Extraperitoneal laparoscopic retroperitoneal lymph node dissection in supine position after chemotherapy for advanced testicular carcinoma

Alternative approaches to retroperitoneal lymph node dissection for paratesticular rhabdomyosarcoma

PURPOSE

The aim of this study was to evaluate outcomes based on surgical approach for retroperitoneal lymph node dissection (RPLND) in patients with paratesticular rhabdomyosarcoma (PT-RMS).

METHODS

Patients undergoing RPLND for PT-RMS over 10 years at a single institution were retrospectively reviewed. Length of stay (LOS), complications, oral morphine equivalents per kilogram (OME/Kg), lymph node yield, and time to chemotherapy were assessed. The surgical approaches compared were: open transabdominal, open extraperitoneal, laparoscopic, and retroperitoneoscopic. For cases with lymphatic mapping, indocyanine green (ICG) was injected into the spermatic cord.

RESULTS

Twenty patients were included: five open transabdominal, six open extraperitoneal, three laparoscopic, and six retroperitoneoscopic operations. LOS was shorter in the retroperitoneoscopic group than laparoscopic (p = 0.029) and both open groups (p < 0.001). Mean OME/kg used was lowest in the retroperitoneoscopic (0.13 ± 0.15) group compared to laparoscopic (0.68 ± 0.53, p = 0.043), open transabdominal (14.90 ± 8.87, p = 0.003), and extraperitoneal (10.11 ± 2.44, p < 0.001). Time to chemotherapy was shorter for retroperitoneoscopic patients (0.13 days ± 0.15) compared to open transabdominal (15.6 days±6.5, p = 0.005). There was no difference in lymph node yield between groups. Spermatic cord ICG demonstrated iliac lymph node avidity on near-infrared spectroscopy.

CONCLUSIONS

Minimally invasive RPLND appears to offer a faster recovery without compromising lymph node yield for patients with PT-RMS.

LEVEL OF EVIDENCE

III.

Anatomical retroperitoneoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors: initial operative experience

To introduce the technique of anatomical retroperitoneoscopic retroperitoneal lymph node dissection (ARRPLND) was performed in 12 consecutive patients with a clinical stage I nonseminomatous germ-cell tumor (NSGCT) between February 2008 and October 2010. All procedures were performed using a modified template nerve-sparing approach. The retroperitoneal space was adequately expanded using double gasbags. After the retroperitoneal fat was cleared, two relatively bloodless planes were entered consecutively to expose the lymph node and permit dissection. Dissection proceeded first in the plane between the anterior renal fascia and posterior peritoneum, and secondly in the avascular plane between the posterior renal fascia and transversalis fascia. The proximal spermatic vein was clipped at the initial stage. En bloc resection of the lymph tissue and fat between the anterior renal fascia and posterior renal fascia were performed. Three patients (25%) had pathologic stage IIA disease and received adjuvant chemotherapy. No recurrence was observed during follow-up ranging from 26 to 58 months. The median operative time was 205 min (range: 165–430 min) and median estimated blood loss was 320 ml (range: 100–1200 ml). There were two intraoperative complications (Clavien grade II) and one open conversion due to perforation of the peritoneum. Postoperative complications (Clavien I) developed in three patients. Normal antegrade ejaculation recovered by 1 month following the operation. Our preliminary results indicate that ARRPLND is technically feasible and associated with satisfactory clinical outcomes for clinical stage I NSGCT. Further studies are necessary to evaluate this technique.

Retroperitoneoscopic Cutaneous Ureterostomy in the Supine Position to Relieve Painful Urinary-related Symptoms in an Advanced Anal Canal Cancer Patient

A case of advanced anal canal cancer with skin metastases that extended to the scrotum, penis, and lower abdomen is presented. The patient had severe pain on contact with voided urine because of skin tumors. The curved penis did not allow insertion of catheter to treat painful urination, and suprapubic cystostomy insertion was also impossible because of skin tumors. A right cutaneous ureterostomy was performed using the retroperitoneoscopic approach in supine position, and the left renal artery was embolized using ethanol to eliminate left kidney function. The patient became completely free from all urinary-related pains until he died of progressive disease.

Inflammatory pseudotumor of the retroperitoneum removed via a retroperitoneoscopic approach

A retroperitoneal laparoscopic approach was found to be useful for treating primary retroperitoneal tumors located below the level of the renal vessels.

Background:

Inflammatory pseudotumors were mostly encountered in the lung. Retroperitoneal inflammatory pseudotumors are relatively rare. Although laparoscopic surgery with a modified flank position is widely performed for retroperitoneal tumors, we placed the patient in the supine position to maintain the normal anatomical view of the retroperitoneal space. We report a case of retroperitoneal inflammatory pseudotumor extracted via retroperitoneoscopic surgery in the supine position.

Methods and Results:

A 53-year-old man presented with back pain and frequent urination. Ultrasonographic examination revealed a solid tumor above the urinary bladder. This tumor was diagnosed as a primary retroperitoneal tumor by computed tomography, magnetic resonance imaging, and angiography. The retroperitoneoscopic procedure was adopted to remove this tumor. Histopathologic examination revealed an inflammatory pseudotumor. There was no evidence of recurrence 5 years after surgery.

Conclusions:

The diagnosis of the inflammatory pseudotumor is rarely made before histologic examination. Only pathologic examination allows the correct diagnosis. Consequently, most patients undergo surgical treatment. A recurrence rate of 25% has been reported for inflammatory pseudotumors. Thus, radical resection is needed. The retroperitoneal laparoscopic approach with the patient in the supine position is useful for surgically treating these primary retroperitoneal tumors located below the level of the renal vessels.

Laparoscopic retroperitoneal lymphadenectomy in the management of low‐stage testicular cancer: Technique and results

Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for detection of lymph node metastases of testicular cancer. Because of its invasiveness and morbidity the acceptance of open RPLND has decreased significantly resulting in a diagnostic deficit. To reduce morbidity and to increase the acceptance of RPLND, laparoscopy has been introduced. Meanwhile, clinical data with long-term follow-ups are available demonstrating the technical feasibility and oncological safety of laparoscopic RPLND. Studies comparing laparoscopy and open surgery could show advantages for the laparoscopic approach concerning blood loss, intraoperative complications and operative time. Antegrade ejaculation can be preserved in the majority of patients. In conclusion, laparoscopic RPLND is a safe method for the management of low-stage germ cell tumors with minimal invasiveness and excellent clinical results. With an increasing number of urologists trained in laparoscopy and an increasing number of published data, it may become a standard approach for low-stage nonseminomatous testicular cancer.

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.

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ-cell tumors: current status

We review the published literature regarding the technical feasibility, oncologic outcomes, morbidity, and cost-effectiveness of laparoscopic retroperitoneal lymph node dissection (LRPLND). With proof that it is feasible, several centers have become expert in LRPLND and morbidity appears to be less than that of open RPLND. As the technique improves, it is likely that LRPLND will become equally if not more cost-effective than conventional RPLND. However, the oncologic outcomes, while on par with open RPLND series, are difficult to attribute to successful LRPLND alone when nearly all patients with positive lymph nodes received chemotherapy postoperatively. Although uncertainties exist, LRPLND holds much future promise.