Bilateral Retroperitoneal Lymph Node Dissection Research Articles

Nerve-sparing technique in RPLND for testicular cancer.

The management of testicular cancer has evolved over time with multimodal therapy. Retroperitoneal lymph node dissection (RPLND), which is a complex and potentially morbid treatment option, remains the mainstay in surgical treatment. This article reviews the surgical template, approach and anatomical considerations with regards to nerve spare in RPLND. The standard full bilateral RPLND template has evolved over time to include the area between the renal hilum, bifurcation of the common iliac vessels, and the ureters. Morbidity with regards to ejaculatory dysfunction has led to further refinements in this procedure. Advancements in anatomical understanding of the retroperitoneal structures and their relationship to the sympathetic chain and hypogastric plexus has allowed for modification of surgical templates. Further refinements in surgical nerve sparing techniques have improved functional outcomes without sacrificing oncological outcomes. Finally, extraperitoneal access to the retroperitoneum and minimally invasive platforms have been implemented to further reduce morbidity. RPLND requires strict adherence to oncological surgical principles regardless of template, approach and technique. Contemporary evidence shows that outcomes are best for advanced testis cancer patients when managed at high volume tertiary care facilities with surgical expertise and access to multidisciplinary care.

Unilateral or Bilateral Retroperitoneal Lymph Node Dissection in Nonseminoma Patients with Postchemotherapy Residual Tumour? Results from RETROP, a Population-based Mapping Study by the Swedish Norwegian Testicular Cancer Group

BackgroundThe distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10–49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection. ObjectiveTo describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10–49 mm. Design, setting, and participantsRETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10–49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007–2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans. Outcome measurements and statistical analysisThe distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured. Results and limitationsIn total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients. ConclusionsMen with postchemotherapy residual disease of 10–49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection. Patient summaryThe surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer.

Post-chemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection for Mixed Malignant Germ Cell Testicular Tumors.

Retroperitoneal lymph node dissection (RPLND) is performed to treat residual disease following chemotherapy for stage II and III testicular cancer. Significant morbidity can be associated with open RPLND. As such, laparoscopic techniques have been demonstrated to be safe and effective in select cases. Outcomes following post-chemotherapy laparoscopic RPLND for mixed malignant germ cell testicular tumors (MMGCT) are limited in the literature. We performed a retrospective chart review for patients who underwent laparoscopic RPLND at our institution for MMGCT from May 2006 to October 2016. Patient clinical data and perioperative and oncologic outcomes were recorded. Twenty-three patients underwent post-chemotherapy laparoscopic RPLND. Thirty-five percent (8/23) underwent bilateral template dissection, whereas 65% (15/23) underwent a modified unilateral template dissection. Robotic assistance was utilized in 22% (5/23) of cases. Bilateral template was inferior to unilateral template RPLND in operative time, estimated blood loss, open conversion rate, length of hospital stay, and complication rate. The mean follow-up was 35.1 months and 43.3 months for the bilateral and unilateral template groups, respectively. The mean lymph node yield and recurrence rate were similar between the 2 cohorts. One recurrence of mature teratoma was noted 67 months after unilateral laparoscopic RPLND. In select patients, laparoscopic RPLND for stage II and III MMGCT is safe and effective in the post-chemotherapy setting. Bilateral template laparoscopic RPLND was associated with inferior perioperative outcomes, but similar oncologic outcomes compared with unilateral template. Patients requiring bilateral template RPLND should be considered for an open approach.

V03-10 EN-BLOC ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS GERM CELL TUMOR

