Nerve-sparing retroperitoneal lymph node dissection for advanced testicular cancer after chemotherapy

BACKGROUND: Nerve-sparing techniques are commonly used in retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular germ cell tumors to preserve postoperative ejaculation. The indications for nerve-sparing procedures have been extended to patients who have residual retroperitoneal tumor postchemotherapy with an increase in the incidence of local recurrence. Here, we report on 26 Japanese men with advanced testicular cancer who underwent nerve-sparing RPLND after partially successful chemotherapy. METHODS: Between January 1995 and December 2000, 26 patients with metastatic or recurrent testicular cancer underwent nerve-sparing RPLND after chemotherapy. Eight patients had seminoma and 18 had non-seminoma. Three patients received high-dose chemotherapy with carboplatin (250 mg/m2 per day x 5 days), etoposide (300 mg/m2 per day x 5 days) and ifosfamide (1.5 g/m2 per day x 5 days) in combination with peripheral blood stem cell transplantation. RESULTS: In all cases, lumbar splanchnic nerves were preserved macroscopically during the operation, at least unilaterally. Twenty-two patients (84.6%) achieved antegrade ejaculation during a mean follow-up at 3.9 months (range: 1-7 months). Three patients have fathered children. Only one patient suffered a retroperitoneal recurrence during a median follow-up at 25.8 months (range: 6-76 months). CONCLUSION: Nerve-sparing procedures for RPLND are appropriate for patients with metastatic testicular cancer, even after chemotherapy. The procedure preserves ejaculatory function in the majority of the patients without increasing the risk of local recurrence. Nerve-sparing RPLND improves the quality of life in patients who require postchemotherapy RPLND to treat residual tumor.     

睾丸癌腹膜后淋巴结清扫的现状及展望(附光盘)

随着临床分期的不断细化以及多学科诊疗的不断进展,睾丸肿瘤的治愈率可以超过95%。腹膜后淋巴结清扫术(RPLND)是睾丸非精元细胞瘤多模式治疗重要的一部分,对总体治愈率做出了重要贡献。双侧保留神经的RPLND对于肿瘤学控制及功能恢复是适当的选择,腹腔镜和机器人辅助的RPLND都是安全有效的选择。     

Morbidity of open retroperitoneal lymph node dissection for testicular cancer: contemporary perioperative data

Study Type – Therapy (prospective cohort)
Level of Evidence 2b

OBJECTIVE

To review differences between primary retroperitoneal lymph node dissection (P‐RPLND) and RPLND after chemotherapy (PC‐RPLND) in a contemporary series of patients with testicular cancer, to validate the proposed low morbidity.

PATIENTS AND METHODS

Patients who had undergone RPLND at our institution in 2001–2008 were identified and their clinical charts reviewed; in all, 190 were identified and perioperative data obtained.

RESULTS

Of the 190 patients who had RPLND, 98 (52%) and 92 (48%) had P‐ and PC‐RPLND, respectively. Histology of the orchidectomy specimen consisted of embryonal carcinoma in 146 (76%) patients, also including lymphovascular invasion in 83 (44%). The mean (range) operative duration was 206 (110–475) min and the mean blood loss was 294 (50–7000) mL. The median hospital stay was 4 days. Mean blood loss, operative duration and hospital stay were significantly less for the P‐RPLND than for PC‐RPLND groups (P < 0.05). There were 18 (9%) perioperative complications in all. There were no deaths in either group.

CONCLUSIONS

The short‐term morbidity of open RPLND is acceptable, and open RPLND is safe and effective at select tertiary centres. When compared with historical data, the present contemporary series shows that the operative duration, blood loss and hospital stay have improved, with few complications. These contemporary data should be considered when comparing laparoscopic with open RPLND.     

Intermediate-term oncological efficacy of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ cell testicular cancer

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Other have reported that laparoscopic RPLND is feasible and safe when performed by skilled laparoscopic surgeons. We show that patients undergoing laparoscopic RPLND do not recur at the site of the lymph node dissection, even when chemotherapy is not given for nodal disease. This shows that laparoscopic RPLND is therapeutically effective in removing tumors that may have spread from the testicle to the retroperitoneum.

