Retroperitoneal Lymphadenectomy Research Articles

Primitive Embryonic-Type Neuroectodermal/Glandular Complexes in Testicular Germ Cell Tumors: A Mimic of Embryonic-Type Neuroectodermal Tumor.

Embryonic-type neuroectodermal elements are often intimately mixed with primitive endodermal-type glands, like those of yolk sac tumors, in germ cell neoplasia in situ (GCNIS)-derived germ cell tumors of the testis. Because the primitive glands mimic tubules or rosettes of embryonic-type neuroectodermal elements, these embryonic-type neuroectodermal/glandular complexes may be misinterpreted as pure lesions of embryonic-type neuroectodermal elements, which, if of sufficient size, may lead to a diagnosis of embryonic-type neuroectodermal tumor, despite that the criteria of the World Health Organization for a "somatic-type malignancy" are not met. A diagnosis of embryonic-type neuroectodermal tumor in the testis may lead to retroperitoneal lymphadenectomy even in clinical stage I patients, and in postchemotherapy resections indicates a poor prognosis. The distinction of the neuroectodermal and glandular elements is not always straightforward based on morphology alone. We, therefore, studied 34 testis-derived germ cell tumors with embryonic-type neuroectodermal/glandular complexes and 2 purely glandular yolk sac tumors to characterize the immunophenotypes and determine an efficient immunohistochemical panel to aid in this differential. We found that GFAP, synaptophysin, and paired-like homeobox 2B (PHOX2B) expression was specific to embryonic-type neuroectodermal elements, although PHOX2B had poor sensitivity. In contrast, positive reactions with antibodies directed against AFP, villin, and CDX2 were specific for the glandular elements, although CDX2 had poor sensitivity. Other markers, including AE1/AE3 cytokeratin, SALL4, glypican 3, SOX2, SOX11, CD56, INSM1, and neurofilament, proved less helpful because of their nonspecificity and/or poor sensitivity. We conclude that the optimal immunohistochemical panel for distinguishing the components of embryonic-type neuroectodermal/glandular complexes includes stains for synaptophysin, GFAP, villin, and AFP.

Are biomarkers expression and clinical-pathological factors predictive markers of the efficacy of neoadjuvant chemotherapy for locally advanced cervical cancer?

IntroductionTo predict the overall pathologic response to neoadjuvant chemotherapy (NACT) of patients with locally advanced cervical cancer (LACC) creating a prediction model based on clinical-pathological factors and biomarkers (p53, Bcl1 and Bcl2) and to evaluate the prognostic outcomes of NACT. Materials and methodsThis is a retrospective study of 88 consecutive patients with LACC who underwent NACT followed by nerve sparing surgery with retroperitoneal lymphadenectomy at National Cancer Institute of Milan, between January 2000 and June 2013. Clinical pathologic data were retrieved from the institutional database. Biomarkers (p53, Bcl1 and Bcl2) were evaluated before and after NACT in the specimen. To investigate their role as predictors of response, we tried several statistical machine learning algorithms. ResultsResponders to NACT showed a 5-years survival between 100%(CR) and 85.7%(PR). Clinical factors were the most important predictor of response. Age, BMI and grade represented the most important predictors of response at random forest analysis. Tree-based boosting revealed that after adjusting for other prognostic factors, age, grade, BMI and tumor size were independent predictors of response to NACT, while p53 was moderately related to response to NACT. Area under the curve (crude estimate): 0.871. Whereas Bcl1 and Bcl2, were not predictors for response to NACT. The final logistic regression reported that grade was the only significant predictor of response to NACT. ConclusionCombined model that included clinical pathologic variables plus p53 cannot predict response to NACT. Despite this, NACT remain a safe treatment in chemosensitive patients avoiding collateral sequelae related to chemo-radiotherapy.

Real-world study of lymphadenectomy in patients with advanced epithelial ovarian cancer.

