Postchemotherapy laparoscopic retroperitoneal lymph node dissection: evaluation of complications

Laparoscopic retroperitoneal lymph-node dissection in metastatic nonseminomatous germ-cell tumors

OBJECTIVES

To support laparoscopic post-chemotherapy retroperitoneal lymph-node dissection (L-PC-RPLND) as a potential new standard, we report on a large dataset of patients systematically undergoing L-PC-RPLND.

PATIENTS AND METHODS

Patients with unilateral residual mass (≥1 cm), normalized markers, limited encasement (<30%) of gross retroperitoneal vessels underwent unilateral L-PC-RPLND with no adjuvant chemotherapy. Surgical performances, histology, hospital stay, complications within 30 days and follow-up visits were recorded. Multivariable linear and logistic regression models were used.

RESULTS

Between February 2011 and January 2021, 151 consecutive patients underwent L-PC-RPLND. Median size of the residual mass was 25 mm (interquartile range [IQR] 20-35 mm). Overall median operative time was 208 min (IQR 177-241) and was 51 min longer (p-value <0.001) for right L-PC-RPLNDs. Eleven procedures were converted to open surgery. Median number of removed and positive nodes was 11 (IQR 8-16) and 1 (IQR 1-2), respectively. Mean hospital stay was 2 days (IQR 2-3). Nine complications (6%) occurred: two were Clavien-Dindo grade III. Definitive pathology revealed post-pubertal teratoma in 65.6%, fibro-necrotic tissue in 23.8%, teratoma with malignant somatic component in 6.6% and viable tumour in 4.0% patients. In multivariable linear regression models, fibro-necrotic tissue (32 min, CI 8.5-55.5; p < 0.01) and residual volume (1.05 min, CI 0.24-1.85; p < 0.01) achieved independent predictor status for longer operative time. All patients, but one, are alive and disease-free after a median follow-up of 22 months (IQR 10, 48).

CONCLUSION

L-PC-RPLND, when adequately planned, is safe and effective for most patients with low to medium volume residual masses.

Clinical outcome of post-chemotherapy retroperitoneal lymph node dissection in metastatic nonseminomatous germ cell tumour: A systematic review

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important element of the management of patients with residual tumour after chemotherapy for disseminated nonseminomatous germ cell tumour (NSGCT). This is a challenging procedure and the outcome varies widely between institutions. There is much debate concerning the anatomical extent of the dissection and the literature is conflicting regarding the outcome of this procedure. In this systematic review we aim to summarise the literature on the relapse rate of PC-RPLND. We performed a search of the literature of the PubMed/MEDLINE and Embase databases, in accordance with the PRISMA guidelines. Studies reporting on the relapse rate of PC-RPLND in NSGCT patients with residual tumour were eligible for inclusion. We calculated the weighted average relapse rates of included studies and assessed the risk of bias using the Newcastle-Ottawa scale. A total of 33 studies, reporting on 2,379 patients undergoing open PC-RPLND (O-RPLND) and 463 patients undergoing minimally invasive PC-RPLND (MI-RPLND) were included. The weighted average relapse rates were 11.4% for O-RPLND, and 3.0% for MI-RPLND. The rates of retroperitoneal relapse were 4.6% and 1.7% after O-RPLND and MI-RPLND, respectively. For O-RPLND specifically, the average retroperitoneal relapse rate was 3.1% after modified dissection and 6.1% after bilateral dissection. We conclude that modified template dissection is oncologically safe in carefully selected patients. Minimally invasive procedures are feasible but long-term data on the oncological outcome are still lacking. PC-RPLND is a complex and challenging procedure, and patients should be treated at high-volume expert centres.

Cancer Treatment-Related Infertility: A Critical Review of the Evidence

Cancer treatments may compromise the fertility of children, adolescents, and young adults, and treatment-related infertility represents an important survivorship issue that should be addressed at diagnosis and in follow-up to ensure optimal decision-making, including consideration of pursuing fertility preservation. Risk of infertility varies substantially with patient and treatment factors. The ability to accurately assess fertility risk for many patients is hampered by limitations of the current literature, including heterogeneity in patient populations, treatments, and outcome measures. In this article, we review and synthesize the available data to estimate fertility risks from modern cancer treatments for both children and adult cancer survivors to enable clinicians to counsel patients about future fertility.

