Role of primary retroperitoneal lymph node dissection in stage I and low-volume metastatic germ cell tumors

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.

Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Metastatic Seminoma: Results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS)

BACKGROUND

Radiation therapy and systemic chemotherapy are recommended treatment options in marker-negative clinical stage (CS) IIA/B seminoma. Despite high cure rates of 82-94%, both therapeutic options are associated with significant long-term toxicities.

OBJECTIVE

To evaluate the feasibility, oncological efficacy, and treatment-associated morbidity of primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) in CS IIA/B seminoma.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, single-arm, clinical phase 2 trial including CS IIA/B seminoma patients was conducted.

INTERVENTION

Primary nerve-sparing retroperitoneal lymphadenectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relapse-free and overall survival, surgery-associated complications according to the Clavien-Dindo classification, and Kaplan-Meier methods for survival calculation were assessed.

RESULTS AND LIMITATIONS

Thirty patients at a mean age of 39.1 (34-52) yr with marker-negative CS IIA and IIB seminomas were recruited. The median follow-up was 22 (8-30) mo. Nineteen (63%) and 11 (36%) patients were diagnosed with stages IIA and B, respectively, at the time of primary diagnosis. Fourteen (47%) and 16 (53%) patients were diagnosed with CS IIA and IIB, respectively, at the time of nsRPLND. Twenty-seven and three patients underwent open and robot-assisted nsRPLND, respectively. The median operating room time was 125 (115-145) min, median blood loss was <150 ml, and median time of hospitalization was 4.5 (3-9) d. Four (13%) patients experienced Clavien-Dindo grade 3a complications. Lymph node histology revealed seminoma in 25 (80%) patients; two and three patients demonstrated embryonal carcinoma and benign disease, respectively. Sixteen patients underwent a serum analysis of miR371 preoperatively, which predicted metastatic disease in 12/13 and benign histology in 3/3 patients. Three of 30 (10%) patients developed an outfield relapse 4, 6, and 9 mo postoperatively and were salvaged by systemic chemotherapy. Limitations are the low patient number and length of follow-up.

CONCLUSIONS

The nsRPLND approach results in a high cure rate at midterm follow-up and is associated with a low frequency of treatment-associated morbidities, making this approach a feasible alternative to radiation therapy or systemic chemotherapy.

PATIENT SUMMARY

The standard treatment of clinical stage IIA/B seminomas is radiation therapy or chemotherapy, which results in a significantly increased frequency of long-term toxicity and secondary neoplasms. In this trial, we demonstrate that nerve-sparing retroperitoneal lymph node dissection is a feasible therapeutic approach with low morbidity and high oncological efficacy.

Clinical efficacy and safety of robotic retroperitoneal lymph node dissection for testicular cancer: a systematic review and meta-analysis

Background

Retroperitoneal lymph node dissection (RPLND) is an effective treatment for testicular tumors. In recent years, with the development of robotics, many urological procedures performed via standard laparoscopy have been replaced by robots. Our objective was to compare the safety and efficacy of robotic retroperitoneal lymph node dissection (R-RPLND) versus Non-robotic retroperitoneal lymph node dissection (NR-RPLND) in testicular cancer.

Methods

Pubmed, Embase, Scopus, Cochrane Library, and Web of Science databases were searched for literature on robotic surgery for testicular germ cell tumors up to April 2023. The statistical and sensitivity analyses were performed using Review Manager 5.3. Meta-analysis was performed to calculate mean difference (MD), odds ratio(OR), and 95% confidence interval (CI) effect indicators.

Results

Eight studies with 3875 patients were finally included in this study, 453 with R-RPLND and 3422 with open retroperitoneal lymph node dissection (O-RPLND)/laparoscopic retroperitoneal lymph node dissection (L-RPLND). The results showed that R-RPLND had lower rates of intraoperative blood loss (MD = -436.39; 95% CI -707.60 to -165.19; P = 0.002), transfusion (OR = 0.06; 95% CI 0.01 to 0.26; P = 0.0001), total postoperative complication rates (OR = 0.39; 95% CI 0.21 to 0.70; P = 0.002), and length of stay (MD=-3.74; 95% CI -4.69 to -2.78; P<0.00001). In addition, there were no statistical differences between the two groups regarding perioperative and oncological outcomes regarding total operative time, the incidence of postoperative complications grade≥III, abnormal ejaculation rate, lymph node yield, and postoperative recurrence rate.