The evidence on the role of retroperitoneal lymphadenectomy is limited to less common histology subtypes of epithelial advanced ovarian cancer. This retrospective cohort study utilized data from the Surveillance, Epidemiology, and End Results Program from January 1, 2010, to December 31, 2019. Patients with stage III-IV epithelial ovarian cancer were included and divided into two groups based on whether they received retroperitoneal lymphadenectomy. The primary outcomes are overall survival (OS) and cause-specific survival (CSS). Among the 10 184 included patients, 5472 patients underwent debulking surgery with retroperitoneal lymphadenectomy, while 4712 patients only underwent debulking surgery. No differences were found in the baseline information between the two groups after propensity score matching. Retroperitoneal lymphadenectomy during debulking surgery was associated with improved 5-year OS (43.41% vs. 37.49%, p < 0.001) and 5-year CSS (46.43% vs. 41.79%, p < 0.001). Subgroup analysis further validate the retroperitoneal lymphadenectomy increased the 5-year OS and CSS in patients with high-grade serous cancer. Although the results were not validated in the less common ovarian cancer (including endometrial cancer, mucinous cancer, low-grade serous cancer, and clear cell cancer), the tendency showed patients with the above four subtypes may benefit from the lymphadenectomy which is restricted for small sample size after propensity score matching. This study revealed that retroperitoneal lymphadenectomy could further improve the survival outcome during debulking surgery in patients with advanced epithelial ovarian cancer. The conclusion was affected by the histology subtypes of ovarian cancer and further studies are needed to validate the conclusion in less common ovarian cancer.

Role of Lymph Node Dissection in Primary Staging Surgery of Early-Stage Mucinous Ovarian Cancer (mOC)- A New Insight

This study is done to evaluate whether it is necessary to do systematic retroperitoneal lymphadenectomy in all early-stage mucinous ovarian cancer (mOC) or do we need to change our routine practice according to new scientific clinical-based evidence. This is a single centre observational study where retrospective data of 81 patients of early stage mOC were prospectively analyzed into two groups depending on the systematic dissection of retroperitoneal lymph node i.e. 1. Lymph node dissection (LND+) group versus 2. Lymph node none-dissection (LND-) group. Log Rank (Mantle- Cox) test was used among these two groups to look for a comparison of outcome in terms of progression free survival (PFS) and overall survival (OS). During 2008-2016 out of 268 patients 123 had primary mOC and among them, 81 were early stage. Out of 81 patients, 48 were in LND+ and 33 patients in LND- group. The incidence of grade I mOC was 79.16% and 84.85% in LND+ and LNDgroup respectively. None of the LND+ cases came positive in the final report which shows very rare involvement of lymph nodes (LN)in early stage mOC. PFS was not statistically significant (p-value 0.061) in between the LND+(91.7%) and LND- (75.8%) groups. The same was true for a 5-year OS. There was no significant improvement of OS in between the LND+ (95.8%) and LND- (87.9%) groups. There was no lymph node recurrence even in LND- groups. This study has given us the insight that in early stage mOC routine systematic lymph node dissection (LND) can be omitted as it does not improve PFS and OS

Evaluation of the effect of cytoreductive surgery on survival in patients with solitary renal cell cancer metastasis

