Differences In Laparoscopic Retroperitoneal Lymph Node Dissections

Laparoscopic retroperitoneal lymph node dissection may be used as a staging or a therapeutic procedure.

As most patients undergoing open retroperitoneal lymph node dissection or chemotherapy are treated unnecessarily (as they have no metastases), a minimally morbid approach to staging the retroperitoneum is highly attractive. In European series, laparoscopic retroperitoneal lymph node dissection serves this purpose and helps delineate those who have metastases and require chemotherapy versus those who may be more safely observed.

TABLE 1 ■ Treatment Options for Clinical Stage I Nonseminomatous Germ Cell Tumors

Typical

Recurrence

Treatment

recurrence (%)

treated with

Success rate (%)

Advantages

Disadvantages

Surveillance

30

3 cycles chemotherapy

>95

No patients treated unnecessarily

Requires rigorous follow-up; 3 cycles of chemotherapy significantly more toxic than 2

Primary

<5

Chemotherapy

>95

No invasive

70% of patients

chemotherapy

or surgery

procedures

treated unnecessarily

Open retroperitoneal

lymph node

dissection

<5

Chemotherapy

>95

Accurate staging

70% patients treated unnecessarily with laparotomy incision,30% of pIIa patients recur

Staging laparoscopic

<5

Chemotherapy

>95

Accurate

Patients with

retroperitoneal

or surgery

staging with

positive nodes

lymph node

advantages of

receive 2

dissection with 2

laparoscopy

treatments

cycles of chemotherapy

(laparoscopy and

for positive

chemotherapy)

nodes

Therapeutic laparoscopic

<5

Chemotherapy

>95

Accurate

Most patients have

retroperitoneal

staging with

received

lymph node dissection

advantages of laparoscopy

chemotherapy due to philosophy of oncologists; without chemotherapy results should mirror open retroperitoneal lymph node dissection. More studies needed

Abbreviation: RPLND, retroperitoneal lymph node dissection.

As a staging procedure, laparoscopic retroperitoneal lymph node dissection is typically performed without retro-caval or retroaortic dissection, and is used to delineate pathologic status. The therapeutic efficacy of this more limited dissection is unknown.

As a staging procedure, laparoscopic retroperitoneal lymph node dissection is typically performed without retrocaval or retroaortic dissection, and is used to delineate pathological status (7). The therapeutic efficacy of this more limited dissection is unknown. As a therapeutic procedure, laparoscopic retroperitoneal lymph node dissection is also effective.

This approach, currently used at Johns Hopkins, limits relapses to outside the template, and may be offered as a singular, primary treatment option, analogous to open retroperitoneal lymph node dissection. Patients with pathological stage II disease can then be observed or treated with chemotherapy per their preference.

The goal of the therapeutic laparoscopic retroperitoneal lymph node dissection is to limit retroperitoneal relapse. All nodal tissue within the template must be excised, including retroaortic and retrocaval tissue.

EFFICACY OF TREATMENT OPTIONS

The goal of the therapeutic laparoscopic retroperitoneal lymph node dissection is to limit retroperitoneal relapse. All nodal tissue within the template must be excised, including retroaortic and retrocaval tissue.

All treatments of clinical stage I nonseminomatous germ cell are effective (Table 1). As such, the choice for treatment is ultimately dependent on patient preference and

Laparoscopic staging retroperitoneal lymph node dissection can evaluate for metastases with minimal long-term morbidity, but requires two cycles of adjuvant chemotherapy. Therapeutic laparoscopic retroperitoneal lymph node dissection offers all the advantages of open retroperitoneal lymph node dissection without the incision, but studies often include treatment with chemotherapy and randomized studies are lacking.

From a surgical perspective, laparoscopic retroperitoneal lymph node dissection should duplicate the open template to maintain established oncological principles, particularly if a patient with pathological stage II a disease should choose observation rather than adjuvant treatment.

comfort with treatment modalities. Surveillance has the advantage of having no patients unnecessarily treated. The main disadvantage is the three cycles of chemotherapy involved for recurrence, and compliance with the rigorous followup schedule. Primary chemotherapy unnecessarily treats 70% of patients who garner no advantage because they harbor no metastases. These patients are exposed to the long-term toxicity of the chemotherapeutic agents. Open retroperitoneal lymph node dissection has the same disadvantage of over treatment and additionally patients have the lifelong cosmetic disadvantage of the open incision. Furthermore, 30% of patients with metastases will recur and require chemotherapy.

