1818.pdf 873Vol. 10 | No. 2 | Spring 2013 |U R O LO G Y J O U R N A L Urology and Nephrology Research Center; Department of Urology, Shahid Labbafine- jad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Abbas Basiri, Mohammad Ali Ghaed, Nasser Simforoosh, Ali Tabibi, Abdolkarim Danesh, Akbar Nouralizadeh, Mehdi Kardoust Parizi Is Modified Retroperitoneal Lymph Node Dissection Alive for Clinical Stage I Non-Seminomatous Germ Cell Testicular Tumor? Corresponding Author: Mohammad Ali Ghaed, MD Urology and Nephrology Research Center, No.103, 9th Boustan St., Pasdaran Ave., Tehran, Iran Tel: +98 21 2256 7222 Fax: +98 21 2256 7282 E-mail: basiri@unrc.ir Received December 2012 Accepted May 2013 Purpose: management of patients with pathological stage (PS) I non-seminomatous germ cell testicular tu- mor (NSGCT) in a retrospective study. Materials and Methods: Between April 2002 and April 2012, 55 patients with clinical stage (CS) - plate. Clinicopathological parameters, retroperitoneal relapse, and antegrade ejaculation rate were evaluated in patients with PS I. Results: Of 55 patients, 41 (74.5%) and 14 (25.5%) subjects were in PS I and II, respectively. In PS I group, the mean patients’ age was 32.8 years (range, 19 to 51 years) at the end of the follow-up period. Three patients missed the follow-up; hence, were excluded from the study. Mean follow-up at the end of the follow-up period. Overall peri and postoperative complication rate was 18% (7 pa- tients). Out of 38 patients, 23 (61%) had post RPLND antegrade ejaculation at the end of the study. Conclusion: with no retroperitoneal micrometastasis after the procedure. Furthermore, this strategy may obvi- ate the need for close, expensive, and potentially harmful follow-up protocol in patients with PS I NSGCT. Keywords: lymph node excision, testicular neoplasms, neoplasm metastasis UROLOGICAL ONCOLOGY 874 | INTRODUCTION Retroperitoneal lymph node dissection (RPLND) has been accepted as a diagnostic and therapeutic management for patients with non-seminomatous germ cell testicular tumor (NSGCT).(1,2) Conventional bilat- both the kidneys and the ureters down to the bifurcation of the common iliac arteries. This radical surgery may result in delayed restoration of the bowel function, prolonged hospital stay, and loss of antegrade ejaculation.(3) However, very low recurrence rate (less than 2%) after this bilateral procedure (4) Nerve-sparing RPLND involves preservation of sympathetic - latory morbidity is achieved and more than 95% of patients may have antegrade ejaculation. However, dissection along the aorta and inferior vena cava may result in vessel disrup- tion.(3,5) to limit contralateral dissection and accompany with faster patients’ recovery and preservation of antegrade ejaculation. (5) The potential risk of recurrence, due to unresected retro- peritoneal lymph nodes, is the major oncological concern (4) - ported as an unacceptable procedure for clinical stage (CS) I NSGCT.(4,6) - agement of CS I NSGCT. MATERIALS AND METHODS From April 2002 to April 2012, a total of 55 patients with - and no evidence of malignancy in the abdominopelvic com- puted tomography (CT) scan and chest X-ray (CXR) after initial orchiectomy. - peutic purpose. All the lymph nodes above the contralateral inferior mesenteric artery as well as ipsilateral lymph nodes between the kidneys, ureters, and common iliac bifurcation were resected. Post RPLND evaluation in patients with pathological stage (PS) I included blood tests (liver function test and serum lev- els of calcium, phosphorus, and alkaline phosphatase) and 4 to 6 months after RPLND and at the end of the follow-up period. Patients with PS II underwent post RPLND chemotherapy. (4,5) RPLND was assessed. Descriptive statistics for clinical and demographic characteristics of the patients are mentioned in other articles. Surgical Technique All of the 55 patients were operated on according to the nodes between the kidneys, ureters, and common iliac bifur- cations were resected except the contralateral lymph nodes below the inferior mesenteric artery. Therefore, in patients with right-sided tumor, pre-aortic, para-aortic, paracaval, pre- caval, interaortocaval, and right common iliac lymph nodes were resected. In patients with left-sided tumor, pre-aortic, para-aortic, precaval, interaortocaval, and left common iliac lymph nodes were resected (Figure). RESULTS Of 55 patients, 41 (74.5%) and 14 (25.5%) subjects were categorized in PS I and II, respectively. Pathological stage - neal lymph nodes after RPLND. The clinico-oncological outcomes were reviewed in patients with PS I. Three patients Urological Oncology Left and right modified retroperitoneal lymph node dissection template. 875Vol. 10 | No. 2 | Spring 2013 |U R O LO G Y J O U R N A L missed the follow-up, and were excluded from the study. The mean age of the patients was 32.8 years (range, 19 to 51 years) at the end of the follow-up period. Only one patient had a known risk factor for testicular tumor (undescending testis in the same side of the tumor). Table demonstrates clin- icopathological characteristics of 38 patients with PS I. Two laparoscopic surgeries needed conversion to open ap- proach due to great vessels injury in one subject and severe peri-operative bleeding in another. Overall peri and postop- erative complication rate was 18% (7 patients). Complica- tions included great vessels injury, peri-operative bleeding, incision site infection, and retroperitoneal hematoma that all were managed conservatively. Blood transfusion was needed in 3 patients due to postoperative hemoglobin drop. Mean follow-up duration was 56 months (range, 6 to 120 the end of the follow-up period. All the patients had nor- RPLND abdominal CT and CXR at the end of the follow-up period. Out of 38 patients, 23 (61%) had post RPLND ante- grade ejaculation at the end of the study. DISCUSSION Approximately, one-third of patients with NSGCT present with CS I, and optimal treatment for these patients is con- troversial. Various treatment modalities have been described, including surveillance, chemotherapy, and RPLND,(7-10) with (11) Retroperitoneal lymph node dissection results in excellent oncological outcomes in CS I; however, patients may suffer from surgical complications and loss of antegrade ejacula- tion.