LAPAROSCOPIC RETROPERITONEAL LYMPHADENECTOMY FOR CANCER OF THE TESTIS

The management of cancer of the testis has changed dramatically over the last 25 years due primarily to the advent of improved and highly effective chemotherapeutic regimens. 21 As a result, the survival and cure rate for all forms of germ cell testis tumors are very high even for advanced stages. Thus, the role of extensive retroperitoneal lymph node dissection (RPLND) for nonseminomatous germ cell tumors (NSGCT) has diminished with modified anatomic templates now being advocated. 3 By performing a modified nerve-sparing RPLND in correctly selected cases, the perioperative morbidity has diminished and preservation of antegrade ejaculation with improved fertility has been demonstrated. 14 For low-stage NSGCT (stage I) in association with negative tumor markers (alphafetoprotein and β-human chorionic gonadotropin) and favorable histology, close surveillance alone has been advocated as a management option. If surveillance is decided upon, a careful follow-up plan must be arranged and patient compliance must be optimal. 12,23 It should be noted, however, that clinical relapse has been reported in 25% to 30% of patients on surveillance protocols. 5,8 Fortunately, salvage combination chemotherapy has been reported to yield greater than 90% cure (> 5-year disease free) rate in this situation but still with a death rate of up to 10% in patients who may fail second-line treatment modalities. 19 Patients with stage I or low-volume stage II pure seminoma are treated effectively with postorchiectomy radiation therapy yielding 5-year survival rates of over 90%. 15 Combination chemotherapy is generally indicated as primary treatment for clinical stages IIB, IIC, and III testis tumors, irrespective of the histology. Following combination chemotherapy for advanced testis cancer, residual tumor mass may be visualized on CT scan for which surgical intervention may be required to determine if viable malignant tissue remains. Such operations are normally very difficult due to the desmoplastic reaction and loss of normal tissue planes as a result of the chemotherapy. 17 Laparoscopy for the diagnosis of the nonpalpable abdominal testis was reported by Cortesi et al 2 in 1976 but did not gain wide spread use until 1988. 1 With the advent of improved teleoptics and instrumentation, laparoscopic intervention has now been applied to almost all areas of genitourinary disease. This is reflected by the large number of published articles related to both ablative and reconstructive urologic procedures over the last 8 years. 7,22 Within the current treatment strategies described previously for patients with testis cancer, laparoscopic RPLND can offer a minimally invasive alternative for precise lymph node staging to determine metastatic disease in patients with clinical stage I NSGCT. 6,9,11,13 Its role as a therapeutic surgical procedure, however, has not been clarified to date in that all patients who have been found with positive lymph node tissue for metastases have received adjunctive combination chemotherapy. Furthermore, its role for resection of postchemotherapy residual abdominal masses visualized on CT scans is currently being examined. 10,13 These issues are discussed in this article. Laparoscopic RPLND is a technically advanced procedure primarily due to the difficulty with exposure of the midline retroperitoneal structures and the presence of the great vessels with their associated branches. Such laparoscopic procedures normally require considerably longer operative time resulting in higher intraoperative surgical costs. 20 At centers where laparoscopic RPLND has been successfully undertaken, these patients experience the usual benefits of minimally invasive surgery: less postoperative pain and narcotic use with shortened hospitalization and convalescence compared with open surgical intervention. The cosmetic appearance of the laparoscopic scars has been reported by patients to be superior to the usual extensive midline or thoracoabdominal incision. When considering laparoscopic RPLND for the management of testis cancer one must be certain that the end result is equivalent to that of open surgery without surgically compromising the patient's chance for cure. I believe that this is the critical issue that needs to be addressed with all minimally invasive procedures, but especially with testis tumors where careful and detailed management should yield high cure rates with minimal morbidity. Anything less may potentially compromise the life of a patient in the most productive years of his life. This author's indications for performing laparoscopic RPLND are as follows: •Clinical stage I nonseminomatous testis tumor •Negative testis tumor markers •Candidate otherwise considered for surveillance •No absolute contraindications to laparoscopic surgery •Individualized decision if patient has relative contraindications to laparoscopic surgery •Residual isolated abdominal or pelvic mass following chemotherapy in the presence of negative testis tumor markers. These cases must be individualized and approached very cautiously. The ideal candidate is the slender healthy man who has not had previous abdominal surgery and whose radical orchiectomy specimen contains a NSGCT. The testicular tumor markers should be negative and CT of the abdomen, pelvis, and chest should not reveal radiologic evidence of metastatic disease (clinical stage I). The goal of laparoscopic RPLND is to replicate what would ordinarily be achieved with a modified RPLND template as described by Donohue et al. 3 Direct attempts to preserve sympathetic fibers are not made but avoidance of preaortic dissection directly below the inferior mesenteric artery is observed.