Fortunately, patients undergoing surgery for advanced testicular cancer are relatively young and healthy men. Large-volume residual disease, postchemotherapy desmoplastic reaction, and prior exposure to bleomycin increase the technical difficulty and perioperative demands of the surgery. Perioperative mortality was approximately 1% in a large series of patients undergoing mediastinal resection [34]. Nonfatal complications have been reported in approximately 0% to 30% of patients [9,12,20,21,34]. Complications specific to postchemotherapy non-retroperitoneal surgery arise from pulmonary, lymphatic, infectious, and vascular causes.

Pulmonary complications include atelectasis, which is treated by vigorous pulmonary physiotherapy; pneumonia, which is managed with appropriate antibiotics; pneumothorax, which is managed with oxygen and observation or chest tube drainage; and adult respiratory distress syndrome (ARDS). ARDS is a complication that may be fatal or require prolonged mechanical ventilation in an intensive care unit. Prior exposure to bleomycin is a risk factor for ARDS. Clinicians must judiciously monitor perioperative fluid administration and avoid exposure to unnecessarily high concentrations of inspired oxygen in bleomycin-treated patients.

Chylothorax occurs secondary to injury of the thoracic duct or its tributaries and has been reported in approximately 2% to 4% of cases [20,34]. Familiarity with lymphatic anatomy in the chest and meticulous lymphostasis can minimize this complication. Clinical presentation includes shortness of breath and desaturation, similar to patients who have a significant pneumothorax. Chest radiograph or CT demonstrates a pleural effusion, and thoracentesis is diagnostic. Chylous fluid has a characteristic milky or turbid appearance with a fat content of 4 to 40 g/L and a total protein content of greater than 30 g/L. Thoracentesis may provide symptomatic relief, but many patients require chest tube drainage. Chylous ascites occurs in approximately 2% to 3% of patients undergoing RPLND but is more prevalent in patients undergoing simultaneous hepatic resection [13,28]. Dietary management of chylous leakage includes a low-fat diet with medium-chain triglycerides or total parenteral nutrition.

Intra-abdominal abscess formation has been reported in patients undergoing hepatic resection and must be managed with intravenous antibiotics and drainage [12,28]. Major vascular injuries are uncommon in experienced centers. One large study of 268 patients who underwent resection of residual mediastinal disease reported bleeding necessitating reoperation in 1.4% of cases [34].

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