BACKGROUND: Cytoreductive nephrectomy and metastasectomy are recommended for patients with solitary renal cell carcinoma metastases.&#x0D; AIM: To determine the impact of cytoreductive surgery on overall survival (OS) in patients with solitary renal cell carcinoma metastases.&#x0D; MATERIALS AND METHODS: A retrospective analysis of the data of 90 patients with solitary metastases of renal cell carcinoma, who underwent systemic therapy and various types of cytoreductive surgery operations at the City Oncological Hospital No. 62 in Moscow and the City Clinical Oncological Dispensary in St. Petersburg from 2006 to 2022, was carried out. In the majority of patients with solitary metastases, G1 and G2 tumors according to Fuhrman were detected (37 patients each, 41.1%). Cytoreductive nephrectomy was performed in 16 (17.8%) patients, metastasectomy was performed in 35 (38.9%) patients, in combination with metastasectomy in 4 (4.4%) patients, in combination with retroperitoneal lymphadenectomy in 19 (21.1%) patients. In addition to cytoreductive surgical treatment of the primary tumor and metastases all patients received systemic therapy.&#x0D; RESULTS: Cytoreductive nephrectomy and metastasectomy had a statistically significant effect on overall survival in renal cell carcinoma patients with solitary metastases. 3- and 5-year survival in patients who underwent CNE was 78.2 1.7% and 40.3 1.6%, while in patients without Cytoreductive nephrectomy it was only 29.2 1.4% and 0%, respectively. The median overall survival was 55 months for patients who underwent cytoreductive nephrectomy and 30 months for those who did not. A similar trend was noted for the outcomes of metastasectomy. In patients after metastasectomy, 3 and 5-year overall survival was 86.3 1.8% and 59.6 1.6%, in patients without metastasectomy 61.3 1.6% and 19.8 1.3%, respectively, median 59 and 38 months for patients with and without metastasectomy, respectively. Statistically significant differences in the overall survival of patients with solitary metastases were revealed depending on the degree of tumor differentiation according to Fuhrman. 3- and 5-year OS of patients was 84.2 1.8% and 59.9 1.7%, 80.3 1.8% and 46.7 1.6%, 52.2 1.8% and 22.2 1.6% for tumors G1, G2 and G3, respectively (p = 0.009), median 63, 56, and 31 months for G1, G2, and G3 tumors, respectively. Depending on the prognosis according to the International Metastatic Renal Cancer Database Consortium (IMDC) classification, the 3- and 5-year overall survival of patients was 83.7 1.8% and 69.4 1.7%, 68.8 1.6% and 37.2 1.5%, 23.7 1.4% and 11.7 1.3% for the group of good prognosis, intermediate prognosis and poor prognosis, respectively (p = 0.0001). Median overall survival was 64, 41, and 25 months for the three prognosis groups, respectively.&#x0D; CONCLUSIONS: Cytoreductive nephrectomy and metastasectomy had a significant impact on overall survival in patients with solitary renal cell carcinoma metastases. The degree of tumor differentiation according to Fuhrman and prognosis according to IMDC also influenced survival rates.

Evaluation of a miRNA-371a-3p Assay for Predicting Final Histopathology in Patients Undergoing Primary Nerve-sparing Retroperitoneal Lymphadenectomy for Stage IIA/B Seminoma or Nonseminoma

Patients with marker-negative clinical stage IIA/B seminoma or nonseminoma represent a therapeutic challenge, as 20–30% might harbor nonmalignant histologies. MicroRNA 371a-3p (miR371) may represent a biomarker with diagnostic and predictive properties in testicular germ cell tumors (TGCTs). We evaluated the predictive accuracy of this biomarker in identifying the presence or absence of lymph node metastases (LNMs) in clinical stage IIA/B TGCT. In a cohort of 24 consecutive patients with marker-negative clinical stage IIA/B TGCT (n = 15 seminoma, n = 9 nonseminoma) serum miR371 was assessed 1 d before nerve-sparing retroperitoneal lymphadenectomy. Histology revealed metastatic TGCT in 22/24 patients (91.7%), with positive miR371a findings for 20 of these 22 patients with metastases (90.9%). Histology revealed no malignancy in one patient and lymphoma in another, both of whom had negative miR371a findings. One additional patient with pure teratoma and one with a microscopic seminomatous LNM had false-negative miR371a findings. The miR371 assay had sensitivity of 90.9% and specificity of 50%. The positive predictive value was 100.0% and the negative predictive value was 75.0%. According to the data available, miR371a represents a highly reliable, personalized tumor marker for predicting the presence of low-volume retroperitoneal LNMs in marker-negative TGCT. miR371 has potential for inclusion in the diagnostic armamentarium for men with equivocal lymph nodes to facilitate avoidance of unnecessary treatment and the associated toxicity. Patient summaryOur study demonstrates that blood tests for the biomarker miR371 are highly reliable in predicting the presence of lymph node metastases in patients with stage IIA/B testicular cancer. For patients with equivocal findings, use of this test may help in avoiding unnecessary treatment.

Male infertility and urological tumors: Pathogenesis and therapeutical implications.