Laparoscopic staging retroperitoneal lymph node dissection can evaluate for metastases with minimal long-term morbidity, but requires two cycles of adjuvant chemotherapy. Therapeutic laparoscopic retroperitoneal lymph node dissection offers all the advantages of open retroperitoneal lymph node dissection without the incision, but studies often include treatment with chemotherapy and randomized studies are lacking.

Unfortunately, high volume centers treating testis cancer have been slow to adopt laparoscopic techniques and as such, comparing the efficacy of open retroperi-toneal lymph node dissection to laparoscopic retroperitoneal lymph node dissection is difficult and requires indirect measures. These comparisons are confounded by surgical differences between the major centers performing laparoscopic retroperitoneal lymph node dissection, and by philosophical differences with regard to postoperative chemotherapy.

All laparoscopic retroperitoneal lymph node dissections are not equal. In the Austrian series, laparoscopic retroperitoneal lymph node dissection in the clinical stage I patient is performed as a staging tool, and nodes are not routinely removed posterior to the lumbar vessels. The rationale for performing this more limited retroperitoneal lymph node dissection relies on the lack of an isolated retrocaval or retroaortic positive node based on pathological analyses of the authors' series (7,8). Furthermore, as the procedure is performed as a staging procedure, the goal is to identify patients who require chemotherapy, and then treat those with positive nodes. In the Johns Hopkins experience, the procedure has evolved. Initially, the procedure was aborted if multiple positive nodes were found, because chemotherapy would be instituted in these cases (9). Because technological advances in instrumentation, suturing, and hemostasis have evolved, a traditional approach is the norm. Currently, an exact replication of the open template is performed on all patients with clinical stage I nonseminomatous germ cell, with complete excision of retroaortic and retrocaval tissue, thus rendering the procedure both a staging and therapeutic procedure.

Despite the more complete lymphatic excision of therapeutic laparoscopic retroperitoneal lymph node dissection, it is the philosophy of some medical oncology departments to routinely give two cycles of chemotherapy in all patients with positive nodes at lymph-adenectomy, rather than risk the chance of recurrence and progression and later treatment with a higher dose of chemotherapy. It is unknown if the long-term sequelae with a modified chemotherapy regimen is similar to that seen with traditional three cycles.

From a surgical perspective, laparoscopic retroperitoneal lymph node dissection should duplicate the open template to maintain established oncological principles, particularly if a patient with pathological stage II a disease should choose observation rather than adjuvant treatment.

Use of adjuvant chemotherapy has elicited a major concern: is the laparoscopic retroperitoneal lymph node dissection an adequate "clean-out" of the retroperitoneum or is the chemotherapy masking retroperitoneal nodes that were missed? This question can be answered with another method to compare the open and laparoscopic retroperi-toneal lymph node dissection: examination of the patients with pathologic stage I disease. If the laparoscopic retroperitoneal lymph node dissection were inadequate, certainly patients would be misdiagnosed with pathological stage I disease, and the positive lymph nodes in the retroperitoneum would be missed, thus leading to a retroperitoneal recurrence. This supposition has not occurred, because no retroperi-toneal recurrences have been reported in our experience or from recent University of Washington data (6,10).

Despite the indirect efficacy of laparoscopic retroperitoneal lymph node dissection, a randomized direct comparison to open retroperitoneal lymph node dissection is theoretically the best approach to establish equal efficacy. Such a comparison has not been performed with other accepted laparoscopic procedures such as tubal ligation, chole-cystectomy, gastric fundoplication, adrenalectomy, nephrectomy, or nephroureterectomy.

With these procedures, it has been apparent that the laparoscopic approach differs from the open approach primarily with regard to access of the abdomen, and intra-abdomi-nal manipulations are similar, if not exact. The oncological community has not assessed laparoscopic retroperitoneal lymph node dissection with these same standards, but ultimately, as more centers offer therapeutic laparoscopic retroperitoneal lymph node dissection, the procedure is likely to replace the open procedure as a new standard to treat clinical stage I nonseminomatous germ cell.

