Intraoperative and early postoperative complications in postchemotherapy retroperitoneal lymphadenectomy among patients with germ cell tumors using validated grading classifications

Abstract

BACKGROUND: Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) is an essential, yet potentially morbid, therapy for the management of patients with advanced germ cell tumors. In the current study, the authors sought to define the complication profile of PC-RPLND using validated grading systems for intraoperative adverse events (iAEs) and early postoperative complications. METHODS: Between 2000 and 2018, all patients who underwent PC-RPLND were analyzed for iAEs and early postoperative complications using the Kaafarani and Clavien-Dindo classifications, respectively. Logistic regression models were conducted to assess patient and tumor factors associated with iAEs and postoperative complications. RESULTS: Of the 453 patients identified, 115 patients (25%) and 252 patients (56%), respectively, experienced an iAE and postoperative complication. Major iAEs (grade ≥3) were observed in 15 patients (3%) and major postoperative complications (grade ≥3) were noted in 80 patients (18%). The most common iAE was vascular injury (112 of 132 events; 85%), which occurred in 92 patients (20%), and the most frequent postoperative complication was ileus, which occurred in 121 patients (27%). Original and postchemotherapy retroperitoneal mass size, nonretroperitoneal metastases, intermediate and/or poor International Germ Cell Cancer Collaborative Group classification, previous RPLND, elevated tumor markers at the time of RPLND, and anticipated adjuvant surgical procedures increased the risk of both iAEs and postoperative complications. Patients who experienced an iAE were significantly more likely to experience a postoperative complication (odds ratio, 2.50; 95% confidence interval, 1.58-3.97 [P < .001]). CONCLUSIONS: In what to the authors' knowledge is the first analysis of PC-RPLND using validated classifications for both iAEs and postoperative complications, advanced disease and surgical complexity significantly increased the risks of major iAEs and postoperative complications. Standardized reporting of adverse perioperative events allows providers and patients to appreciate the consequences of PC-RPLND during counseling and decision making.

Quality reporting in postchemotherapy retroperitoneal lymph node dissection

“…It is extraordinary that among >450 cases, there were no intraoperative changes in plans reported due to an inability to separate tumors from major vessels. Another limitation of the study by Umbreit et al 1 was that some surgeons may not have reported a minor injury during the case in the surgical report.…”

“…Surgeons tackling these cases should be intimately familiar with retroperitoneal anatomy and the indications for adjunctive procedures, and must be adept at vascular techniques to safely extirpate tumors while minimizing morbidity. In their article, 1 Umbreit et al have reported their institutional intraoperative and postoperative complications during PC‐RPLND over an 18‐year period. The series is well annotated and the reporting of intraoperative complications using a validated tool is novel 1 …”

“…In their article, 1 Umbreit et al have reported their institutional intraoperative and postoperative complications during PC‐RPLND over an 18‐year period. The series is well annotated and the reporting of intraoperative complications using a validated tool is novel 1 …”

“…One point of discussion regarding the analysis is the retrospective nature of classifying intraoperative “complications.” Although a suture repair of the vena cava is considered to be a complication in the study by Umbreit et al, 1 others may view it as a necessary part of surgery when peeling masses off the great vessels in the presence of a significant desmoplastic reaction. Umbreit et al rightfully mention that quality reporting is a “benchmark” of quality surgical and value‐based health care delivery.…”

“…Ileus remains one of the most common complications after this type of surgery (27% in the series by Umbreit et al 1 ). The midline extraperitoneal approach, which is feasible even with large retroperitoneal masses, has virtually eliminated the risk of ileus and can significantly decrease gastrointestinal‐related complications and the length of hospital stay 2 .…”