You have accessJournal of UrologyUTUC & Testis Cancer (V03)1 Apr 2020V03-10 EN-BLOC ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS GERM CELL TUMOR James Porter* and Elliot Blau James Porter*James Porter* More articles by this author and Elliot BlauElliot Blau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000849.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Open retroperitoneal lymph node dissection (RPLND) has been the gold standard in both the primary and post-chemotherapy treatment of non-seminomatous germ cell tumors (NSGCT). Of recent interest has been the safety and feasibility of utilizing a robotic-assisted (RA), minimally invasive approach. Proposed advantages to RA-RPLND include decreased morbidity and pain, shorter length of stay (LOS), improved cosmesis and similar oncologic outcomes to the open approach. There have been concerns raised as to the completeness of minimally invasive RPLND with incomplete removal of some lymphatic tissue behind the great vessels. To ensure a thorough dissection, we have developed a technique based on the en bloc removal of all lymphatic tissue within the bilateral template. In this video abstract we demonstrate our approach and technique for bilateral template RPLND utilizing an en-bloc method for extirpation of the specimen. METHODS: Our patient is a 32-year-old male with a history of mixed germ cell tumor of the right testis. He presented with elevated tumor markers and mildly enlarged lymph nodes and was initially stage IIa. He underwent BEP chemotherapy x3, with normalization of serum markers. On follow-up surveillance imaging there was evidence of retroperitoneal recurrence with a growing mass in the paraaortic region. Patient was taken for bilateral robotic RPLND. The robotic approach was performed in the supine position with the patient in Trendelenberg. Four robotic ports were placed in a linear configuration 4cm below the umbilicus and 7cm apart. A 12mm assistant port was placed in the right lower quadrant. Internal suspension sutures were used to provide exposure to the retroperitoneum. Complete en bloc removal of retroperitoneal lymph nodes was performed from the renal vessels to the bifurcation of the iliac arteries bilaterally. RESULTS: Robotic operative time was 6.5 hours. Estimated blood loss was 100cc. There were no complications. The patient was discharged to home post-operative day 1 on a low-fat diet. The specimen was removed en bloc. Pathology revealed 31 lymph nodes; 5 of these with evidence of fibrosis, 1 with viable mature teratoma measuring 4.9 cm. CONCLUSIONS: We present a technique for en bloc removal of retroperitoneal lymph nodes in a patient with a post chemotherapy mass using a supine robotic approach. The en bloc technique ensures complete removal of all lymphatics within the bilateral template including the retrocaval and retroaortic tissues. This method promotes control of lymphatic channels and avoids division of lymph nodes within the template. Robotic RPLND should be attempted in select patients by surgeons with significant experience in oncology and robotic surgery. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e282-e282 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Porter* More articles by this author Elliot Blau More articles by this author Expand All Advertisement PDF downloadLoading ...

Validation of a prediction model for avoiding post-chemotherapy retroperitoneal lymphadenectomy in patients with metastatic nonseminomatous germ cell cancer.

Post-chemotherapy residual masses (PCRMs) may contain persistent cancer or teratoma in more than 50% of patients with metastatic non-seminomatous germ cell tumours (mNSGCTs). Retroperitoneal lymph node dissection (RPLND) is curative, but controversy exists about selection criteria for surgery. A validated prediction model by Vergouwe et al (2007) based on over 1000 patients was evaluated at our centre. mNSGCT patients treated with RPLND for PCRMs were identified from an electronic database. Typographical errors in the model were identified and corrected using their 2003 publication, but retaining the 2007 coefficients. Six clinical variables were included in the model and the calculated probability of benign tissue was compared with pathology. "Benign tissue only" was considered a positive test outcome in patients with a predicted probability of "benign tissue only" greater than 70%. Fifty-two (52) mNSGCT patients between 1980 and 2014 were evaluable. Median age was 32 years (range 17-52) and International Germ Cell Consensus Classification (IGCCC) prognostic stages were: good 46.2%, intermediate 32.7%, and poor 21.2%. Most patients received bleomycin/etoposide/cisplatin (BEP) chemotherapy and full bilateral RPLND. Pathology showed residual cancer or teratoma in 31 patients (59.6%) and benign findings in 21 patients (40.6%). Positive and negative predictive values and accuracy were 100%, 69%, and 73%, respectively. "Benign tissue only" was found in 100% of patients in whom this was predicted using our pre-determined criteria. This study involved a limited number of patients, but confirms the potential value of the Vergouwe et al model. Routine use of this prediction model in clinical practice should be tested for mNSGCT patients with PCRMs.

Post-chemotherapy robotic bilateral retroperitoneal lymph node dissection using a novel single-dock technique.

