology (β = − 0.19; p = 0.014). Thirty-one patients had a postoperative complication Clavien-Dindo Grade ≥ 2 (25.0%). Complication risk was highest in patients undergoing an additional intervention (OR 3.46; 95% CI 1.03–11.60; p = 0.044).

Conclusions

The rate of additional interventions in our series is comparable to what has been reported in high-volume centers. IGCCCG intermediate/poor prognosis patients with high-volume disease and patients undergoing an additional surgical procedure can be classified as high-risk patients.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03229-5) contains supplementary material, which is available to authorized users.