OBJECTIVE

? To assess the therapeutic efficacy of laparoscopic retroperitoneal lymph node dissection (L‐RPLND) for testicular cancer in patients with nodal disease managed without adjuvant chemotherapy.

PATIENTS AND METHODS

? Consecutive patients undergoing RPLND were treated laparoscopically. ? Medical records for 15 patients with pathological stage I and II were reviewed. ? A modified template dissection was performed laparoscopically. When metastatic disease was noted on intraoperative frozen section, a bilateral template dissection was performed.

RESULTS

? All patients had predominantly embryonal carcinoma and/or lymphovascular invasion in their orchidectomy specimen. All patients had normal tumour markers after orchidectomy. ? Laparoscopic RPLND was performed without intraoperative complications. The mean operative time was 299 min and mean length of hospital stay was 1.5 days. ? After L‐RPLND, two patients were pN1 and five patients were pN2. ? Of the patients with nodal disease, five (two pN1 and three pN2) were followed without chemotherapy for a mean of 30 months with no evidence of recurrence. Isolated pulmonary recurrence occurred in two patients with pathologic stage I disease, and another stage I patient had recurrence in the lung and retroperitoneum outside the dissection template.

CONCLUSIONS

? Laparoscopic RPLND appears to be safe while providing the benefits of minimally invasive surgery. ? Although the therapeutic benefit of L‐RPLND needs to be confirmed in additional patients and with longer follow‐up, our results suggest that L‐RPLND provides both diagnostic and therapeutic benefits.     

Post‐chemotherapy nerve‐sparing laparoscopic retroperitoneal lymph node dissection in stage IIB testicular cancer

We report our experience of extraperitoneal nerve‐sparing laparoscopic retroperitoneal lymph node dissection after chemotherapy. Six patients were diagnosed with non‐seminomatous germ cell tumor after orchiectomy and clinical stage IIB disease. Nerve‐sparing laparoscopic retroperitoneal lymph node dissection was carried out for residual retroperitoneal tumors after cisplatin‐based chemotherapy. The median tumor diameter was 2.95 cm before chemotherapy and 1.95 cm after chemotherapy. A modified left (n = 1), right (n = 1) and bilateral (n = 4) template for the dissection area was used. Surgery was successfully completed in all patients and no conversion to open surgery was necessary. Median operative time was 394 min (range 212–526 min). Median blood loss was 75 mL (range 10–238 mL). The overall complication rate was 33.3% (2/6). Two patients had prolonged lymphatic leakage (grade I), which was managed conservatively. Antegrade ejaculation was preserved in all six patients. The histopathological findings showed that two patients had mature teratoma and four patients had necrotic tissue. After a median follow up of 30 months (range 24–36), no recurrence of disease was observed. We can conclude that extraperitoneal nerve‐sparing laparoscopic retroperitoneal lymph node dissection for residual tumors after chemotherapy is a feasible operation. The oncological outcomes need to be confirmed in a certain number of patients with longer follow up.     

Intra-abdominal desmoid tumor following retroperitoneal lymph node dissection for testicular germ cell tumor

In the testicular cancer post-treatment setting a rapidly growing retroperitoneal mass leads to a differential diagnosis including recurrent germ cell tumor, residual mature teratoma, or sarcomatoid degeneration. We report the case of a 27-year-old man with a large abdominal mass occurring in the setting of a mixed germ cell tumor after radical orchiectomy with primary chemotherapy followed by retroperitoneal lymph node dissection. Surgical excision of this mass followed by pathological review revealed an intra-abdominal desmoid tumor. Fluorescence in situ hybridization (FISH) for isochromosome 12p failed to demonstrate a germ cell tumor origin. This is the fourth such case of an intra-abdominal desmoid tumor after retroperitoneal lymph node dissection for testicular cancer in the urologic literature. This case highlights the need for careful consideration of a desmoid tumor when a rapidly growing spindle cell tumor is encountered in a post-treatment testis cancer patient.     

Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer

Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.     