Most genitourinary tract cancers have a negative impact on male fertility. Although testicular cancers have the worst impact, other tumors such as prostate, bladder, and penis are diagnosed early and treated in relatively younger patients in which couple fertility can be an important concern. The purpose of this review is to highlight both the pathogenetic mechanisms of damage to male fertility in the context of the main urological cancers and the methods of preserving male fertility in an oncological setting, in light of the most recent scientific evidence. A systematic review of available literature was carried out on the main scientific search engines, such as PubMed, Clinicaltrials.Gov, and Google scholar. Three hundred twenty-five relevant articles on this subject were identified, 98 of which were selected being the most relevant to the purpose of this review. There is a strong evidence in literature that all of the genitourinary oncological therapies have a deep negative impact on male fertility: orchiectomy, partial orchiectomy, retroperitoneal lymphadenectomy (RPLND), radical cystectomy, prostatectomy, penectomy, as well as radiotherapy, chemotherapy, and hormonal androgen suppression. Preservation of fertility is possible and includes cryopreservation, hormonal manipulation with GnRH analogs before chemotherapy, androgen replacement. Germ cell auto transplantation is an intriguing strategy with future perspectives. Careful evaluation of male fertility must be a key point before treating genitourinary tumors, taking into account patients' age and couples' perspectives. Informed consent should provide adequate information to the patient about the current state of his fertility and about the balance between risks and benefits in oncological terms. Standard approaches to genitourinary tumors should include a multidisciplinary team with urologists, oncologists, radiotherapists, psycho-sexologists, andrologists, gynecologists, and reproductive endocrinologists.

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.

Chylous ascites following retroperitoneal lymphadenectomy in a patient with recurrent dysgerminoma of ovary: A case report

Chylous ascites is an uncommon condition of accumulation of milky fluid rich in lymph and chylomicrons in the peritoneal cavity. Post-surgical complications following dissection near the base of the mesentery, retroperitoneum, or near the cisterna chyli, malignancies (e.g., pancreatic adenocarcinomas, lymphoma, gastric carcinoma), cirrhosis, and trauma are the prime causes of chylous ascites. Here we report a rare case of chylous ascites following clearance of isolated paraaortic nodal recurrence in a 28-year-old female with dysgerminoma of ovary. The patient developed chylous ascites on the fifth day following surgery, which was confirmed by an increased drain fluid triglyceride level. She was managed conservatively with dietary modification including a high-protein and carbohydrate but low-fat-based diet mainly containing medium-chain fatty acids. Subsequently, she recovered from chylous ascites on the sixteenth day, completed second line chemotherapy, and is now doing well.

The prognostic impact of limited-staging surgery in patients with stage IA epithelial ovarian cancer: a multi-center study with a propensity score-adjusted analysis.

Complete-staging surgery is recommended for stage IA ovarian cancer, but may be omitted for various reasons, including the preservation of fertility and an advanced age. We herein investigated the prognostic impact of limited-staging surgery in patients with stage IA epithelial ovarian cancer. We retrospectively collected data on 4730 patients with malignant ovarian tumors from the databases of multiple institutions and ultimately included 293 with stage IA epithelial ovarian cancer. Limited-staging surgery was defined as one that did not involve hysterectomy, systematic retroperitoneal lymphadenectomy or the collection of ascites cytology. We used an inverse probability of treatment weighting analysis with propensity scores and estimated the hazard ratios of recurrence and death with limited-staging surgery. In total, 176 out of 293 patients (39.9%) were assigned to the limited-staging surgery group. After propensity score adjustments, no significant differences were observed in recurrence-free survival or overall survival between the limited- and complete-staging surgery groups. Even in the subgroup analysis with age stratification, recurrence-free survival and overall survival were similar in the limited- and complete-staging surgery groups. The present results indicate the limited prognostic impact of limited-staging surgery for stage IA epithelial ovarian cancer.

AB005. SOH23ABS_086. Robot-assisted laparoscopic retro-peritoneal lymphadenectomy during right radical nephrectomy: operative technique with a dual-console Xi da Vinci surgical system

AB005. SOH23ABS_086. Robot-assisted laparoscopic retro-peritoneal lymphadenectomy during right radical nephrectomy: operative technique with a dual-console Xi da Vinci surgical system

Evaluation of the results of perioperative surgical robots in urology - literature review

