Nerve-sparing Retroperitoneal Lymph Node Dissection Research Articles

Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Metastatic Seminoma: Results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS)

BackgroundRadiation therapy and systemic chemotherapy are recommended treatment options in marker-negative clinical stage (CS) IIA/B seminoma. Despite high cure rates of 82–94%, both therapeutic options are associated with significant long-term toxicities. ObjectiveTo evaluate the feasibility, oncological efficacy, and treatment-associated morbidity of primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) in CS IIA/B seminoma. Design, setting, and participantsA prospective, single-arm, clinical phase 2 trial including CS IIA/B seminoma patients was conducted. InterventionPrimary nerve-sparing retroperitoneal lymphadenectomy. Outcome measurements and statistical analysisRelapse-free and overall survival, surgery-associated complications according to the Clavien-Dindo classification, and Kaplan-Meier methods for survival calculation were assessed. Results and limitationsThirty patients at a mean age of 39.1 (34–52) yr with marker-negative CS IIA and IIB seminomas were recruited. The median follow-up was 22 (8–30) mo. Nineteen (63%) and 11 (36%) patients were diagnosed with stages IIA and B, respectively, at the time of primary diagnosis. Fourteen (47%) and 16 (53%) patients were diagnosed with CS IIA and IIB, respectively, at the time of nsRPLND. Twenty-seven and three patients underwent open and robot-assisted nsRPLND, respectively. The median operating room time was 125 (115–145) min, median blood loss was <150 ml, and median time of hospitalization was 4.5 (3–9) d. Four (13%) patients experienced Clavien-Dindo grade 3a complications. Lymph node histology revealed seminoma in 25 (80%) patients; two and three patients demonstrated embryonal carcinoma and benign disease, respectively. Sixteen patients underwent a serum analysis of miR371 preoperatively, which predicted metastatic disease in 12/13 and benign histology in 3/3 patients. Three of 30 (10%) patients developed an outfield relapse 4, 6, and 9 mo postoperatively and were salvaged by systemic chemotherapy. Limitations are the low patient number and length of follow-up. ConclusionsThe nsRPLND approach results in a high cure rate at midterm follow-up and is associated with a low frequency of treatment-associated morbidities, making this approach a feasible alternative to radiation therapy or systemic chemotherapy. Patient summaryThe standard treatment of clinical stage IIA/B seminomas is radiation therapy or chemotherapy, which results in a significantly increased frequency of long-term toxicity and secondary neoplasms. In this trial, we demonstrate that nerve-sparing retroperitoneal lymph node dissection is a feasible therapeutic approach with low morbidity and high oncological efficacy.

Twenty Years' Experience in Retroperitoneal Lymph Node Dissection for Testicular Cancer in a Tertiary Referral Center.

Background and Objectives: The aim of this article is to present a single-surgeon, open retroperitoneal lymph node dissection (RPLND) series for testicular cancer in a high-volume center. Materials and Methods: We reviewed data from patients who underwent RPLND performed by an experienced surgeon at our institution between 2000 and 2019. We evaluated surgical and perioperative outcomes, complications, Recurrence-Free Survival (RFS), Overall Survival (OS), and Cancer-Specific Survival (CSS). Results: RPLND was performed in primary and secondary settings in 21 (32%) and 44 (68%) patients, respectively. Median operative time was 180 min. Median hospital stay was 6 days. Complications occurred in 23 (35%) patients, with 9 (14%) events reported as Clavien grade ≥ 3. Patients in the primary RPLND group were significantly younger, more likely to have NSGCT, had higher clinical N0 and M0, and had higher nerve-sparing RPLND (all p ≤ 0.04) compared to those in the secondary RPLND group. In the median follow-up of 120 (56-180) months, 10 (15%) patients experienced recurrence. Finally, 20-year OS, CSS, and RFS were 89%, 92%, and 85%, respectively, with no significant difference in survival rates between primary vs. secondary RPLND subgroups (p = 0.64, p = 0.7, and p = 0.31, respectively). Conclusions: Open RPLND performed by an experienced high-volume surgeon achieves excellent oncological and functional outcomes supporting the centralization of these complex procedures.

Robotic retroperitoneal lymph node dissection for primary and post-chemotherapy testis cancer.