There have been no previous reports of post-chemotherapy robotic bilateral retroperitoneal lymph node dissection (RPLND) using a single-dock technique. One deterrent of robotic RPLND is that accessing bilateral retroperitoneal spaces requires patient reposition and surgical robot redocking, therefore increasing operative time. Herein we provide the first step-by-step description of a single-dock technique for robotic bilateral RPLND in the post-chemotherapy setting. We describe port placement and technique for robot positioning to optimize access to bilateral retroperitoneal spaces with a single dock. We also demonstrate the feasibility of sparing the inferior mesenteric artery when utilizing this approach. This single-dock approach was used on two patients at our institution who had residual paracaval masses following chemotherapy for metastatic testicular cancer. Mean operative time was 6h, and neither patient had significant blood loss or suffered from any peri-operative complications.

Retroperitoneal Lymph Node Dissection: Anatomical and Technical Considerations from a Cadaveric Study

Metastatic testis cancer in the retroperitoneum presents a technical challenge to urologists in the primary and post-chemotherapy settings. Where possible, bilateral nerve sparing retroperitoneal lymph node dissection should be performed in an effort to preserve ejaculatory function. However, this is often difficult to achieve, given the complex neurovascular anatomy. We performed what is to our knowledge the first comprehensive examination of the anatomical relationships between the sympathetic nerves of the aortic plexus and the lumbar vessels to facilitate navigation and nerve sparing during bilateral retroperitoneal lymph node dissection. The relative anatomy of the infrarenal vasculature (lumbar vessels, right gonadal vein and inferior mesenteric artery) was investigated in 21 embalmed human cadavers. The complex relationships between these vessels and the sympathetic nerves of the aortic plexus were examined by dissection of an additional 8 fresh human cadavers. Analysis of the infrarenal vasculature from 21 cadavers demonstrated that the position of the right gonadal vein and the inferior mesenteric artery may be useful to locate the right superior lumbar vein and the first pair of infrarenal lumbar arteries as well as the common lumbar trunk (vein) and the second pair of infrarenal lumbar arteries, respectively. Furthermore, the lumbar splanchnic nerves supplying the aortic plexus were most often positioned anteromedial to the respective lumbar vein. The current study describes the complex neurovascular relationships that are crucial to performing successful nerve sparing retroperitoneal lymph node dissection. Surgical techniques are also discussed. Collectively, these results may help surgeons decrease the rate of postoperative retrograde ejaculation and/or anejaculation.

External validation of the Heidenreich criteria for patient selection for unilateral or bilateral retroperitoneal lymph node dissection for post-chemotherapy residual masses of testicular cancer

To validate the Heidenreich criteria for patient selection for unilateral retroperitoneal lymph node dissection (RPLND) for residual masses after chemotherapy for nonseminomatous germ cell tumor (NSGCT). For validation, the data of 59 patients who underwent RPLND for residual masses of NSGCT were used. Of these patients, 23 (39 %) qualified for a modified RPLND, the others had an indication for a bilateral dissection. Results from histopathology after RPLND and follow-up data for relapse inside or outside the zone of the resection template were considered for validation. In the study cohort, median age at time of RPLND was 31 years. The 2-year disease-free survival was 90 and 96 % for the bilateral and the unilateral RPLND patients, respectively. Overall, 8 (14 %) relapses were observed after a median follow-up of 54 month. Of these, 6 were outside of the resection field and 2 were in-field. Of the 23 patients with indication for a modified RPLND, 1 patient relapsed in the contralateral testis and 1 inside the modified RPLND template. No relapse was observed outside the modified RPLND field and inside the untouched contralateral RPLND field. The Heidenreich criteria did therefore not misclassify a single patient. The Heidenreich criteria for the selection of candidates for unilateral RPLND for residual masses after chemotherapy allow a highly reliable selection of patients. The application of the Heidenreich criteria can help to reduce comorbidity and invasiveness of RPLND.

