Laparoscopic Urology 157Urology Journal Vol 7 No 3 Summer 2010 Laparoscopic Bilateral Retroperitoneal Lymph Node Dissection in Stage II Testis Cancer Abbas Basiri,1 Mohammad Asl-Zare,1 Mehrdad Mohammadi Sichani,2 Hooman Djaladat3 Purpose: We report our experience with laparoscopic bilateral retroperitoneal lymph node dissection (RPLND) in 4 patients with stage II testis cancer. Materials and Methods: Between January 2002 and January 2009, 4 patients with stage II testis cancer underwent laparoscopic bilateral RPLND. In 2 patients, laparoscopic bilateral RPLND was performed for residual mass post-chemotherapy. We performed classic bilateral RPLND without patient repositioning. Results: The procedure was done uneventfully without any major peri- operative complication. The demanding part was contralateral, depending side dissection, which was accomplished with the help of a bowel retractor. Patient repositioning was not necessary. Conclusion: Laparoscopic bilateral RPLND can be performed efficiently and safely in stage II testis cancer, without need to repositioning and placement of trocar in contralateral side. Urol J. 2010;7:157-60. www.uj.unrc.ir Keywords: testis neoplasm, lymph node dissection, laparoscopy 1Urology and Nephrology Research Center, Shahid Labbafinejad Medical Center, Shahid Beheshti University, MC, Tehran, Iran 2Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran 3Mohammadi Hospital, Hormozgan University of Medical Sciences, Bandar Abbas, Iran Corresponding Author: Abbas Basiri, 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 June 2010 Accepted July 2010 INTRODUCTION Carcinoma of the testis remains the most common malignancy in males 15 to 35 years old (1) and its primary landing sites for metastases are retroperitoneal lymph nodes. (2) Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was developed for diagnostic and therapeutic benefits of open retroperitoneal lymph node dissection, without its inherent morbidity in patients with clinical stage I nonseminomatous germ cell tumors (NSGCT).(3-5) Because of various advantages of L-RPLND, it has also been introduced in the management of stage II testis cancer.(6,7) Most urologists prefer the strategy of primary chemotherapy followed by L-RPLND for residual mass in advanced stage II testis cancer. In such circumstances, L-RPLND has both diagnostic and curative intent. Laparoscopic RPLND could also be performed as the first step (before chemotherapy) in patients with advanced stage II testis cancer, but it has to be done bilaterally to remove not only the primary landing site, but also other possible sites of tumor spread.(6) Bilateral L-RPLND has only been reported as a staged procedure. Typically, laparoscopy is performed for unilateral dissection and for complete RPLND, repositioning of the patients is assumed to be necessary.(7) To the best of our knowledge, laparoscopic bilateral RPLND without patient repositioning has not been reported previously. Laparoscopic RPLND—Basiri et al 158 Urology Journal Vol 7 No 3 Summer 2010 MATERIALS AND METHODS Between January 2002 and January 2009, transperitoneal bilateral laparoscopic RPLND was performed on 4 patients with stage II NSGCTs. In 2 patients, laparoscopic bilateral RPLND was performed for residual mass after chemotherapy while the other 2 were before chemotherapy. Pre and postoperative patients’ data are presented in Table 1. Under general anesthesia, patients were placed in semi-flank position. Four trocars were used, including 3 midline ports and one in anterior axillary line at the level of the umbilicus. One additional port was placed for bowel retraction. The white line was incised and the colon was completely mobilized from one side to another until visualizing the ureter and the renal vein on the opposite side, to make sure that it is possible to have acceptable exposure to difficult dependent part. The target area for lymphatic dissection was between the two ureters laterally, renal veins superiorly, and iliac vessels inferiorly (Figure 1). After contralateral side lymphatic dissection, between dependent ureter and the aorta or the inferior vena cava (Figure 2), we continued to complete classic dissection in ipsilateral side. During contralateral side dissection, successful bowel retraction provided great help, especially in obese patients. In the presence of huge mass, lumbar vessels were transected for removal of reteroaortic and reterocaval lymphatic tissues. We Figure 1. Laparoscopic RPLND in a patient with primary left testis tumor. LRV, indicates left renal vein; and IVC, inferior vena cava. Figure 2. Contralateral (Right sided) dissection in a patient with primary left testis tumor. IVC, indicates inferior vena cava. Case 1 Case 2 Case 3 Case 4 Tumor side Right Right Left Right Age (years) 25 27 35 28 BMI 20 23 22 28 Tumor Pathology Embryonal cell carcinoma Embryonal/Immature teratoma Yolk sac tumor Embryonal cell carcinoma Size of lymph nodes on CT scan 2 cm 4 cm 4 cm 3.5 cm Pre-operative chemotherapy No No Yes Yes Operative time (minutes) 440 340 420 240 Hospital stay (days) 8 3 8 4 Pre-operative Hb (mg/dL) 14.7 16.6 14 15 Postoperative Hb (mg/dL) 14.3 15.6 13.7 14.6 Complication Lymphatic leakage Nothing Lymphatic leakage Nothing