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PubMed1983

Treatment of sequential bilateral germ cell tumors of the testis following interval retroperitoneal lymph node dissection.

Modification in lymphatic drainage following retroperitoneal lymph node dissection, such as a collateral circulation or lymph node and lymphatic vessel regeneration, was observed in 2 patients in whom a second tumor developed in the remaining testicle. Such alterations of the lymphatic system are difficult to evaluate for the possible presence of metastatic disease. The presence of extensive collateral circulation rules out lymph node dissection or radiation therapy as an appropriate treatment in these patients. A short course of systemic chemotherapy, regardless of the histological type of the second malignancy, seems to be the safest adjunctive treatment in such cases.

Adult↗
PubMed2000

Laposcopic retroperitoneal lymph node dissection: evolution of a new technique.

Retroperitoneal lymph node dissection is the most accurate method of detecting occult lymph node metastases in the retroperitoneum. In clinical stage II disease, a residual tumor after primary chemotherapy has to be removed surgically. For these two indications we have replaced open surgery by laparoscopy, in order to reduce morbidity. Once the learning curve had been overcome, the operative time was in the range of that of open surgery, and from the very beginning morbidity and complication rates were lower. Oncologic long-term outcome was not compromised by the laparoscopic approach. Patient satisfaction was very high.

Humans↗
PubMed2000

Retroperitoneal lymph node dissection for the management of clinical stage I nonseminoma.

PURPOSE: We review the rationale for the use of retroperitoneal lymph node dissection for clinical stage I nonseminomatous testis cancer. MATERIALS AND METHODS: The published literature regarding the alternative treatments for clinical stage I nonseminoma was reviewed as well as the personal experience of the authors to define the role of retroperitoneal lymph node dissection. RESULTS: Retroperitoneal lymph node dissection alone is curative in 50% to 75% of patients with pathological stage II disease. The only significant long-term morbidity is a 1% chance of small bowel obstruction. If recurrence develops after retroperitoneal lymph node dissection, it is virtually always curable with cisplatin based chemotherapy. CONCLUSIONS: Retroperitoneal lymph node dissection retains a therapeutic and staging capability in these patients. The probability for cure, short and long-term morbidity, and minimal need for long-term followup in these patients indicates that retroperitoneal lymph node dissection continues to be standard therapy for clinical stage I nonseminoma.

Germinoma↗
PubMed2000

Risk of systemic metastases in clinical stage I nonseminoma germ cell testis tumor managed by retroperitoneal lymph node dissection.

PURPOSE: We assess the risk of systemic recurrence after retroperitoneal lymph node dissection for clinical stage I nonseminoma germ cell testis tumor based on predominance of embryonal carcinoma and/or vascular invasion in the orchiectomy specimen. MATERIALS AND METHODS: A total of 292 cases of clinical stage I nonseminoma germ cell testis tumor treated with retroperitoneal lymph node dissection from 1990 to 1995 were identified from the Indiana University database. A minimum of 2 years of followup was required for study entry. Review of the written pathological reports classified tumors as embryonal carcinoma predominant, when it was present at a level greater than any other histology, nonpredominant, when it was present but not as the main histological subtype, and absent. Vascular invasion was categorized as present or absent. RESULTS: Of the 292 cases 226 (77. 4%) were pathological stage I and relapse rate after retroperitoneal lymph node dissection was 10.2%. Vascular invasion and embryonal carcinoma predominance in the orchiectomy specimen were predictors of relapse in this group. None of the 35 pathological stage II cases treated with adjuvant chemotherapy had relapse, whereas relapse occurred in 7 of 31 pathological stage II cases (22.6%) not treated with adjuvant chemotherapy. CONCLUSIONS: Pathological stage I cases with predominant embryonal carcinoma and/or vascular invasion in the orchiectomy specimen have a higher probability of systemic recurrence after retroperitoneal lymph node dissection. Dissection alone still has a major therapeutic impact (77%) in patients with clinical stage I, pathological stage II nonseminoma germ cell testis tumor.