Laparoscopic Removal of Spermatic Cord to Reduce Incision Size of Open Retroperitoneal Lymph Node Dissection

To describe a laparoscopic-assisted modification to the traditional open retroperitoneal lymph node dissection (RPLND) to significantly shorten incision length and decrease morbidity of the laparotomy. We describe 3 patients who underwent primary RPLND using the laparoscopic-assisted cord excision for stage I nonseminomatous germ cell testicular tumors. Spermatic cord excision is performed laparoscopically, and a standard nerve-sparing bilateral template RPLND is then performed through a supraumbilical incision. Operative time, intraoperative estimated blood loss, number of lymph nodes resected, complications, length of hospital stay, and follow-up were determined. All patients were clinical stage 1 (T1-2, Nx, M0 S0). The primary testicular tumor size was 2.2-5.5 cm with embryonal components, and all had negative results on abdominal and chestcomputed tomography imaging. Mean estimated blood loss was 267 mL (range, 100-500), operating room time was 293 minutes (range, 254-306), and all patients were discharged on postoperative day 5. There were no complications noted. Node counts were 22-33. The median length of follow-up was 20 months with no recurrence. Laparoscopic removal of the spermatic cord during open RPLND is a simple modification to thestandard technique that reduces incision size without compromising the quality of open RPLND.

Optimal Management of Clinical Stage I Testis Cancer: One Size Does Not Fit All

Optimal Management of Clinical Stage I Testis Cancer: One Size Does Not Fit All

Critical Evaluation of Modified Templates and Current Trends in Retroperitoneal Lymph Node Dissection

Retroperitoneal lymph node dissection (RPLND) is a critical aspect of staging and treatment of nonseminomatous germ cell tumors (NSGCTs) of the testis. RPLND achieves cure in a majority of patients with low-volume metastatic disease and minimizes the need for chemotherapy. Initial surgical approaches to RPLND, involving wide limits to dissection, were associated with high rates of retrograde ejaculation and significant overall morbidity. Evolving modified RPLND templates helped reduce rates of retrograde ejaculation but may be associated with a 3%-23% risk of unresected metastasis. Modified templates have become a standard of care in primary RPLND with low-volume metastatic disease. Only highly select patients at specialized centers should undergo modified template RPLND in the postchemotherapy setting, because risks of unresected disease are higher than in the primary setting. Bilateral RPLND optimizes cancer control and can preserve antegrade ejaculation if nerve sparing is performed. We also briefly discuss minimally invasive approaches to RPLND.

V2152 ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR TESTICULAR CARCINOMA

You have accessJournal of UrologyAward Winning Video Session1 Apr 2013V2152 ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR TESTICULAR CARCINOMA James Porter James PorterJames Porter Seattle, WA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2061AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Retroperitoneal lymph node dissection (RPLND) is an accepted staging and treatment option for clinical stage 1 non-seminomatous germ cell tumor (NSGCT). Laparoscopic RPLND has been performed in an effort to decrease the morbidity of open RPLND. Robotic surgical techniques have recently been employed in urologic procedures with the noted advantages of 3-D vision and greater degrees of instrument freedom. To determine whether the advantages of robotic surgery could be applied to laparoscopic RPLND, we present our experience with robotic RPLND. METHODS Robotic RPLND was performed using two approaches. Early in our experience a lateral approach using 4 robotic trocars and an assistant trocar was used. With more experience and the need to treat post chemotherapy patients, a supine approach with the patient in Trendelenberg position was utilized. The supine approach allows a full bilateral dissection in one setting. The fourth robotic arm is used throughout the procedure and is instrumental in providing exposure of the lymphatic tissue and retraction of the bowel and major vessels. Nerve sparing is performed within the template. The spermatic cord is dissected completely within the inguinal canal by repositioning the robot over the patient's legs. RESULTS Robotic RPLND was performed successfully in 16 patients with 11 performed from the lateral approach and 5 in the supine position. Mean operative time was 259 minutes and mean estimated blood loss was 75 cc. Mean hospital stay was 1.5 days with 10 of 16 patients leaving the hospital the day following surgery. Mean number of lymph nodes removed was 21. Four patients were found to have Stage IIa disease and one patient developed a lung recurrence at 4 months while the remaining three are disease free without post-operative chemotherapy at a mean follow up of 23 months. There was one ureteral transection, no open conversions and no transfusions. Two patients who underwent bilateral RPLND had ejaculatory dysfunction. CONCLUSIONS Robotic RPLND can be performed successfully and provides improved visualization and dexterity over conventional laparoscopic instrumentation. The supine approach facilitates bilateral dissection for post chemotherapy patients. Patients experience significantly reduced morbidity and nodal yield is comparable to open surgical techniques. Further study will be necessary to determine the long term oncologic outcomes of this approach. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e881 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Porter Seattle, WA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1053 External validation of the Heidenreich criteria for the selection of patients for unilateral or bilateral post chemotherapy retroperitoneal lymph node dissection for residual masses of testicular cancer