Follow-up (months) 66 9 3 3 Recurrence No No No No Open conversion No No No No Table 1. Pre and postoperative patients’ data that underwent classic laparoscopic RPLND Laparoscopic RPLND—Basiri et al 159Urology Journal Vol 7 No 3 Summer 2010 tried to preserve postganglionic fibers when we could clearly discriminate them. RESULTS Bilateral laparoscopic RPLND was completed in all of the patients. Conversion to open surgery was not necessary. Operative time ranged from 240 to 440 minutes. No blood transfusion was required. No major intra or postoperative complications occurred. Prolonged lymphatic leakage (7 days) was noted in 2 subjects that were managed conservatively. Hospital stay was between 3 and 8 days. Laparoscopic RPLND was successful to remove 20 to 37 lymph nodes. The related pathology is delineated in Table 2. Patients were followed up between 3 to 66 months, through which no relapses occurred. DISCUSSION Open RPLND has been assumed as the gold standard for the surgical management of low stage NSGCTs. Laparoscopic RPLND has been proposed to be a minimally invasive and valuable alternative approach to open surgery.(8) It provides less morbidity and increases patient’s satisfaction with similar oncologic outcomes compared to open counterpart.(8,9) Laparoscopic RPLND is traditionally indicated for low stage tumors which are candidate for unilateral modified dissection. Whenever widespread retroperitoneal tumor is present, a complete bilateral RPLND is indicated.(7) Laparoscopic bilateral RPLND was first proposed by Palese and colleagues. They declared that although L-RPLND is a feasible operation in patients after chemotherapy, but it is challenging and should be reserved for the patients with limited retroperitoneal residual disease as well as institutions with considerable laparoscopic expertise.(10) Benway and associates showed that in porcine model, laparoscopic bilateral RPLND is capable of providing lymph node yields similar to open RPLND, further supporting the potential for oncologic equivalency via a laparoscopic approach.(8) To the best of our knowledge, this is the first report on performing bilateral L-RPLND in human beings without the need for patient repositioning. We overcame the problem of difficult exposure to contralateral side using a bowel retractor from an additional port. In this study, the results in terms of disease-free and disease-specific survival were favorable. All of the 4 patients survived with no evidence of biochemical or disease recurrence in on average 20-month follow-up. In our series, dissection in contralateral side was feasible and efficient, but further studies with larger sample size are needed to better clarify this issue. Laparoscopic RPLND has its own potential complications, mainly vascular. In some studies, high morbidity has been reported with this technique.(8) Palese and colleagues reported that of 7 patients, 3 subjects (42%) who underwent post-chemotherapy L-RPLND had major complications, including iatrogenic cavotomy, renal and external iliac arteries injury, and duodenal perforation. Interestingly, the only patient who underwent bilateral L-RPLND had no complication.(10) No major complication was seen in our patients. Only 2 of them had lymphatic leakage which was managed with conservative treatment. Our complication rate was much lower than the reported rate in the literature. This might be due to mainly small sample size, but improved Case 1 Case 2 Case 3 Case 4 Cord Stump Negative Negative Negative Negative Para-aortic lymph nodes Negative Positive (3/3) Positive (3/15) mature teratoma Negative Inter-aortocaval lymph nodes Positive (2/5) Negative Positive(9/16) mature teratoma Positive(6-cm mass) teratocarcinoma Para-caval lymph nodes Negative Negative Positive (1/6) mature teratoma Negative Table 2. Pathology of lymph nodes Laparoscopic RPLND—Basiri et al 160 Urology Journal Vol 7 No 3 Summer 2010 experience and less desmoplastic reactions are also contributory factors. It has been assumed that repositioning of the patient from one side to the other side is the only way to obtain a total, although consecutive exposure of the retroperitoneum for L-RPLND. (7) According to our experience, we recommend using a bowel retractor with an extra port to overcome this issue. Another issue is bilateral L-RPLND in obese patients. We recommend starting this procedure from contralateral (dependent) side, because edematous distended bowel will not hamper later ipsilateral dissection. CONCLUSION Bilateral L-RPLND is a feasible procedure in stage II NSGCTs. Using a bowel retractor, we could omit the necessity of the patient repositioning for bilateral L-RPLND. Experienced surgeons at dedicated centers are essential for such a complex surgical approach. CONFLICT OF INTEREST None declared. REFERENCES 1. williams SB, Steele GS, Richie JP. Primary retroperitoneal lymph node dissection in patients with clinical stage IS testis cancer. J Urol. 2009;182: 2716-20. 2. Corvin S, Kuczyk M, Anastasiadis A, Stenzl A. Laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma. world J Urol. 2004;22:33-6. 3. Bhayani SB, Ong A, Oh wK, Kantoff Pw, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. 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