Oncological outcome and complications of post-chemotherapy retroperitoneal surgery in non-seminomatous germ cell tumours - a systematic review

Postchemotherapy Retroperitoneal Lumpectomy in Patients with Nonseminoma Testicular Cancer: A Nationwide Study

BACKGROUND AND OBJECTIVE

Optimal treatment outcomes in patients with