814 860
Surgery in Motion
Midline Extraperitoneal Approach to Retroperitoneal Lymph Node
Dissection in Testicular Cancer: Minimizing Surgical Morbidity
Sumeet Syan-Bhanvadia, Soroush T. Bazargani, Thomas G. Clifford, Jie Cai, Gus Miranda,
Siamak Daneshmand
*USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 8 1 4 – 8 2 0available at
www.scienced irect.comjournal homepage:
www.europeanurology.comArticle info
Article history:
Accepted February 14, 2017
Associate Editor:
Alexandre Mottrie
Keywords:
Testis cancer
Retroperitoneal lymph node
dissection
Extraperitoneal
Germ cell tumor
Nonseminomatous germ cell
tumor
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Abstract
Background:
Retroperitoneal lymph node dissection (RPLND) is an important compo-
nent of the management of testicular germ cell tumor (GCT) but carries significant
surgical morbidity.
Objective:
To describe our experience with a midline extraperitoneal (EP) approach to
RPLND for seminomatous and nonseminomatous GCT.
Design, setting, and participants:
From 2010 to 2015, 122 consecutive patients under-
went RPLND from a prospective database. Patients requiring aortic resection or retro-
crural dissection or with intraperitoneal disease were excluded. The remaining
69 patients underwent midline EP-RPLND.
Surgical procedure:
Open midline EP-RPLND was performed using a standardized
technique.
Outcome measurements and statistical analysis:
Perioperative and long-term outcomes
were analyzed. Complications were graded using the Clavien-Dindo classification. A
descriptive analysis using SAS software was performed.
Results and limitations:
A total of 68 patients underwent midline EP-RPLND success-
fully (98.6%). The median age was 28 yr (range 17–55). On preoperative imaging the size
of the retroperitoneal mass or lymphadenopathy was
<
2 cm in 29 patients, 2–4.9 cm in
15 patients, and
>
5 cm in 24 patients, of which 19 were
>
10 cm. The median estimated
blood loss was 325 ml (interquartile range [IQR] 200–612.5). The median number of
lymph nodes resected was 36 (IQR 24.5–49); the median number of positive nodes was
one (IQR 0–4). The median time for return of bowel function was 2 d (IQR 1–2) and
hospital stay 3 d (IQR 3–4). There were no cases of ileus. Eleven patients had 12 (17.6%)
90-d complications. Of these, six (55%) were Clavien grade 1, five (45%) were grade 2, and
one was grade 3b (1.5%). Antegrade ejaculation rates were 91.6% in the primary group
and 96.8% in the post-chemotherapy group.
Conclusions:
Midline EP-RPLND can be performed safely without compromising the
completeness of the resection. This approach is associated with rapid return of bowel
function, minimal rates of ileus, and short hospital stay.
Patient summary:
A midline extraperitoneal approach for retroperitoneal lymph node
dissection in testicular cancer is safe and effective and leads to faster return of bowel
function and earlier discharge.
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2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. USC Institute of Urology, Keck School of Medicine, University of Southern
California, 1441 Eastlake Avenue, Los Angeles, CA 90033-9178, USA. Tel. +1 323 8653700;
Fax: +1 323 8650120.
E-mail address:
daneshma@usc.edu(S. Daneshmand).
http://dx.doi.org/10.1016/j.eururo.2017.02.0240302-2838/
#
2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.