Sexual dysfunction in testicular cancer patients subjected to post‐chemotherapy retroperitoneal lymph node dissection: a focus beyond ejaculation disorders

Post‐chemotherapy retroperitoneal lymph node dissection (PC‐RPLND) represents an integral part of multidisciplinary treatment of advanced germ cell cancer; however, it is associated with a high complications rate. The present study aimed to describe sexual disorders in 53 patients with testicular cancer who underwent full bilateral, non‐nerve‐sparing PC‐RPLND in our institution, focusing beyond ejaculatory dysfunction. The International Index for Erectile Function (IIEF) questionnaire was used as diagnostic tool of male sexual functioning pre‐operatively and three months after RPLND, while post‐operatively patients were asked to describe and evaluate changes in selected sexual parameters. Study findings demonstrate mixed pattern of changes in sexual functioning, with no difference in erectile functioning before and after operation. However, orgasmic function and intercourse and overall sexual satisfaction were found significantly impaired post‐operatively. Sexual desire and frequency of attempted sexual intercourses were found significantly increased post‐operatively, in comparison with pre‐operative levels. With regard to patients' subjective perception on sexual functioning alterations after PC‐RPLND, a significant number of patients reported higher levels of sexual desire, no difference in erectile function and worse orgasmic function and satisfaction post‐operatively. Thus, patients subjected to PC‐RPLND should be closely and routinely evaluated due to close relationship of sexual dissatisfaction with secondary psychological disorders.     

腹膜后淋巴结清扫在睾丸癌治疗中的应用

腹膜后淋巴结清扫术(RPLND)对分期和治疗睾丸的非精原细胞瘤(NSGCT)有重要作用。RPLND可治愈大多数低负荷转移瘤患者,并最大程度地减少对化疗的需求。开放RPLND手术解剖范围广,术后很大一部分患者出现逆行射精从而导致不育,而且并发症发生率较高。而不断发展的改良RPLND模板有助于降低逆行射精风险,但可能漏掉3%～23%的病灶。而对于化疗后复发的患者,经过严格筛选,在有经验的中心实施化疗后RPLND(PC-RPLND),仍然还能获得较好的肿瘤控制效果。双侧RPLND有利于控制肿瘤,如果行保留神经手术也可以保留顺行射精,而改良的RPLND模板在保留顺行射精的同时也取得了较好的肿瘤控制效果。随着腹腔镜技术的逐步成熟,腹腔镜RPLND也达到了与开放手术相似的手术效果,且并发症发生率更低,术后恢复更快。本文对RPLND在睾丸癌中的适应证、手术方式及手术范围等方面展开探讨。     

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma

Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for the detection of lymph node metastases in stage I nonseminomatous testicular carcinoma. In stage II disease, residual malignant tumor and mature teratoma can be removed. Acceptance of this operation, however, has decreased due to the morbidity caused by the open approach. To reduce this morbidity, and to improve the acceptance of RPLND, laparoscopy has been introduced. Clinical data with long-term follow-up are now available which demonstrate the technical feasibility of laparoscopic RPLND. Studies comparing laparoscopy and open surgery show advantages for the laparoscopic approach in terms of reduced blood loss, intraoperative complications and operative time. Mainly minor complications, such as chylous ascites or lymphocele formation, are observed. The conversion rate to open surgery, mainly due to intraoperative bleeding, is acceptable at less than 10%. As in open surgery, antegrade ejaculation can be preserved successfully. RPLND has also been shown to provide adequate oncological results. In stage I disease, lymph node metastasis is found in 25–41% of cases. Patients with histologically proven retroperitoneal tumor receive adjuvant chemotherapy whereas individuals without evidence of retroperitoneal disease do not require additional treatment. Follow-up controls in both groups, without local recurrence, demonstrate the excellent diagnostic accuracy of this procedure. Meanwhile laparoscopic RPLND has also been introduced successfully in the management of stage II disease. Small volume residual tumors can be removed with an acceptable complication rate. However, this operation is technically demanding and should be performed only at institutions with considerable laparoscopic experience. In conclusion, laparoscopic RPLND is a safe method for low-stage germ cell tumors with minimal invasiveness and excellent clinical results. Thus laparoscopy might contribute to a better acceptance of RPLND.     