Introduction: Operations with the use of surgical robots have become an acceptable method of treating urological complaints. The question remains what the perioperative results look like compared to other methods, such as classical surgery or laparoscopy. The aim of the study is to summarize the current state of knowledge about the use of surgical robots in urology, provide information on the types of procedures that can be performed with their help, safety and results Materials and methods: Literature review in databases: [Pubmed; science direct; google scholar]; searched using the words: [robotic surgery, surgical robots, BPH, robot, cystectomy, nephrectomy, retroperitoneal lymphadenectomy, prostatectomy,]. Publications from 2016 to 2023 were reviewed. Results: Data from multiple publications were collected. Promising perioperative results of surgical robots have been shown. Blood loss, length of hospital stay, and complication rate are lower compared to other methods. Positive surgical margins occur with a similar frequency. The safety of performing operations with the use of surgical robots in patients after previous chemotherapy or radiotherapy has been proven. The duration of the operation is usually longer compared to other methods. Conclusions: Performing surgery with the use of surgical robots is a promising method in urology. In many cases, perioperative outcomes are better. However, there is a lack of good quality studies conducted over a long period of time.

Balloon Trocar Is a Suitable Instrument for Retroperitoneal Para-aortic Lymphadenectomy in Gynecologic Malignant Diseases

To demonstrate the surgical technique of retroperitoneal para-aortic lymphadenectomy to prevent peritoneal rupture in gynecologic malignant disease. In this video, the authors describe how to use a balloon trocar to create a safe and efficient working space without peritoneal rupture. A step-by-step video demonstration of a surgical technique. Department of Gynecology and Obstetrics, Mie University, Tsu, Japan. Para-aortic lymphadenectomy is a part of most gynecologic oncology procedures for primary and recurrent gynecologic malignancies. There are 2 approaches to para-aortic lymphadenectomy: transperitoneal and retroperitoneal approaches. Although there are no significant differences between these approaches (such as in terms of the number of isolated lymph nodes or related complications), they are performed based on the operator's preference. The retroperitoneal approach is an unfamiliar surgical technique compared with usual laparotomy and laparoscopic surgery, and its disadvantages include a steeper learning curve for attaining proficiency. It is also difficult to develop the retroperitoneal space without a peritoneal rupture. In this video, we demonstrate the use of balloon trocars to create a retroperitoneal compartment. The patient was placed in the lithotomy position with the pelvis elevated at 5° to 10°. The left internal iliac approach, which is considered the standard approach, was used in this case (Fig 1). After identifying the left psoas muscles and the ureter crossing the common iliac artery, dissection of the left para-aortic lymph node was initiated (Supplemental Video 1, 2). Herein, we demonstrated a successful surgical technique for retroperitoneal para-aortic lymphadenectomy to prevent peritoneal ruptures.

Impact of different post-operative treatment modalities on long-term outcomes in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIICp cervical cancer

ObjectiveThis retrospective study aimed to evaluate the survival outcomes in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIICp cervical cancer patients receiving different adjuvant treatment modalities after radical...

Incidental damage of obturator nerve during laparoscopic pelvic lymphadenectomy in endometrial cancer – Demonstration of a successful repairing procedure

ObjectiveIn order to highlight the importance of intraoperative complications and their management, we demonstrate a video of an iatrogenic left obturator nerve lesion during a pelvic lymphadenectomy for endometrial cancer staging. The repair was promptly performed using an intracorporeal laparoscopic suture for an end-to-end tension-free nerve anastomosis. DesignStepwise demonstration of the technique with narrated video footage. SettingA 70-year-old woman with a stage IB grade I endometrial adenocarcinoma was submitted to a surgical laparoscopic staging with total hysterectomy(TH), bilateral adnexectomy(BA), and bilateral pelvic and lomboaortic lymphadenectomy. After an uneventful retroperitoneal lomboaortic lymphadenectomy, the left paravesical space was dissected until the obturator fossae and a left pelvic lymphadenectomy followed, during which the left obturator nerve was accidentally transected with LigaSure™. InterventionsA careful inspection revealed an almost complete transection (80%) of the nerve, with both proximal and distal cut ends identifiable and no fraying of the edges. The thickness of the non-sectioned nervous portion was less than 3 mm, but a tension-free reattachment of both edges seemed manageable. The edges were oriented towards each other and a single stitch suture was placed using a 5–0 prolene, providing an epineural end-to-end coaptation. To reinforce the suture, a Fibrin sealant Tissucol® was applied. The contralateral pelvic lymphadenectomy was then performed, followed by TH and BA. The pieces were removed through the vagina using an endobag. The patient was discharged on the second postoperative day. During the follow-up, there were no signs of diminished adductor function, and neither there was any other detectable residual neuropathy or neurologic deficit involving the left thigh. ConclusionIt is crucial to identify intraoperative complications and to develop abilities to manage them. This video proves that it is possible to repair a transected obturator nerve using laparoscopy, when performed by an experienced onco-gynecologist, with extremely good functional results.

