Laparoscopic nervesparing retroperitoneal lymphadenectomy

The laparoscopic approach to retroperitoneal lymphadenectomy is covered elsewhere in this issue. This section will focus specifically on the incorporation of nerve-sparing techniques into the retroperitoneal lymphadenectomy procedure. Laparoscopic bilateral retroperitoneal lymphadenectomy was first reported by Rukstalis and Chodak [31] in 1992 as a feasible approach to Stage I testicular cancer with potentially decreased morbidity. Throughout the mid-1990s several small series further supported the feasibility but primarily as a staging procedure using both bilateral and modified unilateral template dissections for Stage I germ-cell tumors [32-38]. The initial results revealed long procedure time and a relatively high complication rate (primarily hemorrhagic complications) that were attributed to inexperience and the recognition of an operative learning curve. In the late 1990s, the group from the University of Innsbruck, Austria, expanded the indications for laparoscopic RPL to include Stage II NSGCT and postchemotherapy masses [39] proposing that with sufficient experience, laparoscopic RPL could be a therapeutic procedure comparable to open surgery. Virtually all laparoscopic RPLs conducted by the Austrian group have used unilateral templates with the goal of preserving antegrade ejaculation [40-44]. Proponents of open surgery have contended that the boundaries of dissection are limited by a laparoscopic approach and that nerve sparing is in part the result of incomplete or no dissecting nerves on one side.

Results from the largest cohort of patients was reported by Steiner and colleagues [45] based on 185 patients over a 10-year period. The large majority of procedures were primary RPLs performed for clinical Stage I NSGCT (114 patients) and tumor marker-negative clinical Stage IIA disease (6 patients); however, post-chemotherapy RPLs were performed for tumor marker-positive Stage IIA (10 patients), Stage IIB (43 patients), and Stage IIC (15 patients) NSGCT. They reported a significant temporal decrease in operative time and an open-conversion rate of 2.6%. Pathology from clinical Stage I procedures revealed positive nodes (ie, clinical under-staging) in 19.5% of cases and mature teratoma was found in 38.2% of the post-chemotherapy Stage II specimens. With a mean follow-up of 53.7 months for Stage I patients and 57.6 months for Stage II patients, the authors documented one retroperitoneal recurrence and an antegrade ejaculation rate of 98.4%. It should be noted that two cycles of adjuvant cisplatin-based chemotherapy was given in all cases of pathologic stage II disease following primary RPL.

Peschel and colleagues [44] described an explicit nerve-sparing technique for laparoscopic RPL in a series of five patients. Emphasis was placed on the prospective identification and preservation of relevant sympathetic nerves, which had not necessarily been done previously by laparoscopists in conjunction with modified unilateral template dissections. For right-sided dissections, rolling para-caval lymphatic tissue medially first identifies the sympathetic trunk and postganglionic fibers are carefully dissected and preserved to the point where they cross under the IVC. A "split-and-roll" technique [22] is used over the IVC exposing the lumbar vessels and postganglionic fibers and the nodal package is removed en bloc. The identification of postganglionic nerves in the interaortocaval region is facilitated by rotation of the IVC. The nervesparing approach to a left-sided dissection is described as more onerous. The left sympathetic trunk and postganglionic nerves are identified and preserved during the dissection as para-aortic lymphatic tissue is rolled medially. This procedure was performed on two patients with clinical Stage I NSGCT and three patients with clinical stage IIB disease postchemotherapy. In this small series, there were no positive histologic findings and antegrade ejaculation rate was 100%.

Intraoperative electrostimulation of sympathetic nerves has recently been applied to laparo-scopic RPL in a case series by Kaiho and colleagues [46,47]. During six laparoscopic unilateral modified template RPLs, sympathetic nerves within the field of dissection were identified and preserved. While these nerves were stimulated with bipolar electrodes through a laparoscopic port, ejaculatory function was confirmed by endo-scopic visualization of bladder neck closure and emission of semen into the posterior urethra.

In summary, laparoscopic RPLs are being performed by experienced surgeons in various centers with disease control and complication rates comparable to open surgery. The literature acknowledges an overall relative lack of experience with this procedure among urologists, a technical learning curve, and the need for more long-term follow-up data. With continuing efforts to minimize surgical morbidity, the laparoscopic procedure seems to be following an analogous stepwise adoption of modified resection boundaries followed by prospective identification and meticulous preservation of sympathetic nerves with the goal of maintaining ejaculatory function. However, until a sizable experience without adjuvant chemotherapy for positive nodes is reported to demonstrate that surgery alone can be complete, many will regard this procedure as a staging technique.

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