Retrospective review of the outcome of post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testicular cancer: Local experience

Objective: Post-chemotherapy retroperitoneal lymph node dissection (RPLND) for metastatic testicular cancer is an uncommon surgical procedure in Hong Kong. Therefore, in the present article, we review the perioperative and long-term morbidity, as well as the survival outcome for RPLND carried out in a urological centre. Method: This is a retrospective study of patients suffering from metastatic testicular cancer with post-chemotherapy residual mass subjected to RPLND between 1998 and 2008. Patient and tumour parameters including initial presentation, chemotherapy regimens received prior to RPLND, perioperative outcomes, pathology and long-term results were retrieved from hospital notes and reviewed. Results: Seven patients who underwent post-chemotherapy RPLND were included in the present review. The mean follow-up time was 63.7 months (range 6–136 months), and no recurrence or mortality was reported in this series. Early perioperative morbidity included pulmonary oedema (one), chylous ascites (one) and wound dehiscence (one). Other than ejaculatory dysfunction in all of the patients, there was no major-long term complication reported in our series. Conclusion: This local series confirmed the survival benefit and association of minimal long-term morbidity with post-chemotherapy RPLND.     

Clinical outcome of retroperitoneal lymph node dissection after induction chemotherapy for metastatic non-seminomatous germ cell tumors

BACKGROUND: Retroperitoneal lymph node dissection (RPLND) following induction chemotherapy has been considered a critical component in the comprehensive management of advanced non-seminomatous germ cell tumors (NSGCT). The objectives of the present study were to review the clinical outcome of patients who underwent RPLND and to evaluate the probability of necrosis alone, based on some readily available clinical data for these patients. METHODS: Forty-seven consecutive patients with NSGCT were treated with first-line chemotherapy at our institution between January 1993 and September 2002. Twenty-four of these patients, who underwent RPLND with normal values of tumor markers after induction chemotherapy, were included in the study. The cause-specific survival rate was calculated using the Kaplan-Meier method. Various predictive factors for the histology were analyzed using multivariate analysis. RESULTS: The pathological findings at resection were necrosis alone in 62.5% of cases, teratoma in 25.0%, and viable cancer in 12.5%. The cause-specific 3-year survival rate of patients who underwent complete and incomplete resection was 100% and 50.0%, respectively. Among several clinical factors, prechemotherapy tumor size less than 50 mm was found to be an independent predictor of necrosis alone (hazard ratio = 4.45, P= 0.04). CONCLUSION: Metastatic tumor size before chemotherapy appears to be one of the most important factors for the prediction of necrosis alone in the resected specimens of RPLND. The prognosis of patients might be influenced by the degree to which resection has been completed.     

Post-chemotherapy nerve-sparing retroperitoneal lymph node dissection for advanced germ cell tumor

Objective:   To report our experience with post-chemotherapy nerve-sparing retroperitoneal lymph node dissection (RPLND) for advanced germ cell tumor (GCT).
Methods:   Between 1994 and 2008, 92 patients with advanced GCT underwent RPLND after multiple treatments with systemic chemotherapy at our institution. A nerve-sparing RPLND was carried out in 78 patients (84.8%; median age 32 years). Of them, 19 had a seminoma and 59 had a non-seminoma.
Results:   Lumbar splanchnic nerves controlling ejaculatory function were macroscopically preserved during RPLND. Bilateral and unilateral lumbar splanchnic nerves were preserved in 40 patients and 38 patients, respectively. Sixty-five patients could be evaluated for ejaculation. Fifty-four patients (83.1%) achieved antegrade ejaculation with a median postoperative interval of 3 months (range: 1–10 months). Twenty-eight patients (28/30: 93.3%) and 26 patients (26/35: 74.3%) undergoing bilateral and unilateral nerve-sparing RPLND had antegrade ejaculation, respectively ( P  = 0.041). Only two patients (2.6%) had mediastinal and retroperitoneal recurrences during a median follow-up of 42 months (range: 1–138 months), respectively. However, these patients were cured by chemotherapy and surgery.
Conclusions:   Post-chemotherapy nerve-sparing RPLND preserves ejaculatory function in the majority of patients with advanced GCT without increasing the risk of local recurrence.     