COMPLICATIONS OF LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION

The major complication reported during laparoscopic retroperitoneal lymph node dissection is hemorrhage (6,9).

Early in the experience of the procedure hemorrhage necessitated conversion to an open procedure and occasionally blood transfusion. These complications reflect a different era of laparoscopic surgery, in which instrumentation, suturing technology, and hemostatic aids were not available. Currently, techniques have been developed to deal with potential hemorrhage.

Lymphocele formation is also a complication, more commonly seen in early experience. As with open surgery, this can be avoided with careful clipping of lymphatic channels.

Retrograde ejaculation has been reported at a rate similar to that seen with open retroperitoneal lymph node dissection (6).

POSTCHEMOTHERAPY LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION

Postchemotherapy laparoscopic retroperitoneal lymph node dissection is considered a different surgery than the version used for clinical stage I nonseminomatous germ cell. The dissection is more extensive, and more difficult secondary to residual masses and tissue reaction to chemotherapeutic agents. In one series of seven patients, a 42% major complication rate was reported (11). This was the initial series, and involved the learning curve with the procedure. In another series of 68 patients, a 0% complication rate was reported (8). The dissection boundaries in the latter series are unclear. Larger studies with long-term outcomes are needed to evaluate the ultimate efficacy of this approach. Duplication of the open dissection and template is essential.

Postchemotherapy retroperitoneal lymph node dissection should be attempted only by experienced laparoscopists, and patients should be aware of the possibility of open conversion.

SUMMARY

■ Laparoscopic retroperitoneal lymph node dissection for the treatment of clinical stage I nonseminomatous germ cell has evolved into an excellent alternative to traditional modes of therapy.

■ The procedure can replicate the advantages of open retroperitoneal lymph node dissection without the morbidity of a large incision.

■ Although all treatment modalities are effective in low stage nonseminomatous germ cell, laparoscopic retroperitoneal lymph node dissection offers a minimally invasive approach to the disease.

■ Further studies comparative studies of primary chemotherapy, open retroperitoneal lymph node dissection, and laparoscopic retroperitoneal lymph node dissection are needed from high volume centers to elucidate differences in therapy.

REFERENCES

1. Jones RH, Vasey PA. Part I: testicular cancer—management of early disease. Lancet Oncol 2003; 4(12):730-737.

2. Foster RS, Donohue JP. Retroperitoneal lymph node dissection for the management of clinical stage I nonseminoma. J Urol 2000; 163(6):1788-1792.

The major complication reported during laparoscopic retroperitoneal lymph node dissection is hemorrhage.

Lymphocele formation is also a complication, more commonly seen in early experience.

Retrograde ejaculation has been reported at a rate similar to that seen with open retroperitoneal lymph node dissection.

Postchemotherapy retroperitoneal lymph node dissection should be attempted only by experienced laparoscopists, and patients should be aware of the possibility of open conversion.

3. Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Primary retroperitoneal lymph node dissection in clinical stage. A nonseminomatous germ cell testis cancer. Review of the Indiana University experience 1965-1989. Br J Urol 1993; 71(3):326-335.

4. Richie JP. Clinical stage 1 testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol 1990(Nov); 144(5):1160-1163.

5. Sternberg CN. The management of stage I testis cancer. Urol Clin North Am 1998; 25(3):435-449.

6. Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003; 62(2):324-327.

7. Janetschek G, Peschel R, Hobisch A, Bartsch G. Laparoscopic retroperitoneal lymph node dissection. J Endourol 2001; 15(4):449-453; discussion 453-455.

8. Steiner H, Peschel R, Janetschek G, et al. Long term results of laparoscopic retroperitoneal lymph node dissection: a single center 10 year experience. Urology 2004; 63(3):550-555.

9. Nelson JB, Chen RN, Bishoff JT, et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular tumors. Urology. 1999; 54(6):1064-1067.

10. Porter J. Laparoscopic retroperitoneal lymph node dissection. In: Smith AD, eds. Smith's Textbook of Endourology. BC Decker 2006.

11. Palese MA, Su LM, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection after chemotherapy. Urology 2002; 60(1):130-134.

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Responses

  • jaana
    What is disadvantage of retroperitoneal lymph nodes?
    3 years ago

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