Adolescent↗
PubMed1998

Is retroperitoneal lymph node dissection necessary for adult paratesticular rhabdomyosarcoma?

PURPOSE: We assess the benefit of retroperitoneal lymph node dissection for adult paratesticular rhabdomyosarcoma. MATERIALS AND METHODS: A total of 19 adults with paratesticular rhabdomyosarcoma who underwent retroperitoneal lymph node dissection between 1980 and 1997 comprise our study population. Postoperative chemotherapy was administered in all patients, including cyclophosphamide, doxorubicin and vincristine with or without consolidation with ifosfamide and etoposide in 17, and vincristine, actinomycin D and cyclophosphamide in 2. Radiation therapy also was administered in 2 patients. Patients were classified into pathological and clinical groups according to the Intergroup Rhabdomyosarcoma Studies. Mean followup was 6.4 years (range 0.5 to 17.6). RESULTS: A total of 17 patients (89%) were disease-free and 2 (1 in pathological group I and 1 in pathological group II) died of disease that recurred outside of the retroperitoneum. Of 16 clinical group I patients 9 were in pathological group II. There were negative nodes in 2 of 3 clinical group II patients. Thus, abdominal computerized tomography correctly staged only 8 of 19 patients (42%). CONCLUSIONS: Retroperitoneal lymph node dissection accurately stages paratesticular rhabdomyosarcoma and eliminates the need for abdominal radiotherapy in patients in pathological group II. Combined modality therapy with retroperitoneal lymph node dissection and postoperative chemotherapy achieves a high cure rate.

Adolescent↗
PubMed1977

Changes in the lymphatic dynamics after retroperitoneal lymph node dissection.

Lymphatic dynamics in the retroperitoneal space are altered after retroperitoneal lymph node dissection. Obstruction with or without visible collaterals is seen frequently. Lymphaticovenous communications and lymphocysts are also common findings. The immediate sequelae are of minor importance, although the mass effect of lymphocysts may be serious. The collateral pathways and lymphaticovenous anastomoses may result in the appearance of metastases in unusual sites.

Adolescent↗
PubMed1987

Sexual function after bilateral retroperitoneal lymph node dissection for nonseminomatous testicular cancer.

This study concerns the sexual functions of 101 patients who had undergone bilateral retroperitoneal lymph node dissection for stage I or II nonseminomatous testicular cancer between 1969 and 1982. All patients were without evidence of disease after at least 4 years of follow-up. Antegrade ejaculation was present in 12 patients, while 89 patients experienced "dry ejaculation." Urine collected after intercourse or masturbation from 75 patients with dry ejaculation showed retrograde ejaculation in 55 and lack of ejaculatory emission into the urethra in 20 patients. Regarding other sexual functions, 17 patients had a diminished sexual desire (especially those patients who had received radiotherapy), 12 experienced difficulty reaching organism, and 6 complained of erectile dysfunction. The incidence of a contralateral hydrocele developing after retroperitoneal lymph node dissection seems to correlate with ligation of the contralateral spermatic vessels and their lymphatics. A review of the literature is presented comparing the types of dissection with the incidence of sexual disorders after retroperitoneal lymph node dissection. Since preserving normal ejaculation and fertility is important, a modified or unilateral retroperitoneal lymph node dissection, when required, is advocated. In patients, with stage I disease the therapy may be limited to an orchiectomy without lymph node dissection. In patients with retroperitoneal lymph node metastases combination chemotherapy with cisplatin and tumor excision gives good results. Patients with true retrograde ejaculation can be treated with alpha-sympathomimetic drugs such as imipramine HCl, and thus be offered the chance of fatherhood by coitus.

Adult↗
PubMed2003

Anterior extraperitoneal approach to laparoscopic retroperitoneal lymph node dissection: a novel technique.