Robot‐assisted laparoscopic retroperitoneal lymph node dissection for left clinical stage I non‐seminomatous germ cell testicular cancer: Focus on port placement and surgical technique

The aim of our report was to describe the feasibility of robotic retroperitoneal lymph node dissection in the contemporary era. We suggest the linear port location and 90° robotic docking as the main key to minimizing instrument clashing and improving the range of surgical accessibility.     

Outcomes of the management of post-chemotherapy retroperitoneal lymph node dissection-associated anejaculation

Study Type – Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Modern surgical techniques have allowed preservation of fertility in most patients after post‐chemotherapy retroperitoneal lymph node dissection (PC‐RPLND), but some patients still have infertility after surgery. We reviewed our experience treating infertility in 26 men after PC‐RPLND. Using a structured clinical pathway we obtained sperm in 81% of men for use in assisted reproduction.

OBJECTIVE

• ? To evaluate the effectiveness of a clinical pathway on sperm retrieval outcomes in patients presenting with infertility after post‐chemotherapy (PC) retroperitoneal lymph node dissection (RPLND).

PATIENTS AND METHODS

• ? We carried out a retrospective review of patients with advanced testicular cancer, presenting with infertility after PC‐RPLND in a large reproductive urology practice.
• ? We implemented a clinical pathway where pseudoephedrine was first administered. If this medication failed, electroejaculation (EEJ) and/or testicular sperm extraction (TESE) was carried out.
• ? The primary outcome was retrieval of sperm for use in assisted reproduction.

RESULTS

• ? Four men had retrograde ejaculation, of whom two converted to antegrade ejaculation with medical therapy.
• ? In all, 22 patients had failure of emission (FOE) and, of these, no patient converted to antegrade ejaculation with medication.
• ? In patients with FOE, sperm was found in 15/20 of those experiencing a successful EEJ.
• ? Seven patients underwent TESE for azoospermia on EEJ or no ejaculate on EEJ, three of whom had sperm found on TESE.
• ? Sperm was found for assisted reproduction in 81% (21/26) patients.

CONCLUSIONS

• ? There appears to be no role for the use of pseudoephedrine therapy in patients with FOE after PC‐RPLND.
• ? The use of a structured clinical pathway may optimize patient care.

     

后腹腔镜下腹膜后淋巴结清扫术七例报告

目的 探讨后腹腔镜下腹膜后淋巴结清扫术(LRPLND)的方法. 方法 采用后腹腔镜技术行腹膜后淋巴结清扫术7例.患者均为男性,年龄27～39岁,平均31岁.其中睾丸混合癌2例(精原合并胚胎癌为主)、内胚窦瘤2例、绒毛膜上皮癌1例、精原合并畸胎瘤2例;右侧2例,左侧5例.临床分期均为Ⅰ期.全麻,健侧卧位,双气囊扩张法建立后腹腔间隙,分离肾前筋膜与腹膜间及肾后筋膜与腰肌的平面间隙直至髂窝;精索静脉高位结扎切断,自肾门平面向下清除肾前及.肾后筋膜内的脂肪淋巴组织和精索血管;沿腔静脉(右)或腹主动脉(左)的肾门平面起在其后方剪开血管鞘膜,清扫表面的脂肪淋巴组织;注意保护肠系膜下动脉及其对侧的脂肪淋巴组织,在精索跨越髂血管后尽量低位分离.结果最初2例术中穿透腹膜,中转开放手术.后5例腹腔镜下手术成功,平均手术时间285(245350)min,失血100～250 ml.后5例患者中,术后病理分期与临床分期一致4例,1例术后检出2枚阳性淋巴结;每例清扫淋巴结22～31枚,平均25.6枚.随访3～20个月,CT检查未见复发及远处转移,肿瘤标记物检测正常范围.术后1个月内均恢复性功能. 结论 经后腹腔途径的LRPLND可从侧方整体游离清除脂肪淋巴组织,清扫顺序自上而下,手术空间大,解剖标志清晰,可达到与开放手术相同的切除范围,符合肿瘤治疗原则,可用于临床Ⅰ期非精原细胞瘤的诊断及治疗.