Therapeutic supine robotic retroperitoneal lymph node dissection for post-chemotherapy residual masses in testicular cancer: technique and outcome analysis of initial experience

Retroperitoneal lymph node dissection (RPLND) is a therapeutic standard of care for post-chemotherapy residual masses in testicular cancer. While a robotic approach to this procedure has the potential of decreasing the morbidity associated with this major endeavour, it is often criticised for its inability to provide a bilateral complete template resection without redocking and repositioning the patient. Herein, we present the technique and initial outcomes of a supine approach to Robotic RPLND (R-RPLND) using the da Vinci Xi^® system, which obviates the need for repositioning or redocking for a bilateral full template resection. Three patients (age 21-36) with nonseminomatous germ cell tumours of the testis underwent R-RPLND for post-chemotherapy residual retroperitoneal masses with normalised tumor markers. Salient steps of the procedure were as follows: port placement in supine Trendelenburg position, docking of the da Vinci Xi^® system from one side, exposure of retroperitoneum, dissection of paracaval, retrocaval, interaortocaval, paraaortic and bilateral common iliac templates, and excision of gonadal vein. Mean console time and estimated blood loss were 257 (190-305) minutes and 333 (300-400) ml, respectively. Mean lymph node yield was 52 (29-94). One patient had a common iliac vein injury which was managed robotically without further consequence. No drains were placed in all three. There were no postoperative complications and all of them were advanced to a normal diet within 24 h and discharged on the second postoperative day. Histopathology reports were suggestive of necrosis and mature teratoma without any viable tumour. There have been no recurrences in these patients at a mean follow-up of 14 (1-22) months. R-RPLND in the supine position is practical, safe and feasible in the post-chemotherapy setting of testicular cancer. It eliminates the need for repositioning the patient or redocking the robot to achieve a complete resection with adequate lymph node yields, while preserving the benefits of a minimally invasive surgical approach.

Laparoscopic Retroperitoneal Lymph Node Dissection in the Management of Testis Cancer

BACKGROUND

The surgical approach to management of testis cancer has been traditionally through an open incision, but in the last decade, several centers have reported their experience with laparoscopic retroperitoneal lymph node dissection (LRPLND).

METHODS

We reviewed the English literature, summarized the outcomes, and included our initial experience with the LRPLND procedure.

RESULTS

Improvements in operative time, complications, and morbidity have occurred as surgical experience has increased. The procedure is more challenging in postchemotherapy patients. Outcomes at our institute are comparable to reported series from other institutions, and LRPLND is our current procedure of choice for RPLND.

CONCLUSIONS

LRPLND has been shown to be a safe, effective, minimally invasive procedure in the management of testicular cancer patients who require surgery to address the retroperitoneal lymph nodes.

Is there a limit for the laparoscopic approach of a retroperitoneal residual mass postchemotherapy?

OBJECTIVES

Rescue lymphadenectomy for testicular cancer is a complex surgery, with a high number of complications. The laparoscopic approach appears to offer faster recovery and improved quality of life compared with open surgery. The aim of our study is to report on our experience and to define whether there is a limit (oncological, anatomical or technical) for laparoscopic management.

MATERIAL AND METHODS

A retrospective study was conducted of 15 patients who underwent laparoscopic retroperitoneal lymphadenectomy after chemotherapy. In addition to epidemiological and oncologic variables, we analyzed the mean surgical time, intraoperative and postoperative complications, the mean hospital stay and the mean follow-up time.

RESULTS

The mean surgical time was 294 minutes (range, 180-240). There were 4 large-vessel vascular lesions, all of which were large-volume retroperitoneal masses, with diameters >7 cm. The rate of postoperative complications was 33%; there was only 1 case of Clavien >III. The mean hospital stay was 5.38 days (range, 2-9), and the mean patient follow-up was 28.9 months (range, 1-79). There was no recurrence in any of the cases.

CONCLUSIONS

The laparoscopic approach is an oncologically safe option for the rescue treatment of testicular cancer. The complex location of these masses entails the onset of severe intraoperative complications. We have observed a clear relationship between vascular complications and large masses (>7 cm). We therefore believe that it would be appropriate to establish a limit on the size for laparoscopic treatment.