Conclusions

The R-RPLND and O-RPLND/L-RPLND provide safe and effective retroperitoneal lymph node dissection for testicular cancer. Patients with R-RPLND have less intraoperative bleeding, shorter hospitalization period, fewer postoperative complications, and faster recovery. It should be considered a viable alternative to O-RPLND/L-RPLND.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023411696.

Robotic retroperitoneal lymph node dissection for testicular cancer at a national referral centre

Objectives

We aim to determine if robot‐assisted retroperitoneal lymph node dissection (R‐RPLND) can be performed as a safe option to open RPLND in selected patients with metastatic germ cell cancer.

Patients and methods

This population‐based prospective study was performed at a one of two national referral centres for RPLND in Sweden. All patients referred during January 2017–March 2021 were screened for possible inclusion. R‐RPLND was performed using the Da Vinci Xi surgical system. Perioperative parameters, postoperative complications (Clavien–Dindo), final pathology, preservation of antegrade ejaculation and relapse rates were evaluated. Classifiers for selecting patients to open versus robotic RPLND were analysed by logistic regression modelling. The median follow‐up was 23 months.

Results

Of 87 patients referred, 29 were selected for R‐RPLND, 19 in a post‐chemotherapy setting. In median, retroperitoneal tumour diameter was 18 mm, BMI 24 kg/m², operative time 433 min, estimated blood loss 50 ml and length of stay 3 days. One patient underwent open conversion due to failure to progress. Four patients had Clavien–Dindo grade 3 complications, of which three were chylous‐related. No in‐field recurrences occurred during follow‐up.

Conclusion

This population‐based study suggests that R‐RPLND can be safely performed in at least one third of patients referred for an RPLND. A relatively high rate of lymph‐leakage may represent a potential drawback. Tumour size may be the most important discriminator when deciding on robotic versus open RPLND. Further studies with longer follow‐up are needed to validate the results.

Intricacies of retroperitoneal lymph node dissection for testis cancer

PURPOSE OF REVIEW

Retroperitoneal lymph node dissection (RPLND) and retroperitoneal tumor resection for germ cell cancer are complex operations requiring experience and expertise in surgical techniques necessary to achieve complete resection while minimizing morbidity. This article reviews the intricacies of RPLND for testis cancer.

RECENT FINDINGS

Surgical management of advanced testis cancer begins with an intimate understanding of retroperitoneal anatomy and the various techniques necessary to safely extirpate tumors. Preoperatively patients should undergo comprehensive counseling and obtain up-to-date imaging along with tumor markers to assist in surgical planning and evaluation of extraretroperitoneal (ERP) disease. Surgeons must be well versed in nerve-sparing techniques to maintain ejaculatory function. Newer techniques using a midline extraperitoneal technique minimizes morbidity and length of hospital stay. Special consideration should be given to the possibility of encountering ERP disease in advanced germ cell tumors, with management of these cases in tertiary care centers with multidisciplinary teams.

SUMMARY

The perioperative care of the testis cancer patient undergoing RPLND is complex. The goal is to achieve complete resection to render patients disease free while minimizing surgical and long-term morbidity. Advanced testis cancer patients should be managed at tertiary care facilities with surgical expertise and access to multidisciplinary care.

Indications, feasibility and outcome of robotic retroperitoneal lymph node dissection for metastatic testicular germ cell tumours

