Laparoscopic retroperitoneal lymph node dissection

PURPOSE: Retroperitoneal lymph node dissection is the most sensitive and specific diagnostic modality for detecting occult lymph node metastases in clinical stage I testicular tumor. In stage II disease, residual tumors after chemotherapy have to be removed surgically. To reduce the morbidity of these procedures we have replaced open surgery by laparoscopy. PATIENTS AND METHODS: Between August 1992 and December 1999 125 patients underwent laparoscopic RPLND (stage I: 76 pts., stage II: 49 pts.) RESULTS: Laparoscopic RPLND could be completed as planned in all but two patients in whom bleeding required conversion to open surgery. Once the learning curve had been overcome, mean operative time decreased significantly from 476 to 219 min for stage I and averaged 226 min in stage IIB disease. Only minor postoperative complications occurred such as asymptomatic lymphoceles (7 pts.) and chylous ascites (6 pts.). Mean post-op hospital stay was 3.3 and 3.5 days, respectively (stages I and II). Mean followup is currently 46 months for stage I and 35 months for stage II tumors. Over this period a single retroperitoneal recurrence was observed (stage I), which, however, was not due to surgical failure, but to false negative histologic findings. All other patients have remained free of relapse. CONCLUSIONS: Laparoscopic RPLND is a demanding procedure with a long and steep learning curve. It has proved feasible also after chemotherapy. The diagnostic accuracy of laparoscopic RPLND was as good as that of the open procedure, while the morbidity is significantly lower. Tumor control was not compromised by the laparoscopic approach.     

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.     

Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer

BACKGROUND AND PURPOSE: Laparoscopic retroperitoneal lymph-node dissection (RPLND) has been advocated for and utilized in the management of testicular cancer. In this overview, we present our technique and results in comparison with the worldwide experience with laparoscopic RPLND in the management of clinical stage I and II cancers. PATIENTS AND METHODS: Over the last 13 years, 162 patients with testicular cancer clinical stage I (N = 103) or II (N = 43 IIB, 16 IIC) underwent laparoscopic RPLND. All intraoperative and postoperative data were evaluated, as well as the worldwide experience with the procedure. With a mean follow-up of 62 months (range 6-113 months) for clinical stage I and 53 months (range 10-89 months) for clinical stage II, oncologic efficiency was evaluated. RESULTS: The procedure was feasible even after chemotherapy, with only three conversions to open RPLND in clinical stage I. The mean operative time was 217, 216, and 281 minutes for clinical stages I, IIB, and IIC, respectively. The mean blood loss was 144 mL and 165 mL for clinical stage I and II, respectively. The hospital stays were 3.6 and 3.8 days, respectively. During follow-up, we had two retroperitoneal relapses (1.2%) and four distant relapses (2.5%). CONCLUSION: Laparoscopic RPLND has demonstrated its surgical and oncologic efficacy. The morbidity and the complication rate are low. Recurrence rates are comparable to those of open surgery. Laparoscopic RPLND is safe, with less postoperative morbidity, quicker convalescence, better cosmetic results, and a diagnostic accuracy equal that of the open technique.     

Post-chemotherapy laparoscopic retroperitoneal lymph-node dissection in testis cancer patients

BACKGROUND AND PURPOSE: Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for the detection of malignant tumor and mature teratoma in stage II nonseminomatous testicular carcinoma after chemotherapy. Acceptance of this operation, however, has decreased because of the morbidity associated with the open approach. To reduce the morbidity and to improve the acceptance of RPLND, laparoscopy has been introduced. In this study, we describe our experiences with laparoscopic RPLND for stage II testicular carcinoma after chemotherapy. METHODS: Sixteen patients underwent 17 laparoscopic RPLND after chemotherapy for clinical stage IIA-III nonseminomatous testicular cancer. Patients with post-chemotherapy residual masses >1 cm and normalization of tumor markers were considered for the procedure. Our dissection field included the resection of the residual tumor as well as the ipsilateral template. RESULTS: Laparoscopic RPLND was completed in all patients. Operative time ranged from 125 to 370 minutes (mean 240 +/- 56 min). No transfusions were required, and no intra- or postoperative complications occurred because of the procedure. A bleomycin-induced interstitial pneumonia developed in one patient. After a mean follow-up period of 26 +/- 11 months (range 4 to 38), two disease recurrences were observed. CONCLUSION: Laparoscopic RPLND after chemotherapy is a feasible and oncologically safe procedure. However, the technique is challenging and should only be performed in selected patients with low residual tumor volume.     