PURPOSE: We describe a novel technique of laparoscopic retroperitoneal lymph node dissection via an anterior extraperitoneal approach. MATERIALS AND METHODS: With the patient in a modified flank position an 8 mm. incision is made along the lateral border of the ipsilateral rectus muscle at the umbilical level. Extraperitoneal space creation with finger dissection is initially made at this site and adequately enlarged with a balloon dilator, followed by gas insufflation and placement of 4 laparoscopic trocars. Laparoscopic retroperitoneal lymph node dissection based on a left modified template is then performed in a completely extraperitoneal manner. RESULTS: Surgical time was 330 minutes, blood loss was 150 ml. and 58 lymph nodes were removed. Resumption of physical activity and oral intake was achieved on postoperative day 1. Hospital stay was 36 hours. Postoperative narcotic requirement was 28 mg. morphine sulfate equivalent. There were no intraoperative or postoperative complications. Normal antegrade ejaculation returned postoperatively. CONCLUSIONS: This novel surgical technique is technically feasible and associated with satisfactory clinical outcomes in our preliminary study. Further studies are necessary to evaluate its potential as an alternative to the previously reported transperitoneal and retroperitoneoscopic approaches to laparoscopic retroperitoneal lymph node dissection.

Adult↗
PubMed2003

Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional cell carcinoma of the bladder?

PURPOSE: We identified a subset of patients with bladder cancer (transitional cell carcinoma) and regional nodal metastasis to the retroperitoneal lymph nodes without detectable systemic dissemination. While the majority of these patients respond initially to chemotherapy, most have disease relapse at the same site within a year. We report the results of a phase II study exploring the potential benefit of retroperitoneal lymph node dissection in patients with transitional cell carcinoma of the bladder in whom disease has shown a significant response to chemotherapy. MATERIALS AND METHODS: A total of 11 patients with biopsy proven metastatic transitional cell carcinoma in the retroperitoneal lymph nodes and no evidence of visceral metastatic disease in whom disease showed a significant response to chemotherapy underwent complete bilateral retroperitoneal lymph node dissection. The end point of study was disease specific survival, calculated from the time of retroperitoneal lymph node dissection to death from transitional cell carcinoma of the bladder. RESULTS: Four patients underwent delayed retroperitoneal lymph node dissection. Seven patients underwent concurrent cystectomy, and pelvic and retroperitoneal lymph node dissection. There was no perioperative mortality. Nine patients had evidence of residual disease in the retroperitoneal nodes. Seven patients have recurrence outside of the original surgical field with a median time to recurrence of 7 months and 6 died at a median time to death of 8 months (range 5 to 14). One patient with retrocrural recurrence attained a complete response to salvage chemotherapy and remained disease-free 57 months after retroperitoneal lymph node dissection. For all 11 patients median disease specific and recurrence-free survival rates were 14 and 7 months, respectively. Four-year disease specific and recurrence-free survival rates were 36% and 27%, respectively. We stratified the patients based on the number of involved lymph nodes at retroperitoneal lymph node dissection and noted that viable tumor in no more than 2 lymph nodes correlated with greater disease specific and recurrence-free survival (p = 0.006 and 0.01, respectively). CONCLUSIONS: Retroperitoneal lymph node dissection can be safely performed for metastatic transitional cell carcinoma. Retroperitoneal lymph node dissection has curative potential, particularly in patients with viable tumor in no more than 2 lymph nodes after chemotherapy.

Carcinoma, Transitional Cell↗
PubMed2003

Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group.