Data on robotic retroperitoneal lymph node dissection (R-RPLND) for metastatic testicular germ cell tumours (mTGCTs) are scarce and the use of R-RPLND itself is still under debate. The aim of our study was to evaluate the indications, feasibility and outcomes of R-RPLND, with special emphasis on differences between primary R-RPLND (pR-RPLND) and post-chemotherapeutic R-RPLND (pcR-RPLND) in mTGCTs. We retrospectively analysed the data of patients who underwent R-RPLND for mTGCT between November 2013 and September 2019 in two centres in Germany. Indications, operative technique, intra- and postoperative complications and oncologic outcome were analysed. Twenty-three mTGCT patients underwent R-RPLND (7 pR-RPLND, 16 pcR-RPLND). For pR-RPLND versus pcR-RPLND, median time of surgery was 243 min [interquartile range (IQR) 123-303] versus 359 min (IQR 202-440, p = 0.154) and median blood loss 100 mL (IQR 50-200) versus 275 mL (IQR 100-775, p = 0.018). Intra- and postoperative complications were more frequent in pcR-RPLND (pcR-RPLND: intra/post: 44%/44%; pR-RPLND: intra/post: 0%/29%). However, these were only statistically significant in the case of intraoperative complications (intra: p = 0.036, post: p = 0.579). Intraoperative complications (n = 7), conversions (n = 4) and transfusions (n = 4) occurred in pcR-RPLND patients only. After a median follow-up of 16.3 months (IQR 7.5-35.0) there were no recurrences or deaths. R-RPLND displays a valuable, minimally invasive treatment option in mTGCT. However, R-RPLND is challenging and pcR-RPLND especially bears a considerable risk of complications. This operation should be limited to patients with an easily accessible residual tumour mass and to surgeons experienced in robotic surgery and TGCT treatment.

[Retroperitoneal lymph node dissection in testicular germ cell tumours: indications, complications and special cases]

Die retroperitoneale Lymphadenektomie ist integraler Bestandteil der stadienadaptierten Therapie von testikulären Keimzelltumoren. Verschiedene Ansätze der retroperitonealen Lymphadenektomie werden auf Basis unterschiedlicher Indikationen durchgeführt.

Die nervschonende retroperitoneale Lymphadenektomie als primäre Therapieoption bei nicht seminomatösen Keimzelltumoren im klinischen Stadium I sollte risikoadaptiert erfolgen. Geringfügige perioperative Komplikationen wie Wundinfekte, Lymphozelen und paralytischer Ileus treten bei in etwa 14 % der Patienten auf. Schwerwiegendere Komplikationen wie chylärer Aszites und Lungenarterienembolien treten bei ca. 5,4 % der Patienten auf. Die häufigste Langzeitkomplikation ist hierbei das Auftreten einer Retrograden Ejakulation. Der Erhalt der antegraden Ejakulation kann jedoch bei weit über 90 % der Patienten erreicht werden.

Die postchemotherapeutische retroperitoneale Lymphadenektomie ist integraler Bestandteil der multimodalen Therapie bei retroperitonealen Residualbefunden. Bei residuellen Befunden > 3 cm beim fortgeschrittenen Seminom dient das FDG PET als zuverlässige Entscheidungshilfe zur Durchführung einer retroperitonealen Lymphadenektomie.

Bei ca. 30 % der Patienten mit nicht seminomatösen Keimzelltumoren finden sich residuelle retroperitoneale Tumorbefunde. Diese sollten unabhängig von der Größe der Befunde bei negativen Serumtumormarkern oder Serumtumormarkern im Plateau komplett reseziert werden. Die postchemotherapeutische retroperitoneale Lymphadenektomie stellt einen herausfordernden Eingriff dar und sollte primär an ausgewiesenen Zentren durchgeführt werden. Bei bis zu 25 % der Patienten ist im Rahmen der postchemotherapeutischen retroperitonealen Lymphadenektomie die Resektion umgebender Strukturen indiziert. Eine Beteiligung der aorta abdominalis liegt in 6 – 10 % der Fälle vor, eine Beteiligung der vena cava in ca. 2 % der Fälle. Komplikationsraten liegen bei der postchemotherapeutischen retroperitonealen Lymphadenektomie höher als bei der primären nervschonenenden Lymphadenektomie mit signifikant höherem intraoperativen Blutverlust und signifikant höherer Transfusionsrate. Mit einer Wahrscheinlichkeit von 2 – 7 % tritt chylärer Aszites nach postchemotherapeutischer retroperitonealer Lymphadenektomie häufiger auf. Jedoch kann auch im Rahmen der postchemotherapeutischen Lymphadenektomie bei bis zu 85 % der Erhalt der antegraden Ejakulation erreicht werden. Entscheidend für den Erhalt der antegraden Ejakulation und einer Verbesserung der Morbidität insgesamt ist auch hier das nach Möglichkeit das Anstreben eines nervsparenden Vorgehens durch Anpassung der Felder.