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Long–Term Experience with Laparoscopic Retroperitoneal Lymph Node Dissection in the Management of Low–Stage Testis Cancer

Objectives: We describe our experience with laparoscopic retroperitoneal lymphadenectomy (LRLA) in 34 patients with low–stage germ cell tumors treated from 1992 to 1998. All patients had clinical stage–I disease with no clinical evidence (CT scan, ultrasound, tumor markers) of metastases. A laparoscopic dissection was used to assess the pathologic status of the relevant retroperitoneal lymph nodes. Material and Methods: 17 patients were treated by a transperitoneal laparoscopic approach, whereas in the last 17 patients retroperitoneoscopic retroperitoneal lymph node dissection was performed. The lymph node dissection was performed identically to open surgery with the modified template according to Weissbach including the paracaval, interaortocaval, upper pre–aortic, and right common iliac zonal nodes for right–sided tumors, and para–aortic, upper pre–aortic zones for left–sided tumors. Retrieval of the lymph node chains was accomplished using a small organ bag. Results: The procedure could be completed successfully in 30 of 34 patients with stage–I disease. In these cases the mean duration of the procedure was 248 min. In 3 patients the lymphadenectomy was abandoned, because frozen section showed metastasis. In 1 case conversion to open surgery was necessary because of bleeding from the aorta. One patient developed a delayed ureteral stenosis which required operative repair. Three patients required temporary insertion of an indwelling ureteral stent, and another patient had a pulmonary embolism with an uneventful outcome. One patient with a LRLA on the right side later developed retrograde ejaculation. In 6 of the 33 patients (18%) embryonal carcinoma or mixed carcinoma was found. The postoperative hospital stay averaged 5.3 (3–9) days for the patients without complications or conversion to open surgery. After a median follow–up of 40 months no regional relapse occurred, but 2 patients developed pulmonary metastases which were treated successfully by three cycles of platinum–based chemotherapy. All patients have no evidence of disease. Conclusions: Our experience suggests that LRLA is a safe and accurate method for low–stage germ cell tumors with minimal invasiveness, but because of its technical difficulty it should be restricted to experienced centers.