Quality reporting in postchemotherapy retroperitoneal lymph node dissection

Abstract

Surgical resection of residual masses after chemotherapy remains a critical component of the management of patients with metastatic germ cell tumors. There are clear indications for postchemotherapy retroperitoneal lymph node dissection (PC-RPLND), which remains one of the most challenging procedures performed by urologists. 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 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. Indeed, as operative reports are dissected for keywords such as "inadvertent injury" or "laceration," surgeons need to be increasingly aware of the verbiage used to describe intraoperative events. A mass that is densely adherent to the great vessels inevitably will lead to cavotomies or aortotomies that require suture repair. Are these "intraoperative adverse events" or an expected part of the complex dissection? Reporting these as adverse events has implications for coding, performance-based reimbursement, and other safety measures. A surprising finding of the report by Umbreit et al is that when corroborating the "adjuvant" procedures with the intraoperative complications, several of them appear to have been planned. There were no Clavien-Dindo classification grade 4 aortic or vena cava complications, meaning that all vena cava resections and aortic replacements were planned and not considered to be intraoperative complications. 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. 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 Although documenting and reporting will not change how we recommend this surgery to our patients, I agree it is im...