Kommentar zur retroperitonealen Lymphadenektomie – laparoskopisch vs. robotisch

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.     

Laparoscopic retroperitoneal lymph-node dissection with the waterjet is technically feasible and safe in testis-cancer patient

BACKGROUND AND PURPOSE: The acceptance of open retroperitoneal lymph node dissection (RPLND) for stage I and II nonseminomatous testicular cancer has decreased because of the intraoperative and postoperative morbidity of the procedure. Laparoscopic RPLND is a minimally invasive and safe alternative for low-stage germ-cell tumors. It is, however, technically demanding and should therefore be performed only in experienced centers. The purpose of the present study was to evaluate the waterjet technique for laparoscopic RPLND. PATIENTS AND METHODS: A series of 18 patients with clinical stage I testis cancer (group A) and 7 patients who had received chemotherapy for stage II disease (group B) underwent laparoscopic RPLND at our institution. The procedure was performed identically to the open approach using the modified template according to Weissbach and associates. The waterjet was used for removal of lymphatic tissue from the aorta and the vena cava, as well as from the sympathetic trunk. RESULTS: The operation was completed in all patients without conversion to open surgery. The mean operating time was 232 +/- 48 minutes. The waterjet was able to remove lymphatic tissue easily and atraumatically. At pressures of 20 bar, the lymph-node capsule remained completely intact, thus avoiding tumor-cell spread. Antegrade ejaculation could be preserved in all patients, who, to date, show no evidence of disease. CONCLUSIONS: The waterjet allows the safe and complete removal of lymphatic tissue, leaving vulnerable anatomic structures intact. It can decrease the learning curve of laparoscopic RPLND and contribute to better acceptance of this procedure.     

Lymphadenektomie beim Hodentumor

The rationale to perform retroperitoneal lymph node dissection (RPLND) in testicular cancer depends on the clinical stage and previous therapy. Thus, it can be performed either with diagnostic, prognostic, or therapeutic intention. In verified clinical stage I nonseminoma, RPLND provides one of three adjuvant options. To verify the clinical stage pathologically, surgery is done for diagnostic reasons, since CT scanning provides a false-negative staging in up to 30%. In higher stage lesions RPLND is a therapeutic procedure. The importance, however, of RPLND in clinical stage I nonseminoma is decreasing, since prognostic factors are available to stratify patients with either low or high risk for recurrence. Thus, these patients are selected for surveillance (low risk) or adjuvant chemotherapy (high risk). RPLND after chemotherapy is done for resection of residual tumor with a therapeutic intention. The histology of the residual mass is of prognostic importance and may help define further therapy. Resection of retroperitoneal metastases in patients with chemorefractory tumors is curative in about 25%.     

The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors

An appropriately performed retroperitoneal lymph node dissection (RPLND) is both a diagnostic and a therapeutic procedure in the management of non-seminomatous germ-cell tumors. In an attempt to minimize the morbidity associated with an open RPLND, several investigators have evaluated the role of laparoscopic RPLND. Laparoscopic RPLND is technically feasible in the hands of dedicated experts, and results in a reduced hospital stay, operative blood loss, and post-operative morbidity compared to open RPLND. Currently, however, none of the reports in the literature have adequately evaluated the therapeutic efficacy of laparoscopic RPLND, as the vast majority of patients are treated with adjuvant chemotherapy regardless of the risk of systemic relapse. Future prospective internal review board-approved trials need to be developed to evaluate the therapeutic efficacy of laparoscopic RPLND, with careful observation of patients with pathologic low-volume nodal disease.     

Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status

The purpose of the study was to update the current status of laparoscopic retroperitoneal lymph node dissection in the treatment of clinical Stage I nonseminomatous germ cell testicular cancer. A literature search was conducted to evaluate laparoscopic retroperitoneal lymph node dissection (RPLND) in comparison to other modalities of treatment. All treatment modalities are effective in treating clinical Stage I nonseminomatous germ cell tumors. Morbidity is the major issue that may guide treatment decisions. Laparoscopic RPLND, in its therapeutic form, may replicate open RPLND with a minimally invasive approach. Laparoscopic RPLND is an effective alternative to traditional treatment options.     

Stellenwert der retroperitonealen Lymphadenektomie beim Keimzelltumor

Retroperitoneal lymph node dissection (RPLND) is an integral part in the therapy of nonseminomatous germ cell tumors. However, there has been a shift concerning the indication. For a long period RPLND was the primary choice in clinical stage I nonseminoma. Nowadays a risk-adapted strategy is preferred. RPLND is obligatory after finishing chemotherapy in metastasized patients if residual tumor is seen. In cases of a late relapse surgery is much more important than chemotherapy independent of increased tumor markers. RPLND can also be a salvage strategy in chemoresistant patients. About 25% of these patients have a long-term benefit. Open or laparoscopic surgery can be performed, though the indications for laparoscopy are small.     

