Postchemotherapy laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell testicular tumor

Nikola Knezevic, Tomislav Kulis, Maja Marija Bernat, Marjan Maric, Ivan Milas, Marija Topalovic Grkovic, Zeljko Kastelan,

University Hospital Center Zagreb and University of Zagreb, School of Medicine, Department of Urology, Zagreb, Croatia

Introduction: Laparoscopic retroperitoneal lymph node dissection (LRPLND) has become accepted staging method for clinical stage I nonseminomatous germ cell tumor. Due to gained experience, it is applied as a therapeutic approach for patients with postchemotherapy residual tumor masses. First published series have reported high number of intraoperative and postoperative morbidities with a high number of open conversions. We reviewed our indications, complication rate and results of postchemotherapy RPLND.

Material and methods: Retrospectively we analyzed medical records of 45 patients who were selected for postchemotherapy RPLND according to our criteria. All patients were operated since 2005 by one surgeon. The surgical technique consisted of removing the residual tumor mass plus unilateral template dissection. Selection criteria for laparoscopic operation were: residual retroperitoneal tumor masses after chemotherapy smaller than 6 cm in diameter on CT scan; less or equal to 5 chemotherapy cycles; and normalized testicular tumor markers.

Results: All operations were successfully completed laparoscopically and there was no need for conversion to open surgery or blood transfusion. Mean residual tumor size on CT scan was 3.0 (range 1.1-6.0) cm and the median number of chemotherapy cycles was 3 (range 3-7). In two patients minor intraoperative vascular injuries occurred, which were controlled by laparoscopic techniques. Postoperatively, one patient had prolonged lymphorrhea in duration of 10 days, which resolved by low fat dietary measures. The mean operative time was 190 (range 160-270) minutes and the median hospitalisation was 4 (range 3-12) days. Median number of lymph nodes obtained for pathohistological examination was 17 (range 8-31). Pathohistological examination revealed mature teratoma in 22 patients and necrosis in 21 patients and active tumor in 2 patients. No patient developed infield recurrence during a mean follow up of 36 months.

Conclusion: Postchemotherapy RPLND is challenging mostly due to desmoplastic postchemotherapic reaction and large residual tumor masses. However, in selected patients it is safe, oncologically effective, low morbidity procedure with all the benefits of minimally invasive surgery.