Isao Hara md, Division of Urology, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Email: email@example.com
Aim: To evaluate the feasibility and usefulness of extraperitoneal laparoscopic retroperitoneal lymph node dissection (RPLND) in the supine position after chemotherapy for advanced testicular carcinoma
Methods: Three patients with advanced testicular cancer underwent chemotherapy. Although serum markers were decreased compared with the normal range, residual masses requiring surgical resection were recognized by computed tomography scanning. We applied extraperitoneal laparoscopic RPLND. The patients were placed in the supine position and the first trocar was inserted two finger widths medial to the anterior iliac spine. The retroperitoneal space was dilated using a preperitoneal distention balloon. Two more ports were inserted into the retroperitoneal space and surgery proceeded thereafter.
Results: The residual tumors were completely resected by laparoscopy. The procedure required 250–310 min and the bleeding volume was below 50 mL. Although the histopathological findings consisted only of necrosis in all of the patients, one patient recurred at the same place.
Conclusions: Extraperitoneal laparoscopic RPLND in the supine position for residual tumors after chemotherapy is technically feasible and useful in terms of postoperative recovery. With regard to cancer control, further evaluation should be necessary.
Laparoscopy has become a standard urogenital procedure. Most urogenital malignancies, including renal cell carcinoma,1 prostate cancer2 and bladder cancer,3 can be treated using a laparoscopic approach. Retroperitoneal lymph node dissection (RPLND) for testicular cancer is an important treatment modality, not only for patients with stage I or IIa disease, but also for those with residual tumors after chemotherapy. Although the indication for RPLND in treating stage I or IIa patients remains controversial, the feasibility and usefulness of laparoscopic RPLND for such patients has been reported by several urologists.4–6 However, the usefulness of laparoscopic RPLND for residual tumors after chemotherapy is still under investigation due to the difficulty of the surgical procedure. On the other hand, a novel approach to extraperitoneal laparoscopic RPLND has been described.6 This technique has some specific advantages over the standard peritoneal laparoscopic RPLND. We used the LeBlanc approach to remove residual retroperitoneal masses after extensive chemotherapy and examined the clinical outcome of the procedure for patients with germ cell tumors after chemotherapy.
Materials and methods
A 22-year-old man with a left burned-out testicular tumor showed retroperitoneal lymph node swelling of 4.6 cm in diameter and elevated serum tumor markers, alpha fetoprotein (AFP) and beta human chorionic gonadotropin (β-hCG, 12.4 and 97.4 ng/mL, respectively). The patient underwent three courses of PEB (CDDP, Etoposide and Bleomycin) therapy,7 followed by one course of Super High Dose Chemotherapy (SHD) combined with Peripheral Blood Stem Cell Transplantation (PBSCT).8 The tumor marker levels decreased to the normal range after SHD and the retroperitoneal lymph node swelling diminished to 1.5 cm in diameter. Although we recommended retroperitoneal lymph node dissection (RPLND), the patient refused and was followed up as an outpatient. During the follow up, the AFP level increased to 38 ng/mL. Two courses of PE (cisplatin, etoposide) therapy brought this level to within the normal range. Two additional courses of PEB therapy were administered, but the size of the retroperitoneal lymph node did not change. The patient underwent extraperitoneal laparoscopic RPLND of the residual mass (Fig. 1).
A 20-year-old man with left pure seminoma presented with metastases in the retroperitoneal, mediastinal and left subclavicular lymph nodes, as well as in the lung. The tumor markers, AFP, β-hCG and Lactate dehydrogenase (LDH), were all elevated at 11.3 ng/mL, 7.3 ng/mL and 778 IU/l, respectively. Four courses of PEB therapy caused the tumor markers to decrease to within the normal range and all metastatic lesions except for RPLN completely disappeared. Since only the RPLN had not changed from 4 cm, we performed extraperitoneal laparoscopic RPLND (Fig. 2).
A 27-year-old man presented with right testicular cancer containing teratoma and yolk sac tumor. A retroperitoneal lymph node swelling of 5.2 cm in diameter and multiple lung metastases were identified at that time. The serum concentrations of AFP and β-hCG were 512 and 440 ng/mL, respectively. Three courses of PEB therapy were followed by one course of SHD combined with PBSCT. Although the tumor markers reached normal range after SHD and the metastatic lesions partially responded, the lung metastases and RPLN remained. The metastatic lung lesions were resected as much as possible and the histological diagnosis was simple necrosis. The size of the RPLN reduced to 1.5 cm after chemotherapy and extraperitoneal laparoscopic RPLND was performed.
