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. 2025 Jul 14;25(1):171.
doi: 10.1186/s12894-025-01853-0.

Clinical experience and outcomes of post chemotherapy midline extraperitoneal approach to retroperitoneal lymph node dissection

Basil Razi  1   2   3 , James Kovacic  4   5   6 , Ankur Dhar  4   5   6 , Andrew Shepherd  4   5   7 , Venu Chalasani  4   5   6 , Matthew Winter  4   5   6
Affiliations

Clinical experience and outcomes of post chemotherapy midline extraperitoneal approach to retroperitoneal lymph node dissection

Basil Razi et al. BMC Urol. .

Abstract

Background: To detail the outcomes of an open midline extraperitoneal (midline EP) approach to post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) for metastatic testicular cancer.

Methods: We analysed our prospectively maintained operative database from April 2020 to February 2023 for cases of midline EP approach to PC-RPLND, identifying a total of 11 patients across two hospitals in Sydney, Australia. Demographic and perioperative data was obtained from electronic medical records, including preoperative factors such as cancer staging and preoperative treatment.

Results: Eleven patients were included in this study. The median age was 37 years with a median ASA grade of 3. There were a total of six left-sided and five right-sided cases. A modified template was used in eight cases, and a bilateral template was used in three. Tumour staging ranged from Stage IIA- IIIB, with a median maximal retroperitoneal tumour size post chemotherapy of 4.2 cm. Preoperative histology identified 4 cases of seminoma and 7 cases of nonseminomatous germ cell tumours (NSGCT). The median length of the procedure was 300 min, blood loss was 300mL, length of stay was 5 days, and post-operative days until bowel opening was 2 days. The median lymph node yield was 18, with active malignancy identified in five cases. There were four early complications and no late complications. 91% of the patients had preserved ejaculatory function.

Conclusions: The open midline EP approach to PC-RPLND has demonstrated acceptable perioperative outcomes compared to other open surgical approaches, enabling surgeons to complete complex cases. Therefore, the midline EP approach should be considered when performing PC-RPLND.

Keywords: Extraperitoneal; Oncology; Open surgery; RPLND; Testicular Cancer.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was approved by the Northern Sydney Local Health District - Royal North Shore Hospital Safety and Quality Unit (24-2022). The study was performed in accordance with the Declaration of Helsinki. Informed and written consent was obtained from all patients involved in the study. Consent for Publication: Informed consent was obtained from all patients for the use of their clinical data, pictures and videos. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Abdominal schematic. Red shaded region: Pre-peritoneal space. Yellow shaded region: Retroperitoneum. 1) Visceral peritoneum. 2) Parietal peritoneum. 3) Pre-peritoneal fat. 4) Transversalis fascia. 5) Transversus abdominus muscle. 6) Fusion fascia. 7) Lateroconal fascia. 8) Gerota’s fascia, anterior lamina. 9) Gerota’s fascia, posterior lamina. 10) Quadratuslumborum muscle. 11) Psoas muscle
Fig. 2
Fig. 2
A Midline laparotomy wound, diathermy incision through rectus sheath. B Rectus sheath retracted superiorly. Peritoneum inferiorly. C Lateral advancement of extraperitoneal plane. D Identification of retroperitoneal structures
Fig. 3
Fig. 3
A Retroperitoneum prior to lymph node dissection. Right ureter, abdominal aorta, and left ureter with vessel loops. Forceps point at large soft tissue mass. B 1. Inferior vena cava. 2. Right ureter. 3. Right psoas muscle. 4. Right renal vein. 5. Right gonadal vessels. 6. Right kidney. 7. Aorta. 8. Duodenum
Fig. 4
Fig. 4
Peritoneum remains intact at case conclusion
See this image and copyright information in PMC

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