Endovascular aortic protection prior to retroperitoneal lymph node dissection for testicular cancer

In some cases of metastatic testicular cancer (MTC), retroperitoneal lymph node dissection (RPLND) is indicated after cisplatin-based chemotherapy. 1 The incomplete resection of residual lymph nodes has been associated with decreased disease-speci ﬁ c survival. 2 However, there have been cases in which lymph node dissection in large vascular areas has resulted in injury requiring blood transfusions. 3 Although intra-and postoperative bleeding can be associated with serious adverse outcomes, no effective prophylactic procedures have been reported for vascular injury in RPLND. In this study, endovascular aortic protection (EVAP) was performed in advance of post-chemotherapy RPLND (PC-RPLND) in several patients.


Editorial Comment Editorial Comment to Survival beyond cabazitaxel for metastatic castration-resistant prostate cancer
The authors reported the survival beyond cabazitaxel for metastatic castration-resistant prostate cancer (mCRPC). 1 In this report, real world data showed that the prognosis was better if any treatment for mCRPC was administered after cabazitaxel.Especially, patients who received first-line androgen receptor signaling inhibitors (ARSI), radium-223, olaparib or docetaxel rechallenge after cabazitaxel presented longer OS than those who did not receive subsequent therapy or other treatments with alternative ARSI or estrogen. 1Similar reports have been relatively rare, and this report is clinically meaningful.
Recently, the landscape for mCPRC therapy has rapidly evolved with the approval of several agents including ARSIs such as abiraterone, enzalutamide, and darolutamide, taxanes such as docetaxel and cabazitaxel, and radium-223. 2 However, no randomized controlled trial comparing these treatments has existed, thus the optimal treatment sequence remains unknown.The European Association of Urology and National Comprehensive Cancer Network guidelines do not clearly state an optimal sequence for mCRPC treatments. 2 The Card trial showed that mCRPC patients with cabazitaxel after first-line ARSI and docetaxel showed better progression-free survival and overall survival (OS) than those with the second-line ARSI. 3 On the other hand, few reports exist, especially regarding post-cabazitaxel therapy.An Australian study showed longer OS in patients who received subsequent treatment beyond cabazitaxel than in those without further therapy after cabazitaxel. 4This difference in OS can be explained by the survival benefit of effective treatment even after cabazitaxel and has an important clinical meaning in the management of patients with mCRPC.This finding is supported by recent evidence from the VISION trial, which revealed survival benefit of 177Lu-PSMA-617 after taxanes including cabazitaxel. 5Therefore, further research is required to know the role of each agent after cabazitaxel to prolong OS.
This study was retrospective, and 36 cases were not sufficient.The variety of post-cabazitaxel treatments made interpretation regarding OS improvements difficult.It is necessary to consider the possibility that patients who could undergo any post-cabazitaxel therapies had relatively good general health and cancer status, which might have led to a favorable prognosis.However, it is generally challenging to obtain sufficient background factors in these late treatment line of postcabazitaxel.In the future, further evidence building is expected through the accumulation of cases at multiple centers in the absence of established post-cabazitaxel therapy.
In some cases of metastatic testicular cancer (MTC), retroperitoneal lymph node dissection (RPLND) is indicated after cisplatin-based chemotherapy. 1The incomplete resection of residual lymph nodes has been associated with decreased disease-specific survival. 2However, there have been cases in which lymph node dissection in large vascular areas has resulted in injury requiring blood transfusions. 3Although intra-and postoperative bleeding can be associated with serious adverse outcomes, no effective prophylactic procedures have been reported for vascular injury in RPLND.In this study, endovascular aortic protection (EVAP) was performed in advance of post-chemotherapy RPLND (PC-RPLND) in several patients.
After fully explaining the risks and benefits and obtaining written consent, three patients underwent EVAP followed by RPLND between November 2022 and August 2023.All were referred to our hospital for RPLND after receiving sufficient chemotherapy for clinical stage III disease at other hospitals.All tested negative for various tumor markers (Figure 1a).
EVAP was performed under general anesthesia and X-ray fluoroscopy 4-5 days prior to the RPLND.The device was inserted through the femoral artery, and the stent graft was placed in the aorta from the caudal side of the renal artery bifurcation to just above the aortic bifurcation.After placement, we confirmed a lack of endoleaks using contrast medium.We used a stent graft made of stainless steel and nitinol alloy (Endurant II â , Medtronic, Santa Rosa, CA, USA) Computed tomography images taken before chemotherapy initiation and after EVAP/RPLND in Patient 2 are shown in Figure 1b.
The only EVAP-associated complication was grade I fever according to the Clavien-Dindo classification in one patient.The extent of dissection was the full template in all cases.In Patient 2, strong adhesion was noted between the tumor and the aortic wall, and intraoperative injury to the aortic wall, which was repaired with minimal bleeding.In the other two cases, mild adhesions suspected to be due to stenting were also observed.The intraoperative blood loss volumes were 1257, 1550, and 1862 mL, respectively.The longest observation period was 9 months; however, no distant EVAP-related complications were observed.The patients' detailed perioperative information is shown in Figure 1c.
RPLND for MTC is preceded by EVAP to prevent fatal bleeding.Although a case series of aortic stenting prior to tumor resection has been reported in thoracic surgery, 4 there have been no reports in urologic surgery to the best of our knowledge.Intraoperative