Resection of the Spermatic Vessels and Final Steps

■ Resection of the spermatic vessels is the ultimate step.

■ The lumbar portion of the vascular pedicle is freed from the posterior peritoneum down to where it joins the ureter.

■ Now the instruments will be rearranged and the surgeon will use the iliac port for his instruments and the flank port for the laparoscope.

■ The spermatic vessels will be dissected down to the distal ligature and completely removed extraperi-toneally.

■ The lymphatic tissue and the spermatic vessels are placed in an endoscopic bag and extracted through the iliac incision.

■ Drainage is not necessary.

TECHNICAL CAVEATS

■ Adequate homeostasis is of a crucial importance. Even minimal bleedings must be controlled and stopped instantly to provide a bloodless surgical field. The quality of the dissection had improved significantly since the introduction of grasping forceps for bipolar coagulation and dissection. These instruments are ideal for the dissection of delicate vessels such as the vena cava and renal veins. Broader bipolar forceps allows precise hemostasis without damaging the surrounding structures. The Harmonic scalpel may be used as well for a bloodless transection of the lymphatic tissue.

■ A protruding® segment of bowel can cause insufficient exposure and may render the operation difficult, dangerous, and even impossible. The fan retractor used for the liver can retract the duodenum as well. Retraction of the bowel can be achieved by a surgical sponge held with a traumatic grasper. An additional trocar can be inserted in the midline just caudal to the costal margin for the introduction of a second fan retractor if required in exceptional cases. Exposure could be achieved in all instances and we have never converted to open surgery because of insufficient exposure.

■ Acute bleeding is the most frequent complication. A small surgical sponge that is held with a traumatic grasper can be a substitute for the surgeon's finger to be used for dissection, retraction, or pressure to control bleeding vessels so that subsequent measures can be taken without the pressure of time. Small defects in veins and even the vena cava can be sealed by direct application of fibrin. A larger defect is approximated with an atraumatic grasper with or without the use of endoscopic clips even if they are not placed appropriately and tend to fall off then the defect is sealed by fibrin. The strength of the repair should be enhanced by the additional use of surgicel (oxidized regenerated cellulose) or similar hemostatic substances such as tachocomb. In exceptional conditions laparoscopic vascular suture repairs are feasible if needed (5,15,21).

■ Instruments for general and vascular surgery must be available in the operating room in the event of bleeding that may not be controlled by endoscopic means.

SUMMARY

■ To lower morbidity, retroperitoneal lymphadenectomy was modified over the past 35 years from extended suprahilar to bilateral infrahilar. Subsequently, a modified unilateral approach and then nerve-sparing procedures were refined.

■ These operative refinements were not associated with increase in relapse rates.

■ Significant factors for relapse include pathological stage (p < 0.001) and adjuvant chemotherapy in stage II disease (p < 0.001) (3).

■ The future in this field may encompass the development of a technique that could exactly locate a sentinel lymph node for testicular cancer. Thereby the retroperitoneal lymph node dissection, with its diagnostic accuracy and its therapeutic value, could be applied to selected patients only (22,23).

REFERENCES

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2. Bussar-Matz R, Weissbach L. Retroperitoneal lymph node staging of testicular tumours. TNM Study Group. Br J Urol 1993; 72:234-240.

3. Donhue JP, Thornhill JA, Foster RS, Roland RG, Bihrle R. Retroperitoneal lymphadenectomy for clinical stageA testis cancer (1965-1989): modification of technique and impact on ejaculation. J Urol 1993; 149:243-237.

4. Williams SD, Stablein DM, Einhorn LH, et al. Immediate adjuvant chemotherapy versus observation with treatment at relapse in pathological stage II testicular cancer. N Engl J Med 1987; 317:1433-1438.

5. Steiner H, Peschel R, Janetschek G, et al. Long-term result of laparoscopic retroperitoneal lymph node dissection: a single-center 10 years experience. Urology 2004; 63:550-555.

6. Corvin S, Kuczyk M, Anastasiadis A, Stenzl A. Laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma. World J Urol 2004; 22:33-36.

7. Rassweiler JJ, Frede T, Lenz E, Seemann O, Alken P. Long-term experience with laparoscopic retroperitoneal lymph node dissection in the management of low-stage testis cancer. Eur Urol 2000; 37:251-260.

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9. Rassweiler JJ, Seemann O, Henkel TO, Stock C, Frede T, Alken P. Laparoscopic retroperitoneal lymph node dissection for non seminomatous germ cell tumour: indication and limitation. J Urol 1996; 156:1108-1113.

10. Janetschek G. Laparoscopic retroperitoneal Iymph node dissection. Urol Clin North Am 2001; 28:107-114.

11. Laguna MP, Klepp O, Horwich A, et al. Guidelines on Testicular Cancer. European Association of Urology Update, March 2004.

12. Sogani PC, Perrotti M, Herr HW, Fair WR, Thaler HT, Bosl G. Clinical stage I testis cancer: long-term outcome of patients on surveillance. J Urol 1998; 159:855-858.

13. Nicolai R, Pizzocaro G. A surveillance study of clinical stage I non-seminomatous germ cell tumours of the testis: 1-year follow up. J Urol 1995; 154:1045-1049.

14. Gullen MH, Stenning SP, Parkinson MC, et al. High-risk stage I non-seminomatous germ cell tumours of the testis. AMedical Research Council Report. J Clin Oncol 1996; 14:1106-1113.

15. Janetschek G, Hobisch A, Hittmair A, Holtl L, Peschel R, Bartsch G. Laparoscopic retroperitoneal lymphadenectomy after chemotherapy for stage IIB Nonseminomatous Testicular carcinoma. J Urol 1999; 161:477-481.

16. Klingler HC, Remzi M, Janetschek G, Marberger M. Benefits of laparoscopic renal surgery are more pronounced in patients with a high body mass index. Europ Urol 2003; 43:522-527.

17. Weissbach L, Boedefeld EA. Testicular tumour study group: localization of solitary and multiple metastases in stage II non seminomatous testis tumour as basis for modified staging lymph node dissection in stage I. J Urol 1987; 138:77-82.

18. Holtl L, Peschel R, Knapp R, et al. Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels. Urology 2002; 59:114-118.

19. Janetschek G, Peschel R, Bartsch G. Laparoscopic retroperitoneal lymph node dissection. Atlas Urol Clin North Am 2000; 8:71-90.

20. Le Blanc E, Caty A, Dargent D, Querleu D, Mazeman E. Extraperitoneal laparoscopic para-aortic lymph node dissection for early stage non seminomatous germ cell tumour of the testis with introduction of a nerve sparing technique description and results. J Urol 2001; 165:89-92.

21. Janetschek G, Hobisch A, Peschel R, Bartsch G. Laparoscopic retroperitoneal lymph node dissection. Urology 2000; 55:136-140.

22. Sotoh M, Ito A, Mitsuzuka K, et al. Sentinel node detection and extrapeitoneal laparoscopic retroperitoneal lymph node dissection under gamma probe guidance with clinical stage I testicu-lar cancer. J Endourol 2003; 17(suppl):A67.

23. Pizzocaro G, Nicolai R, Salvioni R. Evaluation and controversies in management of low-stage nonseminomatous germ cell tumours of the testis. World J Urol 1994; 12:113-119.

CHAPTER

LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION FOR CLINICAL STAGE I NONSEMINOMATOUS GERM CELL TESTICULAR CANCER: CURRENT STATUS

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