Laparoscopic lumbar-aortic lymphadenectomy in residual post-chemotherapy tumours in testicular cancer

INTRODUCTION

Open lumbar-aortic lymphadenectomy (OLAL) is the gold standard for treating post-chemotherapy retroperitoneal masses. Laparoscopic OLAL (L-OLAL) has emerged in recent years as an alternative for the handling of patients with these masses, with the additional potential benefits of minimal invasion.

OBJECTIVE

To present our experience with the laparoscopic handling (L-OLAL) of residual post-chemotherapy masses in patients with advanced testicular cancer.

MATERIAL AND METHODS

Between 1993 and 2009, 43 patients underwent post-chemotherapy L-OLAL. A transperitoneal technique was employed in all patients. We assessed demographic, perioperational and pathological variables, as well as complications and follow-up.

RESULTS

A unilateral dissection was performed in 17 patients, while 26 patients underwent a bilateral retroperitoneal dissection. In the first group, 4 patients relapsed. In the second group, there were no relapses. After an average follow-up of 21 months, the overall survival rate reached 95%. We recorded a rate of perioperative complications of only 9.3%.

CONCLUSIONS

In experienced hands, L-OLAL is a technically feasible surgical alternative for the treatment of patients who are carriers of advanced testicular cancer with residual post-chemotherapy masses. The dissection performed should be bilateral to avoid tumour relapses and increase the survival rate of these patients.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients

BACKGROUND

Retroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse.

OBJECTIVE

To evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution.

DESIGN, SETTING, AND PARTICIPANTS

Records of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

This was a descriptive analysis.

RESULTS AND LIMITATIONS

The study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5 cm and 1.4 cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343 min, respectively. Mean blood loss was 84 ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation.

CONCLUSIONS

Postchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.

Laparoscopic and open postchemotherapy retroperitoneal lymph node dissection in patients with advanced testicular cancer--a single center analysis

Background

The open approach represents the gold standard for postchemotherapy retroperitoneal lymph node dissection (O-PCLND) in patients with residual testicular cancer. We analyzed laparoscopic postchemotherapy retroperitoneal lymph node dissection (L-PCLND) and O-PCLND at our institution.

Methods

Patients underwent either L-PCLND (n = 43) or O-PCLND (n = 24). Categorical and continuous variables were compared using the Fisher exact test and Mann–Whitney U test respectively. Overall survival was evaluated with the log-rank test.

Results

Primary histology was embryonal cell carcinomas (18 patients), pure seminoma (2 cases) and mixed NSGCTs (47 patients). According to the IGCCCG patients were categorized into “good”, “intermediate” and “poor prognosis” disease in 55.2%, 14.9% and 20.8%, respectively. Median operative time for L-PCLND was 212 min and 232 min for O-PCLND (p = 0.256). Median postoperative duration of drainage and hospital stay was shorter after L-PCLND (0.0 vs. 3.5 days; p < 0.001 and 6.0 vs. 11.5 days; p = 0.002). Intraoperative complications occurred in 21.7% (L-PCLND) and 38.0% (O-PCLND) of cases with 19.5% and 28.5% of Clavien Grade III complications for L-PCLND and O-PCLND, respectively (p = 0.224). Significant blood loss (>500 ml) was almost equally distributed (8.6% vs. 14.2%: p = 0.076). No significant differences were observed for injuries of major vessels and postoperative complications (p = 0.758; p = 0.370). Tumor recurrence occurred in 8.6% following L-PCLND and in 14.2% following O-PCLND with a mean disease-free survival of 76.6 and 89.2 months, respectively. Overall survival was 83.3 and 95.0 months for L-PCNLD and O-PCLND, respectively (p = 0.447).

Conclusions

L-PCLND represents a safe surgical option for well selected patients at an experienced center.