1053 External validation of the Heidenreich criteria for the selection of patients for unilateral or bilateral post chemotherapy retroperitoneal lymph node dissection for residual masses of testicular cancer

Yolk sac tumor in a patient with transverse testicular ectopia

Transverse testicular ectopia (TTE) is a rare anomaly in which both testes descend through a single inguinal canal. We report a case of yolk sac tumor in the ectopic testis of a patient with TTE. A 24-year-old man presented to our hospital with a left inguinal-mass, right cryptorchidism and elevated alpha-fetoprotein (AFP). A left herniotomy 3 years earlier demonstrated both testes in the left scrotum, one above another positionally. Four months ago, a left scrotal mass appeared and radical orchiectomy of both testes revealed testicular yolk sac tumor of the ectopic testis. An enlarging left inguinal-mass appeared 2 months ago and he was referred to our hospital. Laboratory data showed an elevation of AFP (245.5 ng/ml) and a 46 XY karyotype. He underwent bilateral retroperitoneal lymph node dissection and simultaneous left inguinal mass dissection. Histopathologic examination revealed a diagnosis of recurrent yolk sac tumor in the left inguinal mass. The retroperitoneal lymph node was not enlarged and, on histopathology, was not involved. The patient has now been followed up for 8 months without evidence of biochemical or radiological recurrence.

Nonseminomatous Germ Cell Tumor of the Testes Metastatic to the Corpus Cavernosum of the Penis

Metastases to the penis are rare, with less than 200 cases reported. Within the genitourinary tract, advanced prostate cancer is the most common culprit. These cases typically represent widely disseminated disease and are associated with a poor prognosis. We present images of a case of a testicular nonseminomatous mixed germ cell tumor, which metastasized to the corpus cavernosum of the penis 8 months after a negative bilateral retroperitoneal lymph node dissection. The patient received chemotherapy and experienced a complete response.

Retroperitoneal lymph node dissection: reassessment of modified templates

The retroperitoneum is the initial metastatic site in 90% of patients with nonseminomatous germ cell tumours (NSGCTs) of the testis. A retroperitoneal lymph node dissection (RPLND) provides accurate staging and effective therapy, minimizes the need for adjuvant chemotherapy in patients with low-volume metastases, and optimizes durable cure rates. We review the rationale for and development of RPLND, focusing specifically on the advantages and limitations of the variable surgical templates. Bilateral RPLND has a long-standing record of maximizing cancer control and minimizing secondary therapy. Both modified templates and prospective nerve-sparing techniques were introduced to optimize rates of antegrade ejaculation. Limited resections as advocated by modified templates are appealing in the setting of primary RPLND but can be associated with a 3-23% risk of residual disease. Modified templates have also been advocated for highly selected patients after chemotherapy but, if applied to all patients undergoing surgery after chemotherapy, will lead to an unacceptably high rate of residual disease, even in patients with small masses after chemotherapy. For patients undergoing primary or post-chemotherapy RPLND, a full bilateral template (with nerve-sparing when appropriate) maximizes cure rates while minimizing ejaculatory morbidity and the subsequent need for chemotherapy.