The role of retroperitoneal lymph node dissection (RPLND) in testicular cancer is well established in both the primary and post-chemotherapy setting. The aim of this study was to report our 2 years oncological outcomes of robotic RPLND. A retrospective review was performed of all patients undergoing robotic RPLND by a single surgeon at Princess Margaret Cancer Centre. Demographic, perioperative, and oncologic data were analyzed using descriptive statistics. Between September 2014 and June 2020, 141 patients underwent an RPLND [33 (23.4%) were primary, 108 (76.6%) were post-chemotherapy]. 27 (19.1%) patients underwent a robotic bilateral template nerve-sparing RPLND. RPLND indication was primary (i.e. pre-chemotherapy) in 18 (66.7%), and post-chemotherapy in 9 (33.3%) patients. Stage at RPLND was 2A (n = 15, 55.6%), 2B (n = 9, 33.3%), 2C (n = 1, 3.7%) and 3 (n = 2, 7.4%). Median OR time (incision to closure) was 525 min and blood loss was 200 ml. Nerve sparing was performed in all but one case. Six (22.2%) adjuvant procedures were performed including two (7.4%) vascular repairs. Median length of stay was 2 days. Viable tumor was detected in 17 (63%) and teratoma in 9 (33.3%). Median follow-up was 31.3 months. No adjuvant chemotherapy was given. Three patients (11.1%) relapsed: 2 out-of-field and 1 with both in-field and out-of-field disease. Robotic RPLND can be performed safely. Long-term follow-up of series such as ours, enriched with patients with viable disease and/or teratoma, and not treated with adjuvant chemotherapy is required to ensure oncological outcomes are comparable to the open approach.

High Alert Zones in Nerve-Sparing Retroperitoneal Lymph Node Dissection in Gynecologic Cancers: A Precise Anatomy and Safe Surgical Technique

Background: Retroperitoneal lymph node dissection (RPLND) is one of the most commonly performed surgical procedures in advanced gynecologic cancers such as carcinoma ovary, carcinoma endometrium, c...

Role of primary retroperitoneal lymph node dissection in stage I and low-volume metastatic germ cell tumors.

Early-stage testicular cancers are highly curable. Following orchidectomy, management options for stage I disease include active surveillance, nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy as recommended by the current guidelines. Primary RPLND has for decades played an integral part of treatment in patients with early-stage testicular germ cell tumors (TGCT), particularly in nonseminomatous germ cell tumors (NSGCT) with focus on reducing the long-term morbidity. We review the role of RPLND in stage I NSCGT as well as stage II A/B NSGCT and as seminoma. Radiation therapy and systemic chemotherapy are established treatments for seminoma; however, long-term data has demonstrated the association of such therapies with late toxicity including secondary malignancies, hearing loss, cardiovascular disease as well as metabolic syndromes. Given the well established role of RPLND in NSGCTs, clinicians have developed an interest in utilization of surgery for low-volume retroperitoneal metastatic disease. Two prospective clinical trials (SEMS and PRIMETEST) are underway to determine the role of RPLND alone in low volume metastatic seminoma. RPLND is a highly effective treatment for early-stage germ cell tumors but represents overtreatment in low-volume stage I disease where active surveillance is recommended. RPLND has shown a promising role in low-volume stage II seminomas. Two phase II clinical trials are underway to further determine the curative potential of this approach.

Current management and management controversies in early- and intermediate-stage of nonseminoma germ cell tumors.

Early stage nonseminomatous germ cell tumor (NSGCT) remains a treatable disease, with stage I cancer specific survival exceeding 95%. Using a risk-adapted approach; active surveillance (AS), adjuvant chemotherapy, and retroperitoneal lymph node dissection (RPLND) all options for treatment; with surveillance being increasingly used. With persistently elevated markers (stage IS), chemotherapy remains the hallmark of treatment. Management of stage II NSGCT varies based on status of tumor markers. With negative markers, both induction chemotherapy and upfront RPLND remain options. Management of a residual mass <1 cm after chemotherapy remains controversial, with AS and nerve-sparing RPLND considered options. The development of miR-371a-3p microRNA shows promise a novel biomarker for testicular cancer (GCT). Despite controversies in management, cures for NSGCT are achievable in 95-99% of patients.

Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology.

Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.