[Comments on retroperitoneal lymphadenectomy - laparoscopic versus robotic]

Retroperitoneal lymph node dissection (RPLND) in high risk clinical stage I nonseminomatous germ cell tumors (NSGCT) plays a limited role in modern uro-oncology due to the superior therapeutic efficacy of even one cycle of PEB (cysplatin, etoposide, bleomycin) chemotherapy. There might be an indication for the rare case of pure mature teratoma with unfavorable prognostic risk factors. If RPLND is performed for clinical stage I NSGCT it always has to be performed in a nerve-sparing technique and within the well-defined boundaries of an anatomically adequate template in order to avoid unnecessary adjuvant systemic chemotherapy. In this aspect, laparoscopic RPLND is inferior to open RPLND as basically all patients with lymph node positive disease receive adjuvant chemotherapy. The evidence for robotic-assisted RPLND is too weak to draw any clinically useful conclusions. Currently, it is an experimental procedure.Postchemotherapy RPLND (PC-RPLND) remains a surgery for tertiary referral centres due to the complexity of the surgical intervention and the high probability of adjunctive visceral and/or vascular surgery. In accordance with international guidelines it remains a domain for an open surgical approach. Laparoscopic PC-RPLND is reserved for small residual masses with the option of a unilateral modified template resection in very experienced laparoscopic centres. With regard to robotic-assisted PC-RPLND there is no evidence in the literature with regard to morbidity and complications, short-term and long-term oncological results being in favor of this experimental approach.

Extraperitoneal laparoscopic retroperitoneal lymph node dissection for early-stage testicular nonseminomatous germ cell tumors: initial experience

PURPOSE

To investigate a modified laparoscopic retroperitoneal lymph node dissection technique using an extraperitoneal approach and to evaluate its feasibility.

PATIENTS AND METHODS

A group of consecutive patients from a single institution underwent extraperitoneal laparoscopic retroperitoneal lymph node dissection (EL-RLND) at weeks after orchiectomy for primary testicular nonseminomatous germ cell tumors (NSGCT). All patients were placed in the supine position and tilted up 15 degrees on the affected side. Four trocars were introduced. The templates of lymph node dissection conformed to those of Weissbach and Boedefeld.

RESULTS

EL-RLND was successfully performed in 15 patients (left, 6 patients; right, 9 patients). The mean total operative time for the entire series was 164 ± 49 minutes. The mean blood loss was 118 ± 74 mL. One intraoperative complication was injury of the vena cava, which occurred in one patient. Ureteral obstruction occurred in another patient. The mean postoperative intestinal function recovery time was 2 days. The mean postoperative hospitalization was 5.5 ± 1.1 days. Normal antegrade ejaculation was preserved in all patients. Pathologic studies revealed positive lymph nodes in three (20%) patients. No recurrence or distant metastasis occurred during 2 to 32 months of follow-up.

CONCLUSIONS

EL-RLND is a safe and feasible procedure using an improved extraperitoneal approach that provides minimal invasion and rapid recovery of patients.

[Postchemotherapy retroperitoneal lymphadenectomy for testicular cancer. Literature review by the Oncology Committee of the French Association of Urology, External Genitalia Group]

INTRODUCTION

Postchemotherapy retroperitoneal lymphadenectomy (PC RPLDN) leads to an overall survival rate for testicular cancer exceeding 75%. Several questions still persist concerning: preoperative assessment of residual masses, reducing templates of dissection, choosing surgical approaches or including RPLND in high-risk patients' management.

METHOD

The main series in the literature of the past 20 years were analyzed and selected to address these issues and reach a consensual diagnostic and therapeutic approach.

RESULTS

Forty-eight original articles (1992 to 2011) were selected. They confirm that no preoperative tool can predict the histological nature of residual masses. The unilateral modified template is a valid option for selected patients but the full bilateral dissection remains the standard but more morbid. The laparoscopic approach is being evaluated. The LDNRP PC is indicated in "high risk" situations especially after salvage chemotherapy.

CONCLUSION

The bilateral lymphadenectomy by laparotomy of any supracentimeter residual mass, 6 weeks after chemotherapy, for germ cell tumors of the testicle is a standard of care.

Retroperitoneal lymph node dissection for metastatic germ cell tumours

INTRODUCTION

In the North Trent Cancer network (NTCN) patients requiring retroperitoneal lymphadenectomy for metastatic testicular cancer have been treated by vascular service since 1990. This paper reviews our experience and considers the case for involvement of vascular surgeons in the management of these tumours.