A case of solitary lymph node recurrence 9years after initial treatment for advanced premenopausal endometrioid endometrial cancer; clinical usefulness of hormonal replacement therapy.

There is no consensus on the use of hormone replacement therapy (HRT) after treatment of advanced corpus cancer. We report a case of advanced corpus cancer at a young age, in which HRT was initiated 7years after surgery, and regional lymph node recurrence was later detected. The patient was 35years old at the time of initial treatment in X year, when she was diagnosed with stageIIIC2 corpus cancer and underwent a hysterectomy with bilateral salpingo-oophorectomy and a retroperitoneal lymphadenectomy. HRT was started at X + 7years, and at X + 9years, a 25 × 12-mm-sized mass was found in the hilum of the right kidney. A laparoscopic resection revealed regional lymph node recurrence of the corpus cancer. A retrospective study further revealed that a tumor measuring 12 × 3mm was found at X + 3years and grew to 18 × 7mm in X + 6years, just before the start of the HRT. We hypothesize that HRT did not induce tumor recurrence; instead, it allowed for long-term follow-up and early diagnosis.

Enhanced recovery program in surgical treatment of patients with germ cell tumors of the testicle: experience of a specialized hospital

Background. Surgical treatment after chemotherapy is extremely difficult technically and should only be performed in a specialized medical center. The postoperative period after these surgical interventions is aimed not only at minimizing complications, but also at early mobilization and rehabilitation of patients. The principles of fast-track surgery, or ERAS (Enhanсed Recovery After Surgery) significantly reduce the incidence and degree of complications after various surgical interventions. However, the results of studies on the use of fast track in retroperitoneal lymphadenectomies have not yet been presented.Aim. To determine the effect of enhanced recovery program on treatment outcomes in patients with germ cell tumors of the testicle after retroperitoneal lymphadenectomy.Materials and methods. Retrospective analysis of 2 groups of patients (n = 93) treated at the N.N. Petrov National Medical Research Center of Oncology (Saint Petersburg) was performed. In the 1st group of patients, standard postoperative care after retroperitoneal lymphadenectomy was performed; in the 2nd group, fast track elements were used. Since the introduction of the ERAS protocol into clinical practice (September 2017), all patients have been included in the 2nd group.Results. The presence or absence of preoperative preparation did not affect the incidence of intraoperative complications (p = 0.031). There were significant differences in the duration of hospitalization between the 1st and 2nd groups –15.3 and 11.9 days (p = 0.03), respectively. Assessment of the pain syndrome using the Numeric Rating Scale for Pain (NRS) showed that median pain level in the 1st group was significantly higher than in the 2nd group: 5 ± 1.5 and 3 ± 1.7, respectively (p = 0.04), which indicates a more severe and less controlled pain syndrome in the 1st group of patients. The rate of infectious complications in the postoperative wound in the 2nd group was 3 cases versus 13 in the 1st group (p = 0.009). The rate of lymphorrhea in 2nd group was significantly lower (p = 0.003), median drainage duration was higher in 1st group (p &lt;0.05). In the 2nd group, 70.6 % of patients did not require drainage, which was an important factor in rapid rehabilitation.Conclusion. The use of fast-track principles in patients after retroperitoneal lymphadenectomy significantly reduces the incidence of postoperative complications and rehabilitation time.

Prognostic value of lymph node features in patients diagnosed with stage IIIC endometrial adenocancer.