Is there still a place for retroperitoneal lymph node dissection in clinical stage 1 nonseminomatous testicular germ-cell tumours? A retrospective clinical study

BackgroundPrimary retroperitoneal lymph node dissection (RPLND) ultimately lost its role as the standard management of clinical stage (CS) 1 nonseminomatous (NS) testicular germ cell tumours (GCTs) in Europe when the European Germ Cell Cancer Consensus Group released their recommendations in 2008. Current guide-lines recommend surgery only for selected patients but reasons for selection remain rather ill-defined. We evaluated the practice patterns of the management of CS1 patients and looked specifically to the role of RPLND among other standard treatment options.MethodsWe retrospectively evaluated the treatment modalities of 75 consecutive patients treated for CS1 NS at one centre during 2008–2017. The patients undergoing RPLND were selected for a closer review. Particular reasons for surgery, clinical features of patients, and therapeutic outcome were analyzed using descriptive statistical methods.ResultsTwelve patients (16%) underwent nerve-sparing RPLND, nine surveillance, 54 had various regimens of adjuvant chemotherapy. Particular reasons for surgery involved illnesses precluding chemotherapy (n = 2), patients´ choice (n = 4), and teratomatous histology of the primary associated with equivocal radiologic findings (n = 6). Five patients had lymph node metastases, two received additional chemotherapy. Antegrade ejaculation was preserved in all cases. One patient had a grade 2 complication that was managed conservatively. All RPLND-patients remained disease-free.ConclusionsPrimary RPLND is a useful option in distinct CS1 patients, notably those with concurrent health problems precluding chemotherapy, and those with high proportions of teratoma in the primary associated with equivocal radiological findings. Informed patient’s preference represents another acceptable reason for the procedure. RPLND properly suits the needs of well-selected patients with CS1 nonseminoma and deserves consideration upon clinical decision-making.

Delayed Return of Ejaculatory Function in Adolescent Males Treated With Retroperitoneal Lymph Node Dissection and Adjuvant Therapy for Paratesticular Rhabdomyosarcoma

Due to the rarity of the disease, adverse events related to ejaculatory function following the management of paratesticular rhabdomyosarcoma with multimodal therapy in adolescents are rarely discussed. Two patients, age 14 and 15 at time of diagnosis were treated with multimodal therapy with nerve-sparing retroperitoneal lymph node dissection, chemotherapy, and radiotherapy. Each developed ejaculatory dysfunction during the treatment period, which resolved 1 year after completion of all therapies. We sought to assess the role of each component of multimodal therapy on the observed side effect and the potential for delayed recovery of function after cessation of all therapies.

Primary and Postchemotherapy Retroperitoneal Lymphadenectomy for Testicular Cancer

Clinical stage I (CS I) testicular non-seminomatous germ cell tumours (NSGCT) are highly curable. Following orchidectomy, a risk-adapted approach using active surveillance, nerve-sparing retroperitoneal lymph node dissection (RPLND) and primary chemotherapy is recommended by the current guidelines. CS I is defined as showing negative values for tumour markers (or values declining to their half-life following orchidectomy) and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low- and high-risk NSGCT with an anticipated relapse rate of about 15% and 50%, respectively. The majority of patients will relapse with good and intermediate prognosis tumours, which have to be treated with 3 to 4 cycles of chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy (PC) RPLND for residual masses. Primary chemotherapy with 1-2 cycles of cisplatin, etoposide, bleomycin (PEB) is a therapeutic option for high-risk CS I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. Nerve-sparing RPLND, if performed properly, will cure about 85% of all high-risk patients with CS I NSGCT without the need for chemotherapy. PC-RPLND plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCT). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography scan performed 6-8 weeks after chemotherapy is positive. In non-seminomatous TGCT, PC-RPLND is indicated for all residual radiographical lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication, which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%; however, it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemo-refractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should only be performed in experienced, tertiary referral centres.