PURPOSE: Nerve sparing retroperitoneal lymph node dissection has been the standard diagnostic and therapeutic approach to clinical stage I nonseminoma. However, the application of prognostic risk factors and introduction of laparoscopy have recently called into question the clinical usefulness of nerve sparing retroperitoneal lymph node dissection. We assessed the therapeutic efficacy and associated complications of this procedure in patients with clinical stage I nonseminomatous germ cell tumor treated at 7 tertiary referral centers to evaluate its role in the modern management of low stage testis cancer. MATERIALS AND METHODS: Between January 1995 and September 2000, 239 patients with clinical stage I nonseminomatous germ cell tumor underwent nerve sparing retroperitoneal lymph node dissection in standardized fields of dissection. For retrospective analysis patient charts were reviewed. A minor complication did not prolong hospital stay and a major complication prolonged hospitalization for at least 2 days. Early complications developed within the first 30 days after retroperitoneal lymph node dissection and late complications occurred from postoperative day 31 and thereafter. RESULTS: Nerve sparing retroperitoneal lymph node dissection was performed unilaterally in 209 patients (88.2%) and bilaterally in 30 (11.8%). Median operative time was 214 minutes (range 90 to 395), mean hospital stay was 8 days (range 4 to 39) and mean blood loss was less than 150 ml. A mean of 18.5 lymph nodes (range 9 to 57) were dissected with metastases detected in 67 patients (28%). An average of 2.9 lymph nodes (range 1 to 14) with a mean diameter of 2.6 cm. (range 0.3 to 6.0) showed metastasis. Disease was pathological stage I in 172 patients (71.7%), 52 (17.6%) had 3 or fewer metastatic lymph nodes, and 15 (6.3%) had 4 to 5 and 10 (4.2%) had greater than 5 positive lymph nodes. Minor complications occurred in 14.2% of the cases and major complications were observed in 5.4%. Antegrade ejaculation was preserved in 93.3% of the patients, recurrence developed in 14 (5.8%) and retroperitoneal recurrence was observed in 3 (1.2%), including 1 in field and 2 out field. CONCLUSIONS: Primary diagnostic and therapeutic nerve sparing retroperitoneal lymph node dissection still has a role in the primary management of clinical stage I nonseminomatous germ cell tumor. Surgery is associated with low morbidity and patient followup is easy and cost-effective due to the concentration on extraretroperitoneal locations. Primary nerve sparing retroperitoneal lymph node dissection is curative in about 70% of clinical stage I nonseminoma cases with a maximum of 3 positive lymph nodes.

Adult↗
PubMed1995

Hyperamylasemia after post-chemotherapy retroperitoneal lymph node dissection for testis cancer.

PURPOSE: Postoperative hyperamylasemia was evaluated in patients undergoing post-chemotherapy retroperitoneal lymph node dissection for testis cancer. MATERIALS AND METHODS: Serum levels of amylase, lipase and bilirubin were evaluated prospectively in the immediate postoperative period in 39 consecutive patients who underwent post-chemotherapy retroperitoneal lymph node dissection. RESULTS: Hyperamylasemia was found in 16 patients (41%), hyperlipasemia in 17 (43%) and hyperbilirubinemia in 9 (23%). Peak elevations were observed at 24 hours postoperatively and most returned to normal at 1 week. Elevation of these parameters was significantly associated with length and difficulty of the procedure. No patient demonstrated clinical acute pancreatitis. CONCLUSIONS: Extended retraction of the pancreas during post-chemotherapy retroperitoneal lymph node dissection may cause a minor reversible injury to the pancreas expressed as hyperamylasemia, hyperlipasemia and, rarely, jaundice. These findings are important to consider in the differential diagnosis of hyperamylasemia following post-chemotherapy retroperitoneal lymph node dissection.

Adolescent↗
PubMed2002

Beneficial impact of a clinical care pathway in patients with testicular cancer undergoing retroperitoneal lymph node dissection.

PURPOSE: Since 1997, we have used a clinical collaborative care pathway for patients undergoing retroperitoneal lymph node dissection. We examined its impact on perioperative care and outcome. MATERIALS AND METHODS: We examined the records of all patients with germ cell carcinoma who underwent retroperitoneal lymph node dissection from July 1990 to July 2001. Variables examined included clinical/pathological stage, hospital stay, postoperative care and the complication rate. RESULTS: A total of 118 patients underwent retroperitoneal lymph node dissection for germ cell carcinoma during this period, including 46 (39%) before pathway implementation in 1997 and 72 patients (61%) after pathway implementation. Of the 118 patients 40 (34%) underwent the procedure after chemotherapy. This rate remained fairly constant in the period before and after pathway initiation (31% and 36%, respectively). After pathway implementation fewer patients received a nasogastric tube (94% versus 5%, p <0.001) and had complications (26% versus 16%, p = 0.036). Mean hospital stay decreased after pathway implementation in all primary and post-chemotherapy retroperitoneal lymph node dissection cases (4.2 versus 6.4 days, p <0.005). Although patients who underwent the procedure after chemotherapy were more likely to have complications than those who underwent a primary procedure, the difference was not statistically significant (p = 0.09). CONCLUSIONS: Our collaborative clinical care pathway safely and efficiently outlines routine postoperative care and significantly decreased hospital stay.

