Long-term experience with laparoscopic retroperitoneal lymph node dissection in the management of low-stage testis cancer

Objectives: We describe our experience with laparoscopic retroperitoneal ly mphadenectomy (LRLA) in 34 patients with low-stage germ cell tumors treated from 1992 to 1998. All patients had clinical stage-I disease with no clini cal evidence (CT scan, ultrasound, tumor markers) of metastases. A laparosc opic dissection was used to assess the pathologic status of the relevant re troperitoneal lymph nodes. Material and Methods: 17 patients were treated by a transperitoneal laparos copic approach, whereas in the last 17 patients retroperitoneoscopic retrop eritoneal lymph node dissection was performed. The lymph node dissection wa s performed identically to open surgery with the modified template accordin g to Weissbach including the paracaval, interaortocaval, upper pre-aortic, and right common iliac zonal nodes for right-sided tumors, and para-aortic, upper pre-aortic zones for left-sided tumors. Retrieval of the lymph node chains was accomplished using a small organ bag. Results: The procedure could be completed successfully in 30 of 34 patients with stage-I disease. In these cases the mean duration of the procedure wa s 248 min. In 3 patients the lymphadenectomy was abandoned, because frozen section showed metastasis. In 1 case conversion to open surgery was necessa ry because of bleeding from the aorta. One patient developed a delayed uret eral stenosis which required operative repair. Three patients required temp orary insertion of an indwelling ureteral stent, and another patient had a pulmonary embolism with an uneventful outcome. One patient with a LRLA on t he right side later developed retrograde ejaculation. In 6 of the 33 patien ts (18%) embryonal carcinoma or mixed carcinoma was found. The postoperativ e hospital stay averaged 5.3 (3-9) days for the patients without complicati ons or conversion to open surgery. After a median follow-up of 40 months no regional relapse occurred, but 2 patients developed pulmonary metastases w hich were treated successfully by three cycles of platinum-based chemothera py. All patients have no evidence of disease. Conclusions: Our experience suggests that LRLA is a safe and accurate metho d for low-stage germ cell tumors with minimal invasiveness, but because of its technical difficulty it should be restricted to experienced centers.