V06-01 RETROPERITONEAL LYMPH NODE DISSECTION: LEARNING MODULE FOR TRAINEES

You have accessJournal of UrologyAdrenal, Testis, UTUC Oncology & More1 Apr 2018V06-01 RETROPERITONEAL LYMPH NODE DISSECTION: LEARNING MODULE FOR TRAINEES Laura Douglass, Evan Kovac, Patrick Meade, Andrew Stephenson, Steven Campbell, and Max Maizels Laura DouglassLaura Douglass More articles by this author , Evan KovacEvan Kovac More articles by this author , Patrick MeadePatrick Meade More articles by this author , Andrew StephensonAndrew Stephenson More articles by this author , Steven CampbellSteven Campbell More articles by this author , and Max MaizelsMax Maizels More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1580AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Retroperitoneal lymph node dissection (RPLND) is a relatively uncommon procedure for the treatment of suspected metastatic testis cancer and requires specific and specialized skills. Currently, no widely available teaching modules exist in order to train medical students and urologic residents for the procedure. We report the first widely available video-assisted online teaching module for RPLND geared towards urologic trainees. METHODS The patient used for our module is a 21-year old male with a diagnosis of clinical stage 1 non-seminoma. The primary orchiectomy specimen contained 80% embryonal cancer, 15% yolk sack and 5% teratoma without lymphovascular invasion. Post-orchiectomy tumor markers were negative. After discussing the risks, benefits and alternative of each treatment option and after providing written consent, we performed and recorded a primary, open, nerve-sparing RPLND. The recorded procedure was then edited into short segments that display its individual components and then uploaded to an online teaching module. RESULTS The following components were identified: incision, exposure of retroperitoneum, control of small bowel, identification of dissection landmarks, node dissection with nerve-sparing procedure (including split and roll technique), excision of spermatic cord, closure. Screenshots and video clips were added for each step. In additions, pitfalls and rescue maneuvers were explained with accompanying video examples. Finally, low-fidelity simulation techniques were provided in order to exemplify the specific surgical skills associated with each step. The online module can be found at:http://www.cevlforhealthcare.org/cevl/cevl_ver_2/MENU_UROLOGY/menus_by_institution/cleveland_clinic/ccf_rplnd/story_html5.html CONCLUSIONS We describe the first online RPLND teaching module geared towards medical students and urologic trainees. We hope that this module will assist trainees in familiarizing themselves with the specific steps and skillset required for this rare procedure. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e661 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Laura Douglass More articles by this author Evan Kovac More articles by this author Patrick Meade More articles by this author Andrew Stephenson More articles by this author Steven Campbell More articles by this author Max Maizels More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

When is surgical resection of metastases in testicular germ cell tumors indicated and is there a scientific basis?

Surgical resection of metastases represents an integral part of curative management in patients with testicular germ cell tumors (GCT). Primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for low volume metastases in clinical stagesI-IIB has to be differentiated from the more complex and more extensive postchemotherapeutic procedures. In Europe, primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for clinical stageI nonseminomatous GCT (NSGCT) plays asubordinate. In clinical stageIIA/B, nsRPLND is indicated for patients with marker-negative metastases in whom cure rates of about 65% can be achieved with surgery alone. For clinical stageIIA/B seminomas, nsRPLND represents an individual, still experimental procedure with high cure rates. Postchemotherapy residual tumor resection (pRTR) for advanced seminomas is only indicated in the context of aFDG-PET/CT-positive residual mass >3 cm in diameter. For NSGCT, pRTR is indicated in patients with residual masses >1 cm and negative or plateauing tumor markers to resect persisting teratoma or vital cancer. Complete resection of all masses including resection of adjacent vascular, visceral or skeletal metastases is mandatory to achieving the highest cure rate possible. Due to the complexity and the lower rate of significant morbidity and mortality, these procedures should be done at tertiary referral centers.

602 Unilateral and nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with non-seminomatous germ cell tumours – indication and recurrence rates

602 Unilateral and nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with non-seminomatous germ cell tumours – indication and recurrence rates

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

Lararoscopic Retroperitoneal Lymph Node Dissection for Paratesticular Rhabdomyosarcoma in Older Children/Adolescents