PATIENTS AND METHODS

Patients referred by the NTCN to the vascular service for retroperitoneal lymphadenectomy between 1990 and 2009 were identified through a germ cell database. Data were supplemented by a review of case notes to record histology, intraoperative and postoperative details.

RESULTS

A total of 64 patients were referred to the vascular service for retroperitoneal lymph node dissection, with a median age of 29 years (16-63 years) and a median follow-up of 4.9 years. Ten patients died: eight from tumour recurrence, one from septicaemia during chemotherapy and one by suicide. Of the 54 who survived, 7 were alive with residual masses and 47 patients were disease-free at the last follow-up. Sixteen patients required vascular procedures: four had aortic repair (fascia), three had aortic replacement (spiral graft), four had inferior vena cava resection, two had iliac artery replacement and two had iliac vein resection.

CONCLUSIONS

Retroperitoneal lymph node dissection often involves mobilisation and/or the resection/replacement of major vessels. We recommend that a vascular surgeon should be a part of testicular germ cell multidisciplinary team.

Laparoscopic resection of a residual retroperitoneal tumor mass of nonseminomatous testicular germ cell tumors

Background

Resection of a residual retroperitoneal tumor mass (RRRTM) is standard procedure after combination chemotherapy for metastatic nonseminomatous testicular germ cell tumors (NSTGCT).

Methods

At the University Medical Center Groningen, 79 consecutive patients with disseminated NSTGCT were treated with cisplatin combination chemotherapy between 2005 and 2007. Laparoscopic RRRTM was performed for patients with RRTM located less than 5 cm ventrally or laterally from the aorta or the vena cava. The 29 patients who fulfilled the criteria had a median age of 25 years (range, 16–59 years). The stages of disease before chemotherapy treatment according to the Royal Marsden classification were 2A (n = 6, 21%), 2B (n = 14, 48%), 2C (n = 3, 10%), and 4 with a lymph node status of N2 (n = 6, 21%).

Results

The median duration of laparoscopy was 198 min (range, 122–325 min). The median diameter of the RRTM was 21 mm (range, 11–47 mm). Laparoscopic resection was successful for 25 patients (86%). Conversion was necessary for three patients (10%): two due to bleeding and one because of obesity. One nonplanned hand-assisted procedure (3%) also had to be performed. Histologic examination of the specimens showed fibrosis or necrosis in 12 patients (41%), mature teratoma in 16 patients (55%), and viable tumor in 1 patient (3%). The median hospital stay was 1 day (range, 1–6 days). During a median follow-up period of 47 months (29–70 months), one patient experienced an early relapse (1 month after the end of treatment) (4%).

Conclusion

For properly selected patients, laparoscopic resection of RRTM is an improvement in the combined treatment of disseminated NSTGCT and associated with a short hospital stay, minimal morbidity, rapid recovery, and a neat cosmetic result. Long-term data to prove oncologic efficacy are awaited.

Laparoscopic retroperitoneal lymph node dissection for low-stage cancer: a Washington University update

BACKGROUND AND PURPOSE

At present, open retroperitoneal lymph node dissection (RPLND) remains the preferred approach at many high-volume centers for the surgical treatment of patients with low-stage testis cancer. Despite the potential advantages of a minimally invasive approach, including improved cosmesis and shorter recovery times, there remain concerns over the quality of dissection and oncologic control offered through a minimally invasive approach. Our objective was to critically evaluate the safety and intermediate-term oncologic efficacy of laparoscopic RPLND (L-RPLND).

PATIENTS AND METHODS

A retrospective chart review was performed, evaluating all patients who underwent L-RPLND between 2003 and 2009. Patient records were updated by telephone interview.

RESULTS

A total of 59 patients underwent L-RPLND during the study period, of which 13 had previously undergone chemotherapy. Mean age at treatment was 32 years. Mean operative time and estimated blood loss were 291 minutes (176-620 min) and 184 mL (range 0-1800 mL), respectively. Mean lymph node count was 21.6 (range 5-48). Mean hospital stay was 2 days (range 1-4 d). There were three open conversions because of intraoperative complications. One patient needed a transfusion. Five patients had six (8.5%) postoperative complications: three lymphoceles, two chylous ascites, and one deep venous thrombosis/pulmonary embolus. Of 18 patients with node-positive pathology, 13 received adjuvant chemotherapy and 5 underwent surveillance. Retroperitoneal recurrence did not develop in any patient undergoing surveillance during a mean follow-up of 21.3 months. One postchemotherapy RPLND (1.7%) patient experienced a retroperitoneal recurrence.