Our study investigated the lymph node (LN) features most affecting survival in endometrial adenocancer (EAC) patients with LN involvement. This retrospective study was based on a review of the records of patients diagnosed with EAC, who underwent hysterectomy and systematic retroperitoneal lymphadenectomy at the gynecologic oncology clinics of three centers between January 2009 and January 2019. A total of 120 stage IIIC endometrioid-type EAC patients were included in the study. The patients were divided into small (<10 mm) and large (≥10 mm) groups according to the size of the largest metastatic LN. Patients were divided into single and multiple metastasis groups according to the number of metastatic LNs. The patients were divided into pelvic and paraaortic groups according to the location of the metastatic LNs. The effects of prognostic factors on disease-free survival (DFS) and overall survival (OS) were evaluated by Cox regression analysis. Large-sized metastatic LNs were an independent prognostic factor for DFS (hazard ratio [HR] = 5.4, 95% confidence interval [CI]: 1.-26.2; P = 0.035) and OS (HR = 9.0, 95% CI: 1.1-68.0; P = 0.033). The number (P = 0.093 for DFS, P = 0.911 for OS) and location (P = 0.217 for DFS, P = 0.124 for OS) of metastatic LNs were not independent prognostic factors for DFS or OS. Large-sized metastatic LNs were an independent prognostic factor for survival in patients with stage IIIC EAC. Larger prospective studies including similar patient populations are required to verify these findings.

Upper-Abdominal Cytoreduction for Advanced Ovarian Cancer—Therapeutic Rationale, Surgical Anatomy and Techniques of Cytoreduction

Cytoreductive surgery (CRS) is the cornerstone of treating advanced ovarian cancer. Approximately 60–70% of patients with advanced ovarian cancer will have involvement in the upper abdomen or the supracolic compartment of the abdominal cavity. Though the involvement of this region results in poorer survival compared, complete cytoreduction benefits overall survival, making upper-abdominal cytoreduction an essential component of CRS for advanced ovarian cancer. The upper abdomen constitutes several vital organs and large blood vessels draped with the parietal or visceral peritoneum, common sites of disease in ovarian cancer. A surgeon treating advanced ovarian cancer should be well versed in upper-abdominal cytoreduction techniques, including diaphragmatic peritonectomy and diaphragm resection, lesser omentectomy, splenectomy with or without distal pancreatectomy, liver resection, cholecystectomy, and suprarenal retroperitoneal lymphadenectomy. Other procedures such as clearance of the periportal region, Glisson’s capsulectomy, clearance of the superior recess of the lesser sac, and Morrison’s pouch are essential as these regions are often involved in ovarian cancer. This manuscript covers the surgical anatomy of the upper abdomen, the techniques and therapeutic rationale of upper-abdominal cytoreduction, and specific measures for perioperative management of these patients. The main focus is the description of various peritonectomies and regional lymphadenectomies.

Decreased Muscle Mass Prior to and Following Chemotherapy Predicts Morbidity in Testicular Cancer Patients Undergoing Post-Chemotherapy Retroperitoneal Lymph Node Dissection.

The importance of nutritional status before oncologic surgery has been demonstrated in several solid malignancies. Testicular cancer primarily effects young men, and therefore clinicians may not consider sarcopenia as a factor in this population. We therefore sought to determine the impact of decreased muscle mass, measured by psoas muscle diameter, on outcomes in patients undergoing post-chemotherapy retroperitoneal lymphadenectomy (PC-RPLND) for metastatic germ cell tumors (mGCTs). Records of all patients undergoing PC-RPLND for mGCTs at our institution were reviewed. Muscle mass was assessed by measuring cross-sectional area of the psoas muscle on pre-chemotherapy and pre-operative computerized tomography. Psoas Index (PSI) was calculated by adjusting total psoas area for patient height (cm2/m2). Univariate and multivariate analysis was performed to assess the predictive value of sarcopenia for morbidity and mortality following PC-RPLND. From 2014-2019, 95 patients underwent PC-RPLND, of whom 64 patients had both pre-chemo and pre-operative cross-sectional imaging. Prior to chemotherapy, mean PSI was 7.36 cm2/m2, which decreased to 7.06 cm2/m2 (P=.041) following chemotherapy. Patients with Stage III disease had a lower mean PSI than patients with Stage I disease (6.84 cm2/m2 vs 7.46 cm2/m2, P=.047). Patients who suffered post-operative complications had a lower mean PSI (6.39 cm2/m2 vs 7.37 cm2/m2, P=.020). Decreased muscle mass was predictive of morbidity in patients undergoing PC-RPLND. Patients with higher disease burden had lower pre-operative muscle mass. Further assessment of pre-operative nutritional status in this population may reduce morbidity following PC-RPLND.