Testicular tumors are far more common in adults than in children. For this reason, management of pediatric testis tumors has been based on experience in adults. However, there are important differences between testis tumors occurring in children and those occurring in adults. These differences involve tumor histopathology, malignant potential, and pattern of metastatic spread [1]. The majority of primary testis tumors in the Prepubertal Testis Tumor Registry of the Urologic Section of the American Academy of Pediatrics were yolk sac tumors, followed by teratomas and stromal tumors. Because teratomas and most stromal tumors are benign in children, it would follow that fewer than two thirds of prepubertal testis tumors have malignant potential, compared with 90 % of tumors in adults. It is even possible that the majority of prepubertal tumors are benign. Several single-center studies suggest that teratomas are more common than yolk sac tumors in pediatric patients; however, these studies were not limited to prepubertal patients [2–5] . Paratesticular rhabdomyosarcomas usually present with an enlarging painless scrotal mass. By the time they present it is usually not possible to distinguish from a primary testis tumor on physical examination, though the extra-testicular nature of the tumor is usually apparent on ultrasound. Trans-scrotal biopsies of solid scrotal masses should be avoided due to the risk of seeding of the incision if the mass is indeed a rhabdomyosarcoma. The excision of the tumor should be performed just as for a testicular malignancy. The metastatic evaluation for paratesticular rhabdomyosarcoma includes a CT (Computed tomography) of the chest, abdomen, and pelvis. A majority of patients will have clinical stage 1 disease. The most common sites of metastases are the retroperitoneum and lungs. Patients with retroperitoneal metastases should undergo a modified unilateral nerve-sparing RPLND (Retroperitoneal lymph node dissection). All patients should receive chemotherapy and those with positive retroperitoneal nodes should receive radiation therapy as well [1]. We report on two older children/adolescents who underwent Laparoscopic-RPLND.

Inguinal polypropylene plug: A cause of unusual testicular tumor pelvic metastasis

We report the case of a patient who had undergone polypropylene plug placement 3 years before and referred to our institution with testicular tumor. CT scan demonstrated an enlargement of pelvic lymph nodes on the tumor side while retroperitoneal nodes were normal. Orchifunicolectomy was performed and histopathological examination showed a mixed germ cell tumor involving the tunica vaginalis, rete testis, epididymis and spermatic cord. After surgery the patient was addressed to adjuvant chemotherapy according to PEB scheme. Clinical re-staging showed a decrease of the pelvic bulk disease whereas retroperitoneal nodes were still normal and tumor markers were negative. Left external, internal and common iliac lymphadenectomy as well as left modified template nervesparing retroperitoneal lymph node dissection was performed. Intraoperatively the node bulk was firmly adherent to the external iliac artery and extended until the common iliac bifurcation. In the deeper part of this enlarged and firm lymphatic chain the polypropylene plug placed at the time of hernioplasty was found. Behind the plug all retroperitoneal nodes appeared normal and resulted negative on histopathologic examination. The patient had an unusual metastatization, probably due to the plug.

Retroperitoneal lymphadenectomy and resection for testicular cancer: an update on best practice

Clinical stage I testicular nonseminomatous germ cell tumours (NSGCTs) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines. Clinical stage I is defined as negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low-risk and in high-risk NSGCTs with an anticipated relapse rate of about 15% and 50%. The majority of patients will relapse with good and intermediate prognosis tumours which have to be treated with three to four cycles chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for residual masses. Primary chemotherapy with one or two cycles of cisplatin (Platinol), etoposide and bleomycin (PEB) is a therapeutic option for high-risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. nsRPLND, if performed properly, will cure about 85% of all high-risk patients with clinical stage I NSGCT without the need for chemotherapy. PC-RPLND forms an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCTs). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography (PET) scan performed 6-8 weeks after chemotherapy is positive. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%, however it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemorefractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