CONCLUSIONS

L-RPLND is a diagnostic and therapeutic treatment option for patients with low-stage testis cancer, offering excellent oncologic control and acceptable perioperative morbidity. Intermediate-term results suggest that L-RPLND is a viable alternative to the open surgical procedure. Carefully selected patients may be candidates for L-RPLND in the postchemotherapy setting.

Controversial technology: the Chunnel and the laparoscopic retroperitoneal lymph node dissection (RPLND)

• Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was first introduced in 1992, initially as a staging procedure. • With advances in instrumentation and laparoscopic techniques, as well as improved understanding of laparoscopic anatomy, L-RPLND has developed to duplicate open RPLND. • Unlike the relatively rapid adoption of laparoscopy for other applications including nephrectomy and prostatectomy, L-RPLND has been slow to be universally accepted. • The limited numbers of patients requiring RPLND and technical challenges in performing the dissection have undoubtedly contributed to its delayed reception. • This review will present available data on this technique and discuss issues potentially inhibiting acceptance by traditional surgeons.

Retroperitoneal lymph node dissection after chemotherapy

Retroperitoneal lymph node dissection after chemotherapy (PC-RPLND) plays a crucial role in managing patients with advanced germ cell tumours (GCTs). In the last few years improvements in radiographic staging, a better understanding of the role of serum tumour markers, and the introduction of cisplatin-based chemotherapy have all contributed to this surgical therapy. PC-RPLND is necessary when residual radiographic abnormalities are present after chemotherapy. The need for a PC-RPLND in the face of normal findings from computed tomography (CT) is controversial. CT criteria alone are not sufficiently reliable to distinguish viable tumour or teratoma from necrosis. No combination of variables can predict negative retroperitoneal pathology with sufficient accuracy after induction chemotherapy. Unresected teratoma or viable GCT are at least partly chemorefractory and, if untreated, will progress. So completeness of resection is an independent and consistent predictive variable of clinical outcome. In PC-RPLND surgical margins should not be compromised in an attempt to preserve ejaculation, although nerve-sparing dissections are possible in patients with marker normalization after chemotherapy and necrotic tissue in frozen-section histology. In these patients nerve-sparing techniques and the reduction of surgical field to the left- or right-sided template are applicable to preserve antegrade ejaculation and consecutive fertility. The size and location of residual masses coupled with the retroperitoneal desmoplastic reaction make PC-RPLND a technically demanding procedure that should be performed by experienced surgeons in dedicated referral centres.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection in nonseminomatous germ-cell tumor

BACKGROUND AND PURPOSE

Postchemotherapy retroperitoneal lymph node dissection (RPLND) remains essential in the management of metastatic testicular carcinoma and represents a surgical challenge. We determined to assess the feasibility and complications of laparoscopic RPLND in patients who were treated with induction chemotherapy for testis cancer.

PATIENTS AND METHODS

We performed a retrospective analysis of data that was prospectively recorded from 26 patients who underwent laparoscopic RPLND postplatinum-based chemotherapy between 2000 and 2006. The surgical technique consisted of excision of the residual mass plus unilateral template dissection. A transperitoneal technique was used in 24 patients, and an extraperitoneal approach was used in 2 patients. Operative details, perioperative morbidity data, and histologic findings were assessed for the study.

RESULTS

Primary pathologic evaluation of the testis tumor revealed pure embryonal carcinoma in 4 patients, teratocarcinoma in 1 patient, and mixed nonseminomatous germ-cell tumors in 21 patients. All patients had residual disease in the retroperitoneum on a preoperative CT scan, with a median size of 3.4 cm (range 2-6 cm). Procedures in three (11.5%) patients were converted to open surgery. Median operative time was 183 minutes (range 120-260 min). Median estimated blood loss was 400 mL (range 100-600 mL), and blood transfusion was necessary in one patient. Median hospital stay was 5 days (range 2-6 d). Median number of lymph nodes obtained on final histologic examination was 7 (range 4-13). Perioperative complications included eight lymphovascular and one intestinal. At a mean follow-up of 27 months (range 14-36 mos), no recurrences have been observed and no patient was lost to follow-up.

