Reoperative Retroperitoneal Surgery

doi:10.1016/j.ucl.2007.02.008

Urologic Clinics of North America

Volume 34, Issue 2, May 2007, Pages 227-233

https://doi.org/10.1016/j.ucl.2007.02.008 Get rights and content

Although RPLND is both a diagnostic and therapeutic procedure, it must be performed with therapeutic intent. Adequacy of initial RPLND is a prognostic variable for clinical outcome. Effective cisplatin-based chemotherapy will not reliably compensate for suboptimal initial surgery. Many patients undergoing either primary RPLND or PC-RPLND will have unresected extratemplate disease if modified templates are used. Anatomic mapping studies, which provided the basis for modified templates, have significant limitations. Teratomatous elements are often found in the retroperitoneum of patients requiring reoperative surgery, which can be performed with acceptable morbidity in tertiary centers with experienced surgeons. The integration of chemotherapy and reoperative surgery can result in survival rates of almost 70% in patients with retroperitoneal relapse after initial suboptimal RPLND.

Section snippets

Testicular tumors and patterns of metastasis

One feature of testis GCTs that has significantly affected its successful management is the predictable and systematic pattern of metastatic spread from the primary site to the retroperitoneal lymph nodes and subsequently to the lung and posterior mediastinum [8], [9]. Lymphatic spread is common to all histologic subtypes of GCT, although choriocarcinoma often metastasizes hematogenously [9]. Anatomic studies in the early 1900s identified the primary lymphatic drainage of the testis to the area

Retroperitoneal lymph node dissection

There are several reasons to treat the retroperitoneal lymph node in patients with testicular cancer. First, based on the results of RPLND and surveillance series, the retroperitoneum is the initial and often only site of metastatic spread in up to 90% of patents with GCT [9], [13]. Second, accurate clinical staging of the retroperitoneum continues to have an approximately 30% error rate despite improved radiographic imaging [9]. Third, untreated retroperitoneal lymph node metastases are

Retroperitoneal relapse after RPLND

Although tumor recurrence in the retroperitoneum after RPLND is rare, unresected retroperitoneal disease appears to be an underestimated and, consequently, underreported phenomenon. There are several reasons that may explain this apparent discrepancy. First, the use of postoperative cisplatin-based chemotherapy may eliminate occult micrometastatic disease. Second, routine postoperative CT scanning is not routinely performed for follow-up after RPLND, with many centers relying on chest

Modified templates and retroperitoneal mapping studies

In 1988 Jewett and Torbey [31] stated that “all modified dissections introduce a risk of incomplete resection of involved nodes.” In general, ipsilateral lymph nodes are resected between the level of the renal vessels and the bifurcation of the common iliac artery, contralateral dissection is limited or omitted, and interartocaval nodes are variably resected for left-sided primary tumors [8]. All modified RPLND templates limit dissection in anatomic regions felt to be at reduced risk for

Clinical implications of incomplete surgical resection

Several investigators have clearly and consistently shown the prognostic significance of complete resection of retroperitoneal disease [3], [7]. Stenning and colleagues [35] reported that the risk of disease progression for patients without complete resection of all residual masses was approximately four times the risk for those with complete resection [35], [36].

Data from Indiana University and more recently, MSKCC, clearly show that patients requiring reoperative retroperitoneal surgery are

Morbidity of reoperative surgery

Reoperative retroperitoneal surgery can be a technically demanding procedure because of extensive adhesions and significant desmoplastic reaction secondary to prior surgery and chemotherapy, and extravasated blood and/or lymphatic fluid. In 1993, Waples and Messing [41] described nine patients undergoing extensive reoperative retroperitoneal surgery and reported a mean anesthetic time of 9.5 hours and mean blood loss of 6.3 L. Perioperative complications occurred in five (56%) patients and

Summary

Although RPLND is both a diagnostic and therapeutic procedure, it must always be performed with therapeutic intent. An uncontrolled retroperitoneum can result in late relapse, reoperative surgery, and compromised clinical outcome.

Incomplete resection of metastatic retroperitoneal disease has been shown to be a significant and independent adverse prognostic variable for patients with NSGCT. A substantial proportion of patients undergoing primary RPLND and PC-RPLND will have unresected

Acknowledgment

This work is supported by the Craig Tifford Foundation and the Fred S. Strauss Fund.

The authors gratefully acknowledge the expert assistance of Asha D. Mathew.