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.     

Robot-assisted laparoscopic retroperitoneal lymph node dissection in an adolescent population

Abstract Laparoscopic retroperitoneal lymph node dissection (RPLND) has been shown to be safe and effective in appropriately selected pediatric and adolescent patients with paratesticular rhabdomyosarcoma (RMS) and testicular germ-cell tumors (T-GCT). While the use of robot-assisted laparoscopy has expanded rapidly in many areas, there are very limited reports of its use with RPLND. We present two cases of adolescents who were treated using robot-assisted laparoscopic RPLND (R-RPLND)-one with paratesticular RMS (PT-RMS) and one with testicular GCT (T-GCT)-with good outcomes and low morbidity.     

Management of adult Leydig-cell testicular tumors: assessing the role of laparoscopic retroperitoneal lymph node dissection

BACKGROUND AND PURPOSE: Leydig-cell tumors represent <5% of malignant testicular tumors in adults. Orchiectomy is curative in approximately 90% of cases; however, the remaining men can develop metastases refractory to chemotherapy and radiation. We evaluated the role of laparoscopic retroperitoneal lymph node dissection (RPLND) in adult Leydig-cell tumors. PATIENTS AND METHODS: Between 1999 and 2001, laparoscopic RPLND was performed with four transperitoneal ports within a unilateral template for six patients with pure Leydig-cell tumors. Presenting signs and symptoms, operative time, blood loss, intraoperative complications, postoperative complications, length of hospitalization, pathology reports, ejaculatory function, and survival were reviewed retrospectively. RESULTS: Laparoscopic RPLND was successful, without open conversions or reinterventions. Two vascular injuries occurred during dissection; additional intraoperative complications were not observed. Postoperatively, one patient developed erysipelas, but no other postoperative complications were recorded. The mean operative time was 190 minutes, and the mean length of hospitalization was 4.3 days. Pathologic analysis of lymph nodes revealed no evidence of metastatic Leydig-cell tumor. At 12 months' mean follow-up (range 3-29 months), no recurrences have been identified. CONCLUSIONS: Laparoscopic RPLND is a safe, minimally invasive procedure for Leydig-cell tumors. Additional clinical experience is required to evaluate its effectiveness for pathologic stage II tumors and to determine if a therapeutic advantage can be realized with a protocol employing laparoscopic RPLND for adult Leydig-cell tumors.     

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

AIM: To evaluate the feasibility and usefulness of extraperitoneal laparoscopic retroperitoneal lymph node dissection (RPLND) in the supine position after chemotherapy for advanced testicular carcinoma. METHODS: Three patients with advanced testicular cancer underwent chemotherapy. Although serum markers were decreased compared with the normal range, residual masses requiring surgical resection were recognized by computed tomography scanning. We applied extraperitoneal laparoscopic RPLND. The patients were placed in the supine position and the first trocar was inserted two finger widths medial to the anterior iliac spine. The retroperitoneal space was dilated using a preperitoneal distention balloon. Two more ports were inserted into the retroperitoneal space and surgery proceeded thereafter. RESULTS: The residual tumors were completely resected by laparoscopy. The procedure required 250-310 min and the bleeding volume was below 50 mL. Although the histopathological findings consisted only of necrosis in all of the patients, one patient recurred at the same place. CONCLUSIONS: Extraperitoneal laparoscopic RPLND in the supine position for residual tumors after chemotherapy is technically feasible and useful in terms of postoperative recovery. With regard to cancer control, further evaluation should be necessary.     

Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer

PURPOSE: To report the long-term oncologic outcome and morbidity of laparoscopic retroperitoneal lymph-node dissection (L-RPLND) in clinical stage I nonseminomatous testicular germ-cell tumors (NSGCT) from a single institution. PATIENTS AND METHODS: From August 1992 to May 2005, 136 patients with clinical stage I disease underwent L-RPLND. The mean follow-up was 68 months (range 8-151 months). Patient selection was not based on histologic findings or the presence of risk factors. Lymphadenectomy was performed within the boundaries described by Weissbach and Boedefeld. RESULTS: The laparoscopic procedure could be completed in 129 patients (94.9%). Seven required conversion to open surgery. The median blood loss was 50 mL (range 20-3000 mL), and the mean operative time was 261 minutes (range 115-570 minutes). There were no perioperative deaths. The mean postoperative hospital stay was 4.1 days. Antegrade ejaculation was preserved in all patients. In the series, 25 patients (18.4%) had pathologic stage IIA disease and received adjuvant chemotherapy consisting of two cycles of cisplatin, etoposide, and bleomycin; none of these patients has relapsed. Eight patients (5.9%) suffered relapses, although L-RPLND had yielded negative lymph nodes in all of them. All eight patients were salvaged with cisplatin-based chemotherapy, with surgery also performed in two patients. All other patients (N = 128, 94.1%) remained relapse free. None of the patients died because of tumor progression. CONCLUSIONS: The L-RPLND has proved to be an excellent staging tool, which should be developed into a less-invasive alternative to primary open RPLND. The oncologic outcome of L-RPLND without adjuvant chemotherapy in pathologic stage II disease is being investigated.     

Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumors: Indications and Limitations

Purpose

We describe our experience with laparoscopic retroperitoneal lymph node dissection in 26 patients with nonseminomatous germ cell tumors: 17 had stage I disease with no clinical (computerized tomography, ultrasound or tumor markers) evidence of metastases and 9 (2 with stage IIb and 7 with stage IIc disease) had residual tumor after chemotherapy but with negative tumor markers. Laparoscopic dissection was performed to assess more fully pathological status of the relevant retroperitoneal lymph nodes in both groups.

Materials and Methods

The patient was positioned and trocars were introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position with 3, 10 mm. and 2, 5 mm. ports). After the white line of Toldt was incised and the colon was reflected anteromedially, the retroperitoneal space was exposed. The landmarks of lymph node dissection were then isolated, including the ureter, aorta, inferior vena cava and both renal veins. Lymph node dissection was performed identical to that for open surgery, with a modified template including the paracaval, interaortocaval, upper preaortic and right common iliac nodes for right tumors, and para-aortic and upper preaortic nodes for left tumors. Lymph node chains were retrieved with a small organ bag.

Results

The procedure was completed successfully in 16 of 17 patients with stage I disease (mean duration 268 minutes for the left and 312 minutes for the right sides). No intraoperative complications were encountered. One patient had delayed ureteral stenosis requiring operative repair, 1 had a pulmonary embolism with an uneventful outcome and 1 who underwent laparoscopic retroperitoneal lymph node dissection on the right side later had retrograde ejaculation. Embryonal carcinoma was found in 1 of the 17 patients.Average postoperative hospital stay was 4.5 days for patients without complications or conversion to an open procedure. After a median followup of 27 months no patient had regional relapse but 2 had pulmonary metastases that were treated successfully with 3 cycles of platinum based chemotherapy. Laparoscopic dissection was significantly more difficult in patients with stage II tumors after chemotherapy. Only in 2 patients with stage IIb disease was laparoscopic lymphadenectomy successful. In 5 of the 7 patients with stage IIc cancer portions of the dissection had to be done after conversion to an open (conventional) operation via a small incision (suprainguinal or pararectal). In 1 patient the laparoscopic approach was completely abandoned and converted to an open operation via a standard midline incision. In all 9 cases histopathological examination revealed complete necrosis. No patient has evidence of disease.

Conclusions

Our preliminary experience suggests that a modified laparoscopic retroperitoneal lymph node dissection is feasible for stage I tumors. However, it cannot be recommended after previous chemotherapy (stages IIb and IIc disease).     

Extraperitoneal laparoscopic retroperitoneal lymph node dissection after chemotherapy for nonseminomatous testicular germ-cell tumor: surgical and oncological outcomes

Purpose

To assess the surgical and oncological outcomes of laparoscopic retroperitoneal lymph node dissection (RPLND) after chemotherapy.

Methods

Twenty patients with metastatic nonseminomatous testicular germ-cell tumor underwent extraperitoneal laparoscopic RPLND after chemotherapy. The procedure was not indicated for patients with a pre-chemotherapy mass larger than 5?cm. Morbidity and oncological outcome were reviewed retrospectively. Surgical complications were graded according to the Clavien classification system.

Results

Laparoscopic RPLND was completed in all patients, and there was no conversion to open surgery. The median operating time was 223?min (range, 137?C399?min). The median blood loss was 20?ml (range, 10?C520?ml). There were no intraoperative complications. Postoperatively, 4 patients (20?%) had prolonged lymphorrhea (grade I) and 9 (45?%) had chyle leakage (grade I). Histological examination of the residual mass revealed necrosis in 16 (80?%) and the presence of teratoma with/without viable tumor in 4 (20?%). With a median follow-up of 45?months (range, 24?C112), no patient has had disease recurrence. Normal antegrade ejaculation was preserved in all of the 14 patients studied.

