Rplnd

0 12 24 36 48 60 72 84 96 108 120 132 144 Survival in months

PC-RPLND

PC-RPLND

0 12 24 36 48 60 72 84 96 108 120 132 144 Survival in months

Fig. 1. Adverse impact of redo-RPLND. Disease-specific survival for patients undergoing reoperative retroperitoneal surgery following primary RPLND (A) and PC-RPLND (B). (Data from McKiernan JM, Motzer RJ, Bajorin DF, et al. Reoperative RPLND for germ-cell tumor: clinical presentation, patterns of recurrence, and outcome. Urology 2003;62:732.)

chylous ascites requiring peritoneovenous shunting, and aortic injury resulting in lower-extremity amputation. Sexton and colleagues [42] recently reported the M.D. Anderson experience of 21 patients who underwent repeat RPLND and noted a 29% and 48% intraoperative and postoperative complication rate, respectively. Dissecting in an aortic subadventitial plane was reported in two cases, one requiring aortic grafting [42]. Postoper-atively, the most common complications were prolonged ileus and/or partial small-bowel obstruction, and chylous ascites. There was one postoperative death attributable to a pulmonary embolus [42].

In 2003, McKiernan [3] reported the reoperative retroperitoneal surgery experience from MSKCC and noted an overall 27% complication rate, not significantly different from the Indiana experience reported by Bainel (21%) for PC-RPLND without reoperation [3,43]. There was one death attributable to pulmonary embolus. The most common complications in this series of 61 reoperations were lymphocele [4], ileus [3], wound infection [2], small bowel obstruction (SBO) [2], ureteral injury [2] and renal infarction [1,3].

The data suggest that reoperative retroperito-neal surgery can be performed with acceptable morbidity in dedicated tertiary centers with experienced surgeons [3,7,8,42]. Careful preoperative planning, excellent exposure, and strict adherence to basic surgical principles are critical to minimize perioperative morbidity [8]. Achieving a complete resection is critical to avoid a repeat local recurrence and optimize the clinical outcome; sacrificing adjacent organs (kidney, bowel, spleen) or graft replacement of a great vessel may be necessary [8,44]. It is important to rule out occult systemic disease to minimize risk of extraretroper-itoneal relapse.

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