Nerve-sparing Retroperitoneal Lymph Node Dissection Research Articles

A modified technique for nerve-sparing retroperitoneal lymph node dissection in stage II nonseminomatous germ cell tumors using intraoperative measurement of bladder neck pressure alterations following sympathetic nerve fiber electrostimulation.

We present a simplified method for nerve-sparing retroperitoneal lymph node dissection in patients with nonseminomatous testicular cancer. The sympathetic fibers involved in antegrade ejaculation are identified by intraoperative electrostimulation, resulting in an increase of bladder neck closure pressure. This increase is demonstrated by intraoperative monitoring of both the intravesical pressure and the pressure within the bladder neck by a two-channel microtip measuring catheter. 4 patients with stage I and 6 patients with stage II nonseminomatous testicular cancer were operated on with this modified technique. Ejaculation was preserved in all cases. Semen volume ranged from 2.2 to 4.0 ml. Sperm cell count ranged from 2 to 22 x 10(6)/ml with 20-50% motile spermatozoa, except for 2 of the 3 patients who initially presented with preoperative azoospermia following chemotherapy. In 1 of these 3 patients, postoperative semen analyses revealed a recovery of germ cell function demonstrated by oligoasthenozoospermia.

Primary Retroperitoneal Lymph Node Dissection in Clinical Stage A Non‐seminomatous Germ Cell Testis Cancer Review of the Indiana University Experience 1965–1989

The results of primary retroperitoneal lymph node dissection (RPLND) in 464 patients with clinical stage A non-seminomatous germ cell (NSGC) testis cancer treated over 25 years (1965-1989) were reviewed. The results were analysed in clinical terms and subdivided into early (1965-1978) and contemporary (1979-1989) groups in order to be comparable with series using radiotherapy or surveillance. Between 1965 and 1978 (86 clinical stage A patients) the overall relapse rate of 15% (n = 13) was similar to that of radiotherapy series but survival (97.7% after RPLND) was superior to that achieved with irradiation (87%). From 1979 to 1989, 378 clinical stage A patients had primary RPLND and 30% of them (n = 112) had cancerous nodes. The relapse rate for pathological stage A (n = 266) was 12% and 2 patients died. The relapse rate in pathological stage B patients without adjuvant chemotherapy was 34%. No relapse was seen among 48 pathological stage B patients who received post-operative adjuvant chemotherapy. The death rate was 0.8% among 378 clinical stage A RPLND patients. While not statistically significantly different from death rates reported in current surveillance series, these consistent results spanning 2 eras (before and after cisplatin) over 25 years suggest a sound basis for the surgical approach. The anatomical and medical principles in oncology, which have supported this approach, still remain cogent today. Now that nerve-sparing techniques have been developed, the only long-term morbidity of RPLND (anejaculation) has been avoided. It would seem appropriate to include nerve-sparing RPLND techniques in the management of clinical stage A disease.

Nerve sparing retroperitoneal lymphadenectomy in low stage non-seminomatous germ cell tumors of the testis

In order to maintain antegade ejaculation after retroperitoneal lymph node dissection (RLND) for low stage non-seminomatous germ cell cancer, we implemented a nerve sparing technique in which the sympathetic nerves are preserved. 41 patients were clinically staged: 30 patients stage 1 and 11 patient stage IIa or IIb. Laparotomy revealed that in 2 patients the nerve sparing technique was not feasible. 15 patients had lymph node metastasis at frozen section examination and underwent a bilateral nerve sparing RLND. The remaining 24 patient underwent an unilateral nerve sparing RLND. Clinical understaging occurred in 27% (11/41) and overstaging in 7% (3/41). Patients with lymph node metastases received 2 cycles of adjuvant chemotherapy. Mean follow-up was 18 months. Antegrade ejaculation was preserved after bilateral and unilateral nerve sparing RLND in 86% (12/14) and 96% (22/23) respectively. No recurrences were seen retroperitoneally or hematogenous and so far the good prognosis has not been influenced by this new technique.

Is Routine Primary Retroperitoneal Lymph Node Dissection Still Justified in Patients with Low Stage Non‐seminomatous Testicular Cancer?

We present 8 years' experience of primary retroperitoneal lymph node dissection (RLND) in 190 patients with low stage non-seminoma; 154 patients had clinical stage I (CSI) and 36 had clinical stage IIa (CSIIa) disease. Of the 154 patients with CSI tumours, 33 had increased serum AFP and/or HCG before RLND (CSIM+) and 121 had normal tumour markers (CSIM-). Retroperitoneal lymph node metastases (pathological stage II) (PSII) were found in 38 of 121 patients with CSIM-, in 19 of 33 patients with CSIIM+ and in 26 of 36 patients with CSIIa. In a multivariate analysis, the presence of small vessel infiltration (demonstrated in histological sections of the primary tumour) and a prolonged tumour marker half-life were predictive factors for PSII. These 2 factors enabled a group of non-seminoma patients with CSI disease to be identified who had a 15% risk of retroperitoneal tumour growth (low risk group) as compared with a high risk group where 60 to 70% of patients had retroperitoneal lymph node metastases. Relapses occurred in 7 of 107 patients with PSI and in 6 of 83 patients with PSII disease; in the latter group, 5 relapses developed before the start of routine adjuvant chemotherapy; 6% of patients developed major post-operative complications. In addition, "dry ejaculation" was the principal side effect following RLND (unilateral RLND: 20/132 patients; bilateral RLND: 50/54 patients). The comparative cost to the health service during the first year of follow-up was estimated for low risk non-seminoma patients with CSI subjected to RLND and for those in whom a surveillance policy was adopted. The latter approach was preferable. It was concluded that a surveillance policy should be followed in low risk non-seminoma CSI patients provided that frequent follow-up is possible. A more active policy is recommended in high risk patients (e.g. adjuvant chemotherapy without RLND). Nerve-sparing RLND may be considered in patients with CSIIa disease and negative tumour markers.

Management of Patients With Clinical Stage I or II Nonseminomatous Germ Cell Tumors of the Testis

Eighty patients with clinical stage I or II nonseminomatous germ cell tumors of the testis were managed with modified protocols, including modified nerve-sparing retroperitoneal lymph node dissection for patients with stage I cancer, retroperitoneal lymph node dissection for patients with low-volume stage II cancer, and initial chemotherapy with or without subsequent retroperitoneal lymphadenectomy for patients with high-volume stage II cancer. Patients with low-stage disease (clinical stage I) were treated successfully with modified retroperitoneal lymph node dissection (relapse rate, three of 40 patients). Clinical understaging was evidenced in 14 of 48 patients with clinical stage I disease who were found to have pathologic involvement of the retroperitoneal lymph nodes, including six patients with extensive retroperitoneal nodal involvement (pathologic stage B2). Of nine patients with retroperitoneal tumors less than 3 cm in diameter, four patients were satisfactorily treated with retroperitoneal lymph node dissection alone while five patients required chemotherapy after retroperitoneal lymph node dissection. Of 26 patients with retroperitoneal tumors 3 to 5 cm in diameter, 17 patients were treated with chemotherapy alone. All patients remain free of disease after the completion of definitive therapy. We conclude that therapeutic options should be modified based on histologic factors in the primary tumor, extent of retroperitoneal disease as indicated on a computed tomographic scan, and presence or absence of elevated tumor markers. By consideration these factors, optimum therapy can be selected to achieve the highest long-term survival rate with the least morbidity.