Conclusions

Extraperitoneal laparoscopic RPLND can be performed with acceptable morbidity and excellent cancer control in select patients. Surgeons should be aware of relatively high incidence of chyle leakage following this procedure.     

Retroperitoneale Lymphadenektomie – pro robotisch

The indications to perform primary retroperitoneal lymph node dissection (RPLND) in patients with clinical stage I non-seminomatous germ cell tumors have changed. An initial surgical staging can be justified only for exceptional situations, such as a pure teratoma. Other indications can be the surgical staging and treatment of high risk patients in elective surgery. In this situation, however, only sparse data are available regarding the oncological and therapeutic effect of a minimally invasive approach compared to open surgery. Data are available on the feasibility of laparoscopically performed post-chemotherapy RPLND; however, patients for this approach must be highly selected. In general, robotic-assisted RPLND potentially offers major advantages in terms of safety and oncological efficiency compared to a classical laparoscopic approach. Especially in post-chemotherapy RPLND, the division of lumbar vessels and the control of great vessel lesions may be facilitated. However, only surgeons who are capable of handling a major vessel lesion endoscopically should consider using a robotic-assisted technique. Only patients with relatively small residual tumors without a major involvement of great vessels can be considered as candidates for robotic-assisted post-chemotherapy RPLND.     

Laparoscopic versus open orchiopexy in the management of abdominal testis: A descriptive study

AIMS: Treatment of patients with abdominal non-palpable testis (NPT) is still controversial among pediatric urologists. This is a prospective randomized comparative study between open and laparoscopic orchiopexy for management of abdominal testis. The aim of this study was to evaluate the success rate and morbidity of both approaches. METHODS: Eighty-two patients with a mean age of 5.3 years were evaluated by laparoscopy for 87 NPT. Patients with viable abdominal testes were randomly treated with either open or laparoscopic orchiopexy procedures. RESULTS: On laparoscopy, 75 viable abdominal testes were found. According to location: 41 (47.1%) testes were high abdominal, 27 (31%) testes were low abdominal and 7 (8%) testes were peeping from the internal ring. Laparoscopic first stage Fowler-Stephens orchiopexy was done initially for those with high abdominal testes. For further management, all patients were divided randomly into open (36 cases) and laparoscopic (39 cases) groups where primary (with spermatic vessel preservation) or second stage Fowler-Stephens orchiopexy was done. Statistical analysis was done using Student's t-test. Laparoscopic procedures showed significant less morbidity than the open counterparts. Follow up ranged from 9 to 31 months and included evaluation of testicular site and size. All testes were located satisfactorily inside the scrotum. Five cases of testicular atrophy were encountered (three and two testes with open and laparoscopic second stage Fowler-Stephens orchiopexy respectively) after 1 year follow up. CONCLUSION: Results of open versus laparoscopic orchiopexy procedures (primary or staged) are fairly comparable. However, laparoscopy provides significantly less morbidity.     

Expanding the indications for laparoscopic radical nephrectomy

PURPOSE OF REVIEW: Laparoscopic radical nephrectomy is an established treatment for patients with clinical T1 renal cell carcinoma who are unsuitable for nephron-sparing surgery. In this review we summarize the expanding indications for laparoscopic nephrectomy, including large tumors, locally advanced disease, venous thrombi and cytoreductive surgery. RECENT FINDINGS: Laparoscopic nephrectomy remains the foremost conventional laparoscopic procedure in urologic surgery. Multiple studies have demonstrated the feasibility of laparoscopic radical nephrectomy for stage T2 tumors, showing less morbidity and earlier return to activity compared to the open approach. Confirmation of durable oncologic control requires randomized prospective trials with longer follow-up. With growing experience, laparoscopic surgery has been extended to patients with renal cell carcinoma associated with limited local invasion and lymph node metastases. Experimental studies demonstrate the technical feasibility of laparoscopic radical nephrectomy in the presence of renal vein and inferior vena cava thrombi. In well-selected patients with metastatic renal cell carcinoma, laparoscopic cytoreductive nephrectomy can be performed safely, with less morbidity than open nephrectomy. SUMMARY: Minimally invasive surgery results in significantly less postoperative morbidity than does open surgery. The intermediate oncologic outcomes of laparoscopic radical nephrectomy for advanced renal cell carcinoma are comparable to those historically achieved with open radical nephrectomy. Longer follow-up is needed to confirm survival equivalence.