Outcomes of retroperitoneal lymph node dissection for testicular cancer by a high volume surgeon from Australia: a case for centralisation

Abstract

Background: There are few studies examining retroperitoneal lymph node dissection (RPLND) for testicular cancer in Australia. This study examines the perioperative outcomes, complications and survival rates following RPLND, by a high volume, single surgeon. Methods: A retrospective, case series of a single surgeon, multi-centre study included all patients who underwent RPLND following testicular cancer at Westmead Public Hospital, Westmead Private Hospital, and Macquarie University Hospital 2005-2020. One hundred one patients identified, with 94 having sufficient available data. Results: At time of operation, median age was 29.5 years. 84.2% had T1 or T2 primary tumours at diagnosis. Most common RPLND indication was residual mass postchemotherapy (92.6%), with bleomycin, etoposide and cisplatin (BEP)x3 and BEPx4 most common chemotherapy regimens (50% and 35% respectively). Post-chemotherapy, largest residual mass ranged from 0.9 to 20 cm (median 3.32 cm). Post-chemotherapy, 95.7% masses were found in retroperitoneum (64.4% para-aortic region). 93.6% had open approach. 42.5% had bilateral nerve sparing. Majority (97.1%) did not require blood transfusion. No complications reported in 52.1% of patients. No deaths recorded within 90 days of surgery. At time of analysis, 91.5% had recurrence free survival, and 92.6% overall survival, at a median follow-up since surgery of 47.5 months (range 11 to 200 months). Conclusions: This retrospective study, addressing peri-operative surgical outcomes for RPLND surgery in Australia, is comparable to high-volume international urological centre studies, and shows that centralisation of post-chemotherapy RPLND to an experienced surgeon, results in low perioperative morbidity and mortality.

Clinical efficacy and safety of robotic retroperitoneal lymph node dissection for testicular cancer: a systematic review and meta-analysis

“…Chemotherapy is effective, but the side effects of chemotherapeutic agents and the risk of cardiovascular disease and secondary tumors are challenging to overcome ( 29 ). Currently, RPLND provides accurate staging, is the effective method for detecting these lesions, and provides a 95% good prognosis ( 30 ).Perioperative complications are the main drawbacks of the open RPLND surgical approach, such as long operative time, high intraoperative bleeding, high chance of postoperative complications, extended hospital stay, and ease of recurrence ( 31 , 32 ). The robotic surgical system exhibits remarkable stability, effectively eliminating the minor hand tremors that can occur during manual procedures.…”

Testicular Cancer Treatments and Sexuality: A Narrative Review

“…Magnetic resonance imaging (MRI) is an alternative to CT. Thus, the rationale for RPLND in TC patients is related to the following: (1) the retroperitoneum is the most common site of metastasis; (2) 15% to 25% incidence of retroperitoneal teratoma (which is chemo-resistant) in those with occult metastasis is found in the retroperitoneum [85][86][87]; (3) RPLND may lead to low risk of abdominopelvic recurrence [84,88]; (4) avoidance of chemotherapy in more than 75% or more of patients if adjuvant chemotherapy is restricted to those with extensive retroperitoneal malignancy (pN2-3) [89][90][91][92]. The disadvantages of RPLND are that all patients undergo major abdominal surgery, it requires the availability of experienced surgeons and thus may not be deliverable to all patients, and it is associated with the highest rate of double therapy [93,94].…”

Nerve-sparing technique in RPLND for testicular cancer

“…Surgical approach, technique and operative platforms have all been instrumental in refining nerve spare RPLND Quality of lymph node dissection or template should not be compromised regardless of attempts at nerve presevation The surgical management of the retroperitoneum in testicular cancer should be managed in high volume cancer centers with multidisciplinary input morbidity with RPLND have shifted the paradigm back towards primary RPLND in stage I disease [28,29,30].…”

“…Therefore, its use relies largely on intraoperative judgment and surgeon experience, and as such, patients should be referred to an experienced surgeon at a high-volume centre [27]. Primary RPLND has seen its use decline in recent decades, however the long-term consequences of platinum chemotherapy and improvements in morbidity with RPLND have shifted the paradigm back towards primary RPLND in stage I disease [28,29,30].…”