Eleven-Year Experience With Midline Extraperitoneal Retroperitoneal Lymph Node Dissection for Germ Cell Tumors

Abstract

Purpose: A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has been associated with decreased morbidity compared to the transperitoneal approach. We aimed to review our 11-year experience in patients with germ cell tumors (GCTs) who underwent EP-RPLND at a single institution.

Materials and methods: All patients with GCT who underwent EP-RPLND between 2010 and 2021 were reviewed. Surgical, perioperative, and oncologic outcomes were reported. A logistic regression model was developed to evaluate variables predictive of early discharge. Oncologic outcomes included 2-year recurrence-free survival (RFS) and recurrence patterns, which were analyzed according to pathology.

Results: Overall, 237 patients underwent EP-RPLND, of which 72% were administered in the postchemotherapy (PC) setting. Median follow-up was 16.7 months (interquartile range [IQR] 3.9-39.6). Median size of retroperitoneal disease was 2.8 cm (IQR 1.8-5.4), of which 16 cases were ≥ 10 cm. There were no cases of postoperative ileus or readmission due to small-bowel obstruction. Median hospital stay was 2 days (IQR 1-3). From 2020 to 2021, 74% of patients were discharged on postoperative day 1 and 89% by postoperative day 2. Thirty-one complications occurred, including 4% grade III to IV complications. In the primary setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.93 (95% CI 0.84-1.00) and 0.85 (95% CI 0.72-1.00), respectively. In the PC setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.88 (95% CI 0.74-1.00) and 0.88 (95% CI 0.81-0.95), respectively. Overall, only 7 patients had in-field recurrence.

Conclusions: Midline EP-RPLND is safe and associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and PC settings, with low rates of in-field relapse.

Keywords: extraperitoneal; germ cell tumor; nonseminomatous germ cell tumor; retroperitoneal lymph node dissection; testis cancer.

Figure.

A, Midline extraperitoneal retroperitoneal lymph node dissection with peritoneal sac mobilized to expose retroperitoneal mass. B, Peritoneal sac retracted cephalad (arrow) after retroperitoneal mass resection demonstrating bilateral dissection template. C, Paraincisional subfascial catheters placed at completion of a primary extraperitoneal retroperitoneal lymph node dissection for local pain control.

Figure 1.

A, Midline extraperitoneal approach for retroperitoneal lymph node dissection with peritoneal sac mobilized to expose retroperitoneal mass. B, Peritoneal sac retracted cephalad (arrow) after retroperitoneal mass resection demonstrating bilateral dissection template. C, Paraincisional subfascial catheters placed at completion of a procedure for local pain control.

Figure 2.

Temporal trends in utilizing an extraperitoneal retroperitoneal lymph node dissection (EP-RPLND) approach compared to a transperitoneal (TP-RPLND) approach over the study period. The graph reports percentages, while the data table reports number.

Figure 3.

Trends in length of stay after extraperitoneal approach for retroperitoneal lymph node dissection stratified by timing of discharge (postoperative day [POD] 1, 2, and ≥3).

Figure 4.

Kaplan-Meier analysis for recurrence-free survival after extraperitoneal approach for retroperitoneal lymph node dissection for overall cohort (A), and stratified by histology and chemotherapy status (B). PostChemo indicates postchemotherapy.