CONCLUSIONS

Postchemotherapy laparoscopic RPLND is technically feasible. The most frequent complications and causes of conversion are lymphovascular.

Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection

BACKGROUND

The anatomical extent of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) has been discussed controversially for many years.

OBJECTIVE

To evaluate the necessity of PC-RPLND with modified or radical template resection in patients with advanced nonseminomatous germ-cell tumors (NSGCT) and residual masses following systemic chemotherapy.

DESIGN, SETTING, AND PARTICIPANTS

The charts of 152 consecutive patients who were treated at two tertiary referral centers were retrospectively reviewed.

INTERVENTION

All patients underwent PC-RPLND, with 54 and 98 patients undergoing a radical template resection and 98 patients undergoing a modified template resection. Modified template resection was performed if the location of the residual mass corresponded to the primary landing zone of testis cancer and the residual mass measured < or = 5 cm in diameter. In all other cases a full bilateral PC-RPLND was chosen.

MEASUREMENTS

The following data were analyzed: location of the residual mass, extent of surgery, length of surgery, treatment-associated complications, nerve-sparing approach, adjunctive surgical procedures, postoperative morbidity, duration of hospital stay, early and late complications, relapse rates, cancer-specific survival rates, and overall survival rates.

RESULTS AND LIMITATIONS

Overall, 84 patients (55.2%) had necrosis/fibrosis, 45 (29.6%) had mature teratoma, and 23 (15.1%) had vital cancer in the surgical specimens. Antegrade ejaculation was preserved in 85% and 25% of patients undergoing modified and bilateral PC-RPLND (p=0.02), respectively. Eight recurrences (5.2%) were observed after a mean follow-up of 39 mo (range 6-105 mo): one patient had an in-field relapse following modified PC-RPLND, and seven patients had recurrences outside the boundaries of full bilateral PC-RPLNDs. The 2-yr disease-free survival rates were 78.6% and 92.8% for bilateral and modified PC-RPLND, respectively. The limitations of this study were a short follow-up, a limited number of patients, and the retrospective nature of the study.

CONCLUSIONS

Full bilateral PC-RPLND is the standard approach to extensive residual masses. In well-defined masses a modified template PC-RPLND does not interfere with oncologic outcome but decreases treatment-associated morbidity.

Complications of laparoscopic retroperitoneal lymph node dissection in testicular cancer

OBJECTIVES

A proposed benefit of laparoscopic retroperitoneal lymph node dissection (LRPLND) is more favorable morbidity in comparison to open retroperitoneal lymph node dissection (RPLND). The objective of this review is to examine and summarize the literature regarding complications in both primary and post-chemotherapy LRPLND (PC-LRPLND) and, where appropriate, we include the opinions of the senior author regarding management.

METHODS

A MEDLINE search was performed using the terms "laparoscopy" or "laparoscopic," "retroperitoneal lymph node dissection" or "RPLND," and "testicular neoplasms." Articles were included on the basis of study design and content. For series updated over time, an effort was made to include only the most recent data to avoid duplicate reporting of patients.

RESULTS

In primary LRPLND, vascular injury is the most common complication, occurring in 2.2-20% of reported cases. Bowel injury is rarely reported but potentially catastrophic. Rates of retrograde ejaculation are less than 5%. Chylous ascites and lymphocele are delayed post-operative complications. Rarely reported complications include nerve injury, retroperitoneal hematoma, and ureteral injury requiring internal stent placement. PC-LRPLND is challenging, with high rates of conversion and complications. Hemorrhage is common. Retrograde ejaculation is several-fold more common in PC-LRPLND than in primary LRPLND. No peri-operative mortality has been reported for either LRPLND or PC-LRPLND.

CONCLUSIONS

LRPLND and PC-LRPLND are technically demanding. Hemorrhage and vascular injury are the most commonly reported complications. Prospective studies will help clarify the proposed benefits of LRPLND.