RETROPERITONEAL LAPAROSCOPIC LYMPH NODE DISSECTION FOR STAGING NON-SEMINOMATOUS GERM CELL TUMORS BEFORE AND AFTER CHEMOTHERAPY

Abstract

We describe our experience with laparoscopic retroperitoneal lymph node dissection in 19patients with non-seminomatous germ cell tumors. Twelve patients had stage I disease with noclinical evidence (CT-scan, ultrasound, tumor markers) of metastases; 7 patients (stage IIb=2,stage IIc=5) had residual tumor after chemotherapy but with negative tumor markers. Alaparoscopic dissection was used to assess more fully the pathologic status of the relevantretroperitoneal lymph nodes of both groups. The patient was positioned and trocars introducedat sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position, fiveports - 3x10mm; 2x5mm). After reflecting the colon anteromedially, the landmarks of the lymphnode dissection were isolated namely the ureter, aorta, inferior vena c ava, and both renalveins. The lymph node dissection included the paracaval, interaorto-caval, upper preaortic, andright common iliac zonal nodes for right-sided tumors, and paraaortic, upper preaortic zones forleft-sided tumors. Retrieval of the lymph nodal chains was accomplished using a small organbag.The mean duration of the procedure was 298 (range 150-405) minutes. In only one patientwas a lymph node positive for tumor (stage I) or showed extensive necrosis (after chemotherapy).No intraoperative complications were encountered but three patients developed a delayedcomplication (ureteral stenosis, pulmonary embolism, and retrograde ejaculation, respectively).Whereas we completed the dissection in each patient with stage I tumors, the laparoscopicprocedure was more difficult in patients with stage II tumors after chemotherapy. In two patientswith stage IIb disease laparoscopic lymphadenectomy was successful. In four other patients partsof the dissection had to be done after conversion to an open (conventional) operation using asmall incision (suprainguinal or pararectal); in one patient the laparoscopic approach wasabandoned and converted to an open operation. In the post-chemotherapy group the outcomedepended primarily on the tumor bulk prior to drug treatment. In two patients in whom allresidual necrotic tissue was removed laparoscopically they had "minor" disease (stage IIb); theothers had stage IIc tumors.Our preliminary experience suggests that a modified laparoscopic lymph node dissection isfeasible for stage I tumors and in selected patients with marker negative residual tumor afterchemotherapy (stage IIb)