Current update of management of clinical stage I non seminomatous germ cell tumors of testis

Minimally Invasive Retroperitoneal Lymphadenectomy

The feasibility of laparoscopic retroperitoneal lymphadenectomy (RLA) for testicular cancer was shown >25 years ago. Initially the indication was clinical stage I (CS I) nonseminomatous germ cell tumor (NSGCT). Compared with that of open surgery, the morbidity was much decreased. However, in Europe, surgery for CS I is now replaced by chemotherapy. A relatively new indication is laparoscopic retroperitonal lymphadenectomy for small unilateral residual tumor after chemotherapy. The technique of unilateral lymphadenectomy for both indications is described in detail and with a video. The most recent development is bilateral laparoscopic RLA for residual tumors larger than 5 cm.

Laparoendoscopic single-site retroperitoneal lymph node dissection in non-seminomatous germ cell malignancy

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. LESS is possible in virtually any urologic surgery.

PATIENT AND METHOD

We present a 38-year-old male with BMI 31.2 and with history of stage I nonseminomatous mixed germ cell tumor showing interaortocaval lymph node recurrence without elevation of tumor markers. Patient was undergone to right laparoendoscopic single-site retroperitoneal lymph node dissection (LDRP-LESS) by umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany).

RESULTS

After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum. Complete retroperitoneal lymph node dissection on the right side from iliac vessels to renal vessels, including the paracaval and interaortocaval space, was performed. The specimen was inserted into a laparoscopic bag and was removed together with multichannel system. Abdominal drainage was not employed. Surgical time was 85 min and estimated bleeding 50 cc. The patient was very satisfied with the cosmetic results and was discharged the following day without needing analgesia. The pathology report revealed metastatic seminoma in 5 of 11 lymph nodes receiving systemic chemotherapy (VP16-CDDPs) for 4 cycles with good tolerance. A year later, the patient was disease-free and had no complications.

CONCLUSIONS

Umbilical primary LDRP-LESS, with excellent oncologic and cosmetic results, is feasible in selected cases. This approach could be considered the least invasive surgical option economically advantageous due to the reusable nature of the instruments used.

Trans- and extraperitoneal retroperitoneal lymph node dissection (RPLND) in the treatment for nonseminomatous germ cell testicular tumors (NSGCT): a single Chinese center's retrospective analysis

PURPOSE

To evaluate the role of two different approaches to perform laparoscopic RPLND: transperitoneal laparoscopic retroperitoneal lymph node dissection (TL-RPLND) and extraperitoneal laparoscopic retroperitoneal lymph node dissection (EL-RPLND).

MATERIALS AND METHODS

Between February 2003 and April 2013, 39 patients with nonseminomatous germ cell testicular tumors were treated by RPLND in our center. Twenty-one patients had TL-RPLND, and 18 patients had EL-RPLND. We performed a comprehensive retrospective study comparing TL-RPLND and EL-RPLND. Certain parameters, including operative time, estimated blood loss, perioperative complications, resected lymph nodes, postoperative intestinal function recovery time, ejaculation, and postoperative tumor markers, were abstracted and compared.

RESULTS

In the EL-RPLND and TL-RPLND groups, the operation times were 178 ± 31 and 207 ± 25 min; the amounts of estimated blood loss were 87 ± 26 and 111 ± 21 ml; the postoperative intestinal function recovery times were 1.2 ± 0.7 and 2.4 ± 0.6 days; the postoperative hospital stays were 5.8 ± 1.1 and 5.5 ± 1.4 days; and the numbers of resected lymph nodes were 16.2 ± 1.5 and 15.8 ± 1.6, respectively. No conversion from laparoscopic to open surgery occurred. No patient in either group received an intraoperative blood transfusion. Overall, two patients developed postoperative fever, and one developed abdominal distension. After a median follow-up of 45 months, no regional relapse or metastases occurred, but 4 patients at clinical stage II were treated successfully by three cycles of platinum-based postoperative chemotherapy. Currently, all patients show no evidence of disease.

CONCLUSION

Our results demonstrate that EL-RPLND was superior to the transperitoneal approach in terms of the operation time, estimated blood loss, and postoperative intestinal function recovery time, whereas no differences were observed in the number of lymph nodes resected. EL-RPLND was demonstrated to be safe and feasible, with satisfactory clinical outcomes when performed by experienced laparoscopic surgeons. Larger cohorts of patients with longer term follow-up are needed for further studies to determine the role of different approaches to L-RPLND.