Adult↗
PubMed1983

Imipramine for the treatment of sterility in patients following retroperitoneal lymph node dissection.

The major long-term morbidity following retroperitoneal lymph node dissection is sterility resulting from sacrifice of the thoracolumbar chain or the hypogastric plexus during dissection of the iliac vessels at the bifurcation. Seven males who were devoid of sperm emission and ejaculation as a result of this kind of operation for testicular cancer were treated with imipramine 25 mg t.i.d. In 2 of the patients, antegrade ejaculation appeared during treatment with this drug. We feel that this success rate of 2 out of 7 calls for further studies, as the problem of these young men was considered hopeless until recently.

Adult↗
PubMed1993

Preservation of ejaculation through a modified retroperitoneal lymph node dissection in low stage testis cancer.

We studied ejaculatory function in 47 patients who underwent modified retroperitoneal lymph node dissection for nonseminomatous germ cell tumors of the testis from 1983 to 1989. Our goal was to assess the effectiveness of a modified node dissection in preserving ejaculatory function while eliminating the risk of retroperitoneal recurrence. There were 13 left and 34 right tumors. Of the patients 45 had clinical stage A cancer, and 2 had clinical stage B2 disease and received preoperative chemotherapy. The template method of dissection was used, which spares the preaortic area below the inferior mesenteric artery, including the sacral promontory. Average operating time was 3 hours 40 minutes. There was no operative mortality. Spontaneous recovery of ejaculation occurred in 38 patients (81%), more commonly with right (88%) than with left dissections (62%). The mean interval to recovery of ejaculation was 5 months (92% within 12 months). Five patients (10%) had recurrence, with a mean followup of 28 months. All recurrences were in the lungs 4 to 8 months after retroperitoneal lymph node dissection, and all patients were salvaged with chemotherapy and are disease-free. We confirmed that a modified template-type retroperitoneal lymph node dissection can be accomplished safely with preservation of ejaculation in more than 80% of the patients without increasing the risk of local recurrence.

Adult↗
PubMed2001

An infrared ureteral stent to aid in laparoscopic retroperitoneal lymph node dissection.

PURPOSE: We used an infrared ureteral stent to aid in laparoscopic retroperitoneal lymph node dissection. MATERIALS AND METHODS: The patient was slender 31-year-old male. An infrared light emitting stent was used. RESULTS: With easy visualization of the ureter laparoscopic retroperineal lymph node dissection required 268 minutes. CONCLUSIONS: The infrared ureteral stent decreases the operative time of laparoscopic retroperitoneal lymph node dissection and makes it a safer and more acceptable treatment option.

Adult↗
PubMed2002

Ejaculatory function in stage T1 nonseminomatous germ cell tumors: retroperitoneal lymph node dissection versus surveillance--a decision analysis.