V1033 ROBOT-ASSISTED RETROPERITONEAL LYMPH NODE DISSECTION MODIFIED NERVE-SPARING LEFT SIDED TEMPLATE

You have accessJournal of UrologyMale Voiding Dysfunction (BPH & Incontinence) & Infection1 Apr 2012V1033 ROBOT-ASSISTED RETROPERITONEAL LYMPH NODE DISSECTION MODIFIED NERVE-SPARING LEFT SIDED TEMPLATE Khurshid R. Ghani, Jay Jhaveri, Quoc-Dien Trinh, Emil Kheterpal, Jesse D. Sammon, Wooju Jeong, Shyam Sukumar, Michael Ehlert, Mani Menon, and Akshay Bhandari Khurshid R. GhaniKhurshid R. Ghani Detroit, MI More articles by this author , Jay JhaveriJay Jhaveri Detroit, MI More articles by this author , Quoc-Dien TrinhQuoc-Dien Trinh Detroit, MI More articles by this author , Emil KheterpalEmil Kheterpal Detroit, MI More articles by this author , Jesse D. SammonJesse D. Sammon Detroit, MI More articles by this author , Wooju JeongWooju Jeong Detroit, MI More articles by this author , Shyam SukumarShyam Sukumar Detroit, MI More articles by this author , Michael EhlertMichael Ehlert Detroit, MI More articles by this author , Mani MenonMani Menon Detroit, MI More articles by this author , and Akshay BhandariAkshay Bhandari Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1137AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Due to the inherent difficulty with dissection, laparoscopic retroperitoneal lymph node dissection (RPLND) is not considered standard treatment for patients with nonseminomatous germ cell tumors. The relatively short learning curve of robotic surgery is providing a comparative advantage over laparoscopic techniques. We report our technique for robot-assisted RPLND in a patient with clinical stage I non-seminomatous testicular cancer. To our knowledge this is the first video description of a left-sided template. METHODS Our patient was a 25-year-old man who underwent a left orchiectomy for a mixed non-seminatous germ cell tumor (90% embryonal) with lymphovascular invasion (Stage 1B). Tumour markers were slightly elevated on admission. Staging CT scans were negative for nodal metastatic disease. The patient underwent a left-sided modified nerve-sparing template RPLND. The technique demonstrated is a transperitoneal 5-port approach with dissection contained to the left ureter laterally, great vessels medially, renal vein superiorly and bifurcation of common iliacs inferiorly. Hem-O-lok clips (Weck, Teleflex Medical, NC, USA) and robotic Harmonic™ device (Ethicon Endosurgery, OH, USA) were used for ligation of lymphatic channels. All lymphatic tissue was placed in an endoscopic bag and extracted via the periumbilical camera port. RESULTS Operative time was 205 minutes. Estimated operative blood loss was 110mL and the patient's post-operative hemoglobin dropped by 0.5 g/dL. The patient was discharged from the hospital postoperative day 1. The final specimen demonstrated pre-aortic, para-aortic and inter-aortocaval nodes with metastatic embryonal carcinoma in 6 of 28 lymph nodes and no evidence of extranodal extension. The patient thereafter underwent 3 cycles of Bleomycin, Etoposide and Cisplatin chemotherapy. Follow-up surveillance scans to date (12 months) do not demonstrate evidence of disease recurrence. CONCLUSIONS Robot-assisted repair of RPLND results in good lymph node yield, short hospital stay and low morbidity. New instrumentation such as the robotic Harmonic™ device is especially useful in this procedure for ligation of lymphatic channels. Analysis of larger case series is required before this technique can be compared to open RPLND. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e419-e420 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Khurshid R. Ghani Detroit, MI More articles by this author Jay Jhaveri Detroit, MI More articles by this author Quoc-Dien Trinh Detroit, MI More articles by this author Emil Kheterpal Detroit, MI More articles by this author Jesse D. Sammon Detroit, MI More articles by this author Wooju Jeong Detroit, MI More articles by this author Shyam Sukumar Detroit, MI More articles by this author Michael Ehlert Detroit, MI More articles by this author Mani Menon Detroit, MI More articles by this author Akshay Bhandari Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Current Update of Management of Clinical Stage I Non Seminomatous Germ Cell Tumors of Testis

The management of patients with testicular germ cell tumors (GCT) has evolved significantly over the past 30years with cure rates approaching nearly 100% for low-stage disease and more than 80% for advanced disease. Controversy surrounds about ideal management of clinical stage I non seminomatous germ cell tumors (CS I NSGCT) of the testis due to multiple treatment options available with more or less equal efficacy. Nerve-sparing retroperitoneal lymph node dissection (RPLND), adjuvant chemotherapy with two cycles of bleomycin, etoposide, and cisplatin , or surveillance have all achieved long-term survival in nearly 100% of patients with clinical stage I NSGCT. Retroperitoneal lymph node dissection is still favoured as the therapy of choice for clinical stage I non-seminomatous germ cell tumors in many centres, but as risk factors for the primary tumor have become better understood, surveillance and risk-adapted therapy, including surveillance for low-risk patients and adjuvant chemotherapy for the high-risk group, is now being considered a therapeutic option. The objective of this study is to review current developments in the management of CS I NSGCT testis with emphasis on risk stratification and treatment recommendations.