The evolution, controversies, and potential pitfalls of modified retroperitoneal lymph node dissection templates

Over the past century, retroperitoneal lymph node dissection (RPLND) for patients with non-seminomatous germ cell tumors has evolved to become an indispensable diagnostic and therapeutic procedure. Bilateral RPLND with inclusion of the suprahilar regions initially established therapeutic efficacy but was associated with significant ejaculatory morbidity. Decades later, multiple anatomic mapping studies demonstrated a predilection for low-volume retroperitoneal metastases to be ipsilateral and infrahilar, leading to the introduction and popularity of several modified templates. By minimizing contralateral dissection and avoiding essential neural pathways, coordinated antegrade ejaculation rates improved considerably. Simultaneously, prospective nerve-sparing techniques were developed to preserve sympathetic nerve function, allowed for modified or bilateral templates, and resulted in minimal ejaculatory morbidity. The primary oncologic concern with modified templates remains the potential for unresected 'extra-template' disease leading to retroperitoneal or systemic recurrences requiring additional therapy. While modified templates continue to be widely used, larger scale and longer-term studies are essential to fully elucidate their appropriate application and therapeutic efficacy.

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

To report our experience with post-chemotherapy nerve-sparing retroperitoneal lymph node dissection (RPLND) for advanced germ cell tumor (GCT). 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. 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. Post-chemotherapy nerve-sparing RPLND preserves ejaculatory function in the majority of patients with advanced GCT without increasing the risk of local recurrence.

Open Versus Laparoscopic Retroperitoneal Lymph Node Dissection: Assessing Adequacy of Dissection in a Porcine Model

Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is emerging as a viable alternative to traditional open retroperitoneal lymph node dissection (O-RPLND). Despite numerous reports confirming clinical oncologic equivalency between the two approaches, however, concerns still remain over the adequacy of laparoscopic dissection. We therefore sought to compare the completeness of dissection between O-RPLND and L-RPLND in a porcine model. Fourteen domestic swine were divided into two equivalent groups. Both groups underwent bilateral retroperitoneal lymph node dissection, approximating templates used in human dissection. In one group, the procedure was performed through an open midline incision, while the other group underwent completely laparoscopic dissection. Tissue was independently analyzed by a pathologist, who recorded lymph node yield based on microscopic evaluation. All animals in the L-RPLND group underwent successful procedures, without the need for conversion. Two open procedures were aborted because of hemorrhage. Mean lymph node yield from O-RPLND was 32, while the mean yield for L-RPLND was 29. This difference was not statistically significant (P=0.65). In the porcine model, L-RPLND is capable of providing a quality of dissection equivalent to that of O-RPLND, in terms of absolute lymph node yield on microscopic examination. The applicability of this data to human patients, however, may be limited by significant anatomic differences between the human and the pig. Further prospective comparison in human patients is critically needed.

Results of Bilateral Nerve Sparing Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer

We evaluated the feasibility and early oncological outcome of a laparoscopic nerve sparing bilateral retroperitoneal lymph node dissection. The surgical technique is described. From July 2004 to December 2007 a total of 42 patients with nonseminomatous germ cell tumor (21 with stage I, 2 with stage IIA marker negative and 19 with post-chemotherapy stage IIB disease) underwent transperitoneal bilateral laparoscopic retroperitoneal lymph node dissection. The sympathetic trunk and postganglionic nerves were identified, and lymphatic tissue was dissected between the nerves. Patients with clinical stage I and IIA disease that was lymph node positive at laparoscopic retroperitoneal lymph node dissection did not receive additional chemotherapy. Surgery was successfully completed in all patients and no conversion to open surgery was necessary. Mean operative time was 323 minutes. No intraoperative complications occurred. Of patients with stage I and marker negative stage IIA disease active tumor was found in 5 retroperitoneal lymph node dissection specimens, and no patients had recurrence. Of 19 patients with post-chemotherapy stage IIB disease teratoma was found in the lymphatic tissue in 4 (21.0%). No retroperitoneal recurrence was observed. Pulmonary metastases developed 9 months after surgery in 1 patient with stage I disease and negative retroperitoneal histology, and were treated successfully. All patients are currently free of disease at a mean followup of 17.2 months. Antegrade ejaculation was preserved in 36 patients (85.7%). Bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection is feasible and associated with low morbidity if performed by experienced hands. The oncological efficacy of this approach is promising and currently under evaluation.