(12) RPLND and surveillance, it seems that surveillance should be performed in low-risk patients. Long-term follow-up in patients who undergo surveillance strategy requires more pa- tients’ compliance, greater expenses, and more X-ray expo- sure.(6) Surgical management of retroperitoneal lymph nodes information and also therapeutic advantages.(5) In the present study, incidence of retroperitoneal micrometas- tasis in patients with CS I NSGCT was 25.5% (14 patients) that was consistent with other studies.(13) This relatively high Clinicopathological characteristics of 38 patients with stage I non-seminomatous germ cell testicular tumor at orchiectomy and modified RPLND. Variables Increased serum tumor marker before orchiectomy, n (%) Alpha fetoprotein Beta-human chorionic gonadotropin Lactate dehydrogenase Primary testicular tumor side, n (%) Right Left Maximum testicular tumor size (range), mm Orchiectomy pathology, n (%) Pure teratoma Pure yolk sac Pure choriocarcinoma Pure embryonalcarcinoma Mixed germ cell (containing embryonalcarci- noma) Mixed germ cell (without embryonalcarcinoma) RPLND type, n (%) Open Laparoscopy Laparoscopy converted to open Mean operative time (range), min Peri and postoperative complications, n (%) Great vessel injury Visceral injury Peri-operative bleeding Myocardial infarction Cerebrovascular accident Deep venous thrombosis Incision site infection Retroperitoneal hematoma Cheiloascitis Acute renal failure Pulmonary thromboemboli Total Mean serum hemoglobin before RPLND (range), mg/ dL Mean serum hemoglobin one day after RPLND (range), mg/dL Blood transfusion, n (%) Mean hospitalization (range), day Mean total number of dissected lymph nodes (range) Mean follow-up duration (range), month Postoperative antegrade ejaculation, n (%) 28 (73) 21 (55) 9 (23) 18 (47) 20 (53) 44 (15 to 98) 2 (5) 2 (5) 0 (0) 5 (13) 25 (66) 4 (11) 3 (8) 33 (87) 2 (5) 237 (80 to 470) 2 (5) 0 (0) 1 (3) 0 (0) 0 (0) 0 (0) 2 (5) 2 (5) 0 (0) 0 (0) 0 (0) 7 (18) 14.9 (9.5 to 7.5) 13.4 (10 to 16) 3 (8) 3.6 (2 to 7) 15.2 (1 to 38) 56 (6 to 120) 23 (61) RPLND indicates retroperitoneal lymph node dissection; and PS, patho- logical stage. Modified RPLND in Stage I NSGCT | Basiri et al 876 | - ment of CS I NSGCT. In order to reduce potential compli- comparable oncological outcomes and acceptable complica- resecting all retroperitoneal lymph nodes noted in bilateral infrahilar regions except below the inferior mesenteric artery of contralateral side. urologists face with two questions. One, does this technique - - sible surgical complications and improve antegrade ejacula- tion? Several investigators have reported various recurrence rates with CS I NSGCT.(7,14) Katz and Eggener believe that higher cancer recurrence rate and more additional therapy are poten- (2) were evaluated in 500 patients with CS I and II NSGCT (364 and 136 patients, respectively), including testicular tumor study group template (TTSG), Indiana template, memorial Sloan-Kettering cancer center template (MSKCC), Innsbruck template, and Johns Hopkins University template (JHU).(5) 0% (MSKCC and Indiana) to 5% (JHU and Innsbruck) extra template relapse rates were reported in CS I. Post RPLND lymph node positive rates of 58% and 42% were reported in CS I and II, respectively. It was concluded that retroperito- template, and this metastasis may contain chemoresistant teratoma. This study reported different extra template retro- RPLND techniques (3% versus 23%, respectively). Fur- thermore, extra template retroperitoneal relapse was nearly for such patients (mean of 54 months). This study demon- strated that absence of positive lymph nodes in MSKCC - roperitoneal relapse rates of 0% and 5%, respectively. The authors concluded that maximum oncological outcomes (less regional lymph node dissection. Despite no extra template recurrence in patients with negative malignant intra template lymph nodes in Eggener and associates’ study,(5) it seems that RPLND in such cases. management of 85 patients with CS I NSGCT. According to his study, no intra template recurrence was noted and only one extra template retroperitoneal recurrence was detected. (14) for CS I NSGCT. However, mean follow-up of 3 years does not seen enough for cancer control. patients with CS I NSGCT and noted relapse rate of 15% and post RPLND antegrade ejaculation rate of 85% at the end of the 5-year follow-up period. Although disease recurred in 14.5% of patients with PS I, no patient had intra or extra tem- plate retroperitoneal recurrence (all recurrences occurred in the liver or lung).(15) The unilateral retroperitoneal template in this study was limited and smaller than our Sloan-Ketter- ing template. In our study, no subjects needed re-operation due to severe complications, and no mortality occurred as a result of opera- a favorable factor that may prevent expensive and long-term possible harmful follow-up. One of the limitations of this study is the small sample size (41 patients), which decreases the power of study. Therefore, further studies with greater sample size are recommended. CONCLUSION the management of CS I NSGCT, and may be considered as - this strategy may obviate the need for close, expensive, and potentially harmful follow-up protocol in patients with PS I NSGCT. CONFLICT OF INTEREST None declared. 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