PURPOSE: Ejaculatory function remains a major concern for patients with low stage nonseminomatous germ cell tumors of the testis. Whereas, it has been extensively studied in patients undergoing retroperitoneal lymph node dissection, preservation of ejaculatory function on surveillance protocols has not been studied. To compare ejaculatory function for surveillance protocols to primary retroperitoneal lymph node dissection appropriately, we constructed a decision analysis model mimicking the standard treatment algorithm for stage 1 nonseminomatous germ cell tumor of the testis. MATERIALS AND METHODS: The primary clinical payoff for this study is ejaculatory function. Based on this model, we established that a primary nerve sparing retroperitoneal dissection must be performed with a 96.8% ejaculatory function rate to be recommended as the appropriate therapy. However, if a highly skilled surgeon routinely performs post-chemotherapy dissection with an ejaculatory function rate of 69.2% or greater, surveillance should be offered as the primary treatment modality. This result simply demonstrates a high skill level to allow the surgeon to salvage ejaculatory function in post-chemotherapy retroperitoneal lymph node dissection settings. If this level cannot be achieved, primary retroperitoneal lymph node dissection is the best choice. If we account for a 10% loss of ejaculatory function from primary chemotherapy, the minimum ejaculatory function rate for primary retroperitoneal dissection decreases to 95.7%. RESULTS: In the post-chemotherapy setting an 85.7% ejaculatory function rate must be achieved for surveillance to be considered the optimal choice. Clearly, less surgical rigor is needed with a primary retroperitoneal lymph node dissection when correcting for the effects of chemotherapy on ejaculatory function. Despite this fact, 1-way sensitivity analysis revealed that our model is insensitive to the ejaculatory function effects of chemotherapy. Furthermore, if the likelihood of recurrence on surveillance is greater than 16%, primary nerve sparing retroperitoneal lymph node dissection should again be recommended. CONCLUSIONS: Thus, to maximize ejaculatory function for patients with stage 1 nonseminomatous germ cell tumor a nerve sparing primary retroperitoneal lymph node dissection should always be performed, unless the likelihood of recurrence on surveillance is low or the surgical skill level allows for a highly successful post chemotherapy nerve sparing dissection.

Adult↗
PubMed2001

Aortic replacement during post-chemotherapy retroperitoneal lymph node dissection.

PURPOSE: We reviewed the records of 15 patients with metastatic germ cell cancer who underwent aortic resection and replacement during post-chemotherapy retroperitoneal lymph node dissection to determine the morbidity and the therapeutic benefit. MATERIALS AND METHODS: Between 1970 and 1998, 1,250 patients underwent post-chemotherapy retroperitoneal lymph node dissection. Our retrospective review revealed that 15 patients underwent aortic replacement at that operation. RESULTS: In addition to aortic replacement 11 patients underwent 15 additional procedures, including nephrectomy in 7, vena caval resection in 3, pulmonary resection in 1, small bowel resection in 2, 1 hepatic resection in 1 and L4 vertebrectomy in 1. No patient had necrosis as the only pathological condition. Three patients (20%) had teratoma and 12 (80%) had viable tumor in the retroperitoneal specimen. All 4 patients who underwent post-chemotherapy retroperitoneal lymph node dissection and aortic replacement after induction chemotherapy alone have no evidence of disease. Only 1 of the 11 patients who received salvage chemotherapy with or without previous post-chemotherapy retroperitoneal lymph node dissection have no evidence of disease. Overall 33% of the patients have no evidence of disease. There were no graft related complications. CONCLUSIONS: Aortic resection at post-chemotherapy retroperitoneal lymph node dissection is justified based on therapeutic benefit and morbidity.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1996

Spinal cord ischemia after post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell cancer.

PURPOSE: We report and analyze several cases of neurological deficit after post-chemotherapy retroperitoneal lymph node dissection that were though to be related to spinal cord ischemia. MATERIALS AND METHODS: We searched the testis cancer data base at our university, which includes 1,447 retroperitoneal lymph node dissections performed from 1982 to 1994, to identify patients who had postoperative neurological complications. The history and clinical course of patients suspected to have spinal cord ischemia were reviewed and potential risk factors were analyzed. RESULTS: The incidence of spinal cord ischemia after post-chemotherapy retroperitoneal lymph node dissection was 0.56% (4 of 712 patients). CONCLUSIONS: Spinal cord ischemia may complicate the course of post-chemotherapy retroperitoneal lymph node dissection in testis cancer patients. Older age, extensive retroperitoneal dissection, prior therapy and certain anesthetic parameters may predispose nonseminomatous germ cell tumor patients to spinal cord ischemia. These risk factors may be used to define a subset of high risk patients, and active measures should be taken in an attempt to minimize the frequency of spinal cord ischemia in these patients.

Adult↗