Does retroperitoneal lymphadenectomy for testicular germ cell tumor require a different approach in the presence of horseshoe kidney?

Abstract

We report our management of stage II testicular nonseminomatous germ cell tumor in 2 patients with horseshoe kidney and discuss the technical challenges posed by this renal fusion anomaly. The embryology and clinical anatomy of horseshoe kidney are discussed with particular reference to the anomalous vascular pattern and routes of testicular lymphatic drainage in this setting. Modifications and innovations of the standard technique of retroperitoneal lymphadenectomy in the presence of horseshoe kidney are discussed in light of our experience with these patients at 2 major tertiary care cancer centers. The significance of contemporary advanced noninvasive radiological techniques, such as helical computerized tomographic angiography with digital 3-dimensional reconstruction and magnetic resonance angiography, in the surgical planning and safe performance of surgery is emphasized. Two young male patients treated at 2 major American teaching hospitals who had coexistent stage II testicular nonseminomatous germ cell tumor and horseshoe kidney underwent salvage retroperitoneal lymph node dissection. There was no evidence of recurrence in these 2 patients 12 and 15 months after surgery, respectively. Horseshoe kidney poses special technical problems during retroperitoneal lymphadenectomy for testicular tumors due to anomalous renal and intra-abdominal vascular patterns. Helical computerized tomography angiography is useful for meticulous surgical planning and the safe performance of surgery in this setting.