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In the Indiana series, 97.5% of patients received chemotherapy before reoperative retroperitoneal surgery.9 The most common histologic finding in the reoperative setting is teratoma (or teratoma with malignant transformation [TMT]), which makes intuitive sense given that most reoperative retroperitoneal surgeries are performed following chemotherapy, either before the initial RPLND or following it, and teratoma is considered chemotherapy resistant (Table 2).2,4,9,40 Although it is a histologically benign entity, the clinical potential of unresected teratoma is unpredictable; it may grow, obstruct, or invade adjacent structures in what has been called growing teratoma syndrome.37
Reoperative retroperitoneal lymph node dissection for metastatic germ cell tumors: Analysis of local recurrence and predictors of survival
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Citation Excerpt :
This finding reveals the therapeutic role of reoperative RPLND in this setting by showing that patients with retroperitoneal disease can achieve surgical cure. However, it does not invalidate the concept that adequate initial resection may potentially avoid a great proportion of these recurrences.5,9 This study has several limitations and most are related to study design.
While reoperative retroperitoneal lymph node dissection results in durable long-term survival, outcomes are comparatively worse than in patients who undergo initial adequate resection. We identified predictors of cancer specific survival and correlated technical aspects of initial resection to local recurrence in patients treated with repeat retroperitoneal lymph node dissection.
We reviewed subsequent data on 203 patients treated with reoperation for recurrent retroperitoneal germ cell tumor after initial retroperitoneal lymph node dissection with local relapse. We used multivariate Cox proportion hazard models for cancer specific survival and multivariate logistic regression for local recurrence.
The only 2 factors associated with local recurrence at lymph node dissection were incomplete lumbar vessel division at initial resection (p <0.01) and teratoma histology in the reoperative pathology specimen (p = 0.01). Median followup was 73 months. Initial survival analysis including preoperative variables indicated that active cancer at initial operation (p = 0.04), increased serum tumor markers (p = 0.02), M1b stage (p <0.01) and salvage chemotherapy (p = 0.01) were independent predictors of worse cancer specific survival. After introducing the final pathological data from reoperation into the final multivariate model only active cancer at reoperation (p <0.01), M1b stage (p = 0.01) and salvage chemotherapy before reoperation (p = 0.02) retained the association with worse oncologic outcomes.
Tumor biology and inadequate surgical technique (incomplete lumbar ligation) are associated with local recurrence after initial retroperitoneal lymph node dissection. Decreased cancer specific survival is expected in this population, mostly driven by active cancer in the final pathology specimen.
Sequelae of treatment in long-term survivors of testis cancer
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Testicular cancer patients are often diagnosed at a young age, and because of the advances in the treatment of this disease, the vast majority have a normal life expectancy after therapy. Thus, recognition of the long-term sequelae of treatment (ie, surgery, radiation therapy, and chemotherapy) is particularly important in these patients.
To review the adverse effects and the risk of secondary malignancy in long-term survivors of testicular cancer.
We conducted a Medline search to identify original articles and reviews on the long-term effects of testicular cancer treatment. Although the search included articles from January 1948 to February 2011, the majority of the included articles were published in the last two decades.
All studies examining the long-term sequelae of treatment in testicular cancer are retrospective in nature, with most classified as cohort, case-control, and/or epidemiologic studies. Given that no standardized method of reporting long-term complications exists, evidence synthesis is limited.
Recent evidence suggests an increased risk of cardiovascular disease, neurotoxicity, and mild reductions in renal function in survivors of testicular cancer. Treatment of testicular malignancy can also negatively affect gonadal function and fertility and has been shown to result in an increased risk of solid malignancy and leukemia.
Complications of lymphadenectomy
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Population-based Study of Perioperative Mortality After Retroperitoneal Lymphadenectomy for Nonseminomatous Testicular Germ Cell Tumors
2009, Urology
To determine whether retroperitoneal lymphadenectomy (RPLND) perioperative mortality (PM) rates reported from a center of excellence (Indiana University: 0% for primary and 0.8% for postchemotherapy RPLND) are applicable to institutions at large.
We used the data from 882 assessable patients with nonseminomatous testicular germ cell tumor treated with RPLND from 1988 to 1997 accessed from the Surveillance, Epidemiology, and End Results (SEER) database. These data did not include data from Indiana University. The observed PM rates were stratified according to age and SEER stage.
The median age at RPLND was 29 years. Of the 882 cases, 435 (49.3%) were performed for localized (Stage I), 380 (43.1%) for regional (Stage II), and 67 (7.6%) for metastatic (Stage III) SEER stage. Of the 882 patients, 7 patients died during the initial 90 days after RPLND, for a 0.8% PM rate. PM increased with increasing age: ≤29 years, 0.0%; 30-39 years, 1.3%; and ≥40 years, 2.7% (χ² trend test, P = .002). PM also increased with increasing stage: 0.0% for localized, 0.8% for regional, and 6.0% for metastatic disease (χ² trend test, P < .001).
RPLND is associated with virtually no or low PM in patients with localized and regional disease. The PM rates for these 2 groups replicated those of Indiana University. In contrast, the PM rate of 6% for patients with distant metastases implies that RPLND for these higher risk patients should ideally be performed at centers of excellence, with the intent of reducing the PM rate.
Retroperitoneal lymph node dissection after chemotherapy
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Reoperative Retroperitoneal Surgery

Section snippets

Testicular tumors and patterns of metastasis

Retroperitoneal lymph node dissection

Retroperitoneal relapse after RPLND

Modified templates and retroperitoneal mapping studies

Clinical implications of incomplete surgical resection

Morbidity of reoperative surgery

Summary

Acknowledgment

Urology

J Urol

J Urol

J Urol

Urology

J Urol

J Urol

Urology

Urology

J Urol

J Urol

J Urol

J Urol

J Urol

J Urol

Treatment of patients with testis cancer: introduction

Urol Oncol

The role of adjuvant post-chemotherapy surgery for nonseminomatous germ cell tumors: current concepts and controversies

Semin Urol Oncol

Therapeutic efficacy of laparoscopic RPLND: unproved and untested

Am J Urol Rev

Late relapse of testicular cancer

J Clin Oncol

Integration of surgery and systemic therapy: results and principles of integration

Semin Urol Oncol

Surgery of testicular tumors

The role of retroperitoneal lymph node dissection in the management of testicular cancer

Urol Oncol