EURURO Vol. 72 No. 5

815 860

1. Introduction
Testicular GCT remains the most common solid organ
malignancy in young males, and its incidence has increased
over the past 20 yr With the current multimodal
treatment algorithms, overall survival rates exceed 95%
. This is largely attributable to the advent of cisplatin-
based therapy 40 yr ago, as well as refinement of surgical
indications and technique. The challenge in this young and
otherwise healthy patient population is minimization of
treatment morbidity, which must be viewed cumulatively
over many decades.
We previously described our novel approach to retro-
peritoneal lymph node dissection (RPLND) via a midline
incision that is completely extraperitoneal . This ap-
proach was initiated as an attempt to minimize the
perioperative and long-term complications associated with
entering the peritoneal cavity, and we demonstrated in a
small initial series that it afforded faster return of bowel
function and shorter length of hospital stay (LOS) without
compromising exposure or the ability to complete a full
node dissection, even in the postchemotherapy (PC) setting.
Here we describe our updated series, review the specifics of
the technique, and report on our outcomes.
2. Patients and methods
2.1. Study population
All patients were from an institutional review board–approved testis
cancer database with prospectively collected data. From 2004 to 2015,
169 patients underwent RPLND (135 PC, 34 primary). As of 2010, all
patients were considered for EP-RPLND except for men undergoing
aortic resection, retrocrural dissection, or intraperitoneal resection
(exclusion criteria). Of the remaining 122, some 69 consecutive patients
underwent EP-RPLND using a midline incision; one patient was
converted to transperitoneal (TP) RPLND because of failure to progress
). Primary cases underwent extended ipsilateral templates; PC
cases underwent either full bilateral or extended ipsilateral templates
according to validated criteria
2.2. Surgical technique
2.2.1. Preoperative preparation and positioning
Patients do not undergo bowel preparation. Heparin prophylaxis is
administered within 1 h before incision. The patient is positioned supine
in a slightly hyperextended position.
2.2.2. Incision and separation of the peritoneum
A midline abdominal incision is made ) from several centimeters
below the xiphoid process (approximating the level of the renal hilum)
to 4–5 cmbelow the umbilicus (approximating the level of the ipsilateral
common iliac artery).
Beginning in the infraumbilical portion of the incision, where
separation of the peritoneum from the fascia is easier, the anterior and
posterior rectus fascias are incised ), and the extraperitoneal
space between the peritoneum and the transversalis fascia is developed
with gentle blunt and sharp dissection.
The peritoneal sac is swept medially off the inferolateral abdominal
wall on the ipsilateral side of the planned dissection, aiming towards the
ipsilateral psoas muscle ).
Care is taken to avoid inadvertent opening of the peritoneum,
especially anteriorly where it becomes thin. Fibrous strands between the
peritoneum and abdominal wall can be taken down sharply to help
prevent tearing of the peritoneum.
2.2.3. Entering the retroperitoneal space
As the peritoneal envelope is peeled off the posterior muscles in the
lower quadrant, retroperitoneal fat will be encountered. The edge of the
sac is peeled back from this and confirmed by visualization of the psoas
muscle D).
2.2.4. Ureteral identification
The ureter and gonadal vessels are visualized along the psoas A),
and this plane is traced superiorly. The sac is separated from the
posterior ribs and then mobilized medially off of Gerota’s fascia.
Often some part of the fat of Gerota’s fascia will be medialized with
the peritoneum, which can be helpful in avoiding entering the sac, and
allows exposure to the renal parenchyma, which aids in ruling out
vascular compromise of the kidney during the case. Of note, the
attachments of the sac just below the liver (right-sided template) and
just below the spleen (left-sided template) can be quite fibrous, and
great care should be taken to avoid peritoneotomy in these difficult-to-
repair areas. Completely freeing the upper pole of the kidney off of the
overlying peritoneum is the safest way to accomplish this B).
2.2.5. Visualization of the great vessels
In the post-chemotherapy setting, ipsilateral residual masses are often
readily visible or palpable at this point. The peritoneal sac at this point is
typically easy to medialize further, stopping once the contralateral renal
hilum is reached. A self-retaining retractor is placed to retract the
abdominal wall and the peritoneal sac ).
Table 1 – Demographic data and perioperative outcomes
Parameter (n = 68) Result
Age (yr) 28 (17–55)
Follow-up (mo) 15.3 (5.7–24.3)
Extraperitoneal retroperitoneal lymph node dissection 68/69 (98.6)
Primary 27 (39.7)
Nonseminomatous germ cell tumor 27 (100)
Stage I 7 (25.9)
Stage IIA 17 (63)
Stage IIB 1 (3.7)
Stage IIC 2 (7.4)
Post-chemotherapy 41 (60.3)
Nonseminomatous germ cell tumor 37 (90.2)
Seminomatous germ cell tumor 4 (9.8)
Retroperitoneal mass or lymphadenopathy on
preoperative imaging (cm)
2.2 (1.3–5.5)
0 cm 6 (8.9)
<2 cm 23 (33.8)
2–4.9 cm 15 (22.1)
5–10 cm 5 (7.6)
>10 cm 19 (27.9)
Intraoperative outcomes
Estimated blood loss (ml) 325 (200–612.5)
Packed red blood cells transfused (units) 0 (0–7)
Lymph node yield (n) 36 (24.5–49)
Positive lymph nodes (n) 1 (0–4)
Postoperative outcomes
Return of bowel function (d) 2 (1–2)
Length of stay (d) 3 (3–4)
Data are presented as median (interquartile range) for continuous
variables and as n (%) for continuous variables.
a Range.
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 0 815