The patients were placed in the supine position. An incision of approximately 15 mm was made ipsilateral to the tumor 3 cm medial to the anterior iliac spine. The fascia of the external oblique muscles was cut and the internal oblique and transverse muscles were then bluntly divided. The retroperitoneal space was developed by inflating a preperitoneal distension balloon (PDB) under observation with a 0-degree video laparoscope. After removing the PDB, an 10-mm blunt port with a balloon was inserted. A second 11-mm trocar was introduced under direct vision in the flank on the midaxillary line at naval height. Peritoneum reflection was bluntly dissected to the medial direction as much as possible to introduce a third 5- or 11-mm trocar just below the subcostal margin at the external clavicular line (Fig. 3). At this step, damage to the peritoneum must be avoided.
The first and/or second port was used for a videoscope. In principle, surgeons use bipolar forceps in the left hand and a cavitational ultrasonic surgical aspirator or electronic scissors in the right. A device for washing and aspiration was also used. We developed the retroperitoneal space medially above the psoas muscle until the ipsilateral great vessel can be recognized. The ureter and the gonadal vein should be attached to the peritoneum. Since we applied this technique to patients with advanced testicular cancer whose serum markers were normalized after intensive chemotherapy, we did not follow the classical template of retroperitoneal lymph node dissection.9 The indication of RPLND after chemotherapy is residual masses over 1 cm in non-seminoma and over 3 cm in seminoma. When a tumor was isolated and localized outside the great vessel, we performed unilateral RPLND. The ipsilateral great vessel was dissected between bifurcation and the renal vessels. However, when tumors were localized in the interaorticocaval space, the ipsilateral great vessel between the bifurcation and renal vessels and the interaorticocaval space between renal vessels and the inferior mesenteric artery were dissected. In the present case, we did not dissect the contralateral great vessel. If residual masses were observed at both sides of the great vessels, we did not apply the laparoscopic technique. When the contralateral side is reached, the intraperitoneal space is lifted above due to pneumatic pressure, which leads to a clear view of the retroperitoneal space. The presence of the bowel can be discounted. Tumor adhesion to adjacent organs is extremely severe after chemotherapy, so care is required when dissecting the tumor and great vessels.
After removing the tumors, we dissected the gonadal vessels by freeing them from the posterior peritoneum and cutting just below the left renal vein or vena cava. We then dissected the vessels until the internal inguinal ring. The gonadal vessels below the internal inguinal ring had been resected at the orchiectomy. The resected tumors and gonadal vessels were placed in an endoscopy bag and extracted through the iliac port.
The operative time was 255–310 min and the volume of blood loss was below 50 mL. Specimens weighed from 10 to 30 g and histopathological findings revealed that all of them were simply necrotic. All of the patients could walk on post operative day (POD) 1 and eat meals on POD 1–2. All were discharged from hospital without major complications. One patient developed chylorrhea from the drainage tube after surgery, but this was improved by a low fat diet. Sexual function and normal ejaculation were preserved in all the patients. Although two patients showed no evidence of disease 12 months after the operation, patient 1 recurred at the paraaortic lesion where the tissue was supposed to be completely resected. He also showed an elevation of AFP (83 ng/mL). He is to have chemotherapy or re-operation as soon as possible.
Progress in the treatment of testicular cancer is remarkable. First of all, the introduction of anti-cancer drugs such as cis-platinum and etoposide was epochal. Thanks to these drugs, approximately 70–80% of patients with testicular cancer metastasis can be cured.7 However, curing the remaining 20–30% of patients who are refractory to standard chemotherapy is difficult. Thus, a second line of chemotherapy for those patients is now under investigation. Dose escalated chemotherapy with bone marrow support8,10 or new anti-cancer agents, such as taxol or gemcitabine, show promise.
While surgery for testicular cancer has not remarkably improved, the importance of surgery cannot be over-emphasized. Although RPLND is the standard procedure for treating testicular cancer, it can also be applied in the following ways. Firstly, RPLND is applied to patients with stage I or IIa non-seminomatous germ cell tumors. In this situation, surgeons should resect a specific area according to a template to preserve sexual functions, especially those of ejaculation and erection.11 However, not all institutions apply RPLND to patients with stage I non-seminomatous germ cell tumors. A surveillance policy is the other option, because standard chemotherapy can cure 100% of patients with stage I disease that recurred during follow-up. Therefore, no definite treatment policy has been established for patients with stage I non-seminomatous tumors.12
Secondly, RPLND can resect tumors that remain after chemotherapy. General consensus states that a specific volume of residual tumor (non-seminoma, >1–2 cm; seminoma, >3 cm) after chemotherapy should be removed by surgery. Normalization of tumor markers is necessary before performing RPLND. The expected pathological findings are necrotic tissue, teratoma or viable cancer tissue. Only viable cancer tissue would require further chemotherapy. Therefore, RPLND after chemotherapy has significant relevance concerning not only the diagnosis, but also the treatment of patients with testicular cancer. The resection area for RPLND after chemotherapy has been controversial. Originally, complete bilateral resection was considered necessary.13,14 However, others have proposed excising the only the residual tumor.15–17 In the present study, the residual masses were not large and patients hoped for normal ejaculation. However, sparing nerves during RPLND after extensive chemotherapy seems to be virtually impossible due to extreme adhesion. Therefore, we followed the resection area according to Oldenburg et al.18 When a tumor was isolated and localized outside the great vessel, we performed unilateral RPLND. The ipsilateral great vessel was dissected between bifurcation and the renal vessels. When tumors are localized at the interaorticocaval space, the ipsilateral great vessel between bifurcation and renal vessels and the interaorticocaval space between renal vessels and inferior mesenteric artery were dissected. In the present case, we did not dissect the contralateral great vessel. If the tumor size is not large, these areas are thought to be sufficient for cancer control. Histopathological findings revealed that all of them were simply necrotic. However, we experienced one local recurrence. In this patient, we completely resected the left side of aorta and histology showed necrosis only. It seems to be very curious that recurrence occurred at the same place. We can not explain whether this recurrence was caused by the laparoscopic procedure, an insufficient area of dissection or the nature of the tumor. Further evaluation should be necessary to answer this question. Laparoscopic RPLND has been attempted in some institutes, mostly to treat stage I-testicular cancer.4–6 Open RPLND is a fairly invasive operation with a large skin incision and retrograde ejaculation is major complication. Bowel ileus due to adhesion is another concern. Since most patients are young and more than half of the stage I patients did not need RPLND, incidences of these complications must be minimized. From this viewpoint, laparoscopic procedure for RPLND seems to be rational. A magnified fine view facilitates the identification of nerves.
A few authors have described laparoscopic RPLND for patients after chemotherapy.5,19 However, Rassweiler et al. reported that laparoscopic RPLND could be performed in only two of eight patients with stage IIb disease because of dense desmoplastic reactions around the aorta and vena cava. In conclusion, they recommended laparoscopic RPLND for stage I or IIa tumors, but not for more than IIb after chemotherapy. In contrast, Janetschek et al. applied a laparoscopic procedure to patients after chemotherapy and found that unilateral RPLND was feasible and not any more surgically complex than laparoscopic RPLND for stage I patients.4
To develop the retroperitoneal space is crucial in obtaining a wide surgical view during laparoscopic RPLND. However, the surgical view can be limited by the transperitoneal approach. In this procedure, the approach can be from the unilateral side. To solve this problem, LeBlanc et al. described extraperitoneal laparoscopic RPLND in the supine position.6 Since this technique approaches from the back, the intraperitoneal space is lifted by pneumatic pressure, resulting in a good view around the great vessels. They applied this technique to 25 testicular cancer patients with clinical stage I or IIa and obtained an excellent outcome. This technique was originally derived from para-aortic lymph node dissection for staging cervical cancer in gynecology patients.20 Recently, Hsu et al. also reported the anterior extraperitoneal approach to laparoscopic retroperitoneal lymph node dissection for a stage I non-seminomatous germ cell tumor patient.21 The basic principle of their techniques seems to be similar. We applied this technique to post-chemotherapy patients. We believe that the excellent view without bowel mobilization offered a substantial advantage in the technically difficult procedure.
We have demonstrated that extraperitoneal RPLND in the supine position resulted in an excellent surgical outcome, improved postoperative recovery, despite the small number of patients, and offers a short follow up. Although histopathological findings were all necrotic tissue, we experienced one local recurrence at the resected area. Further experience will clarify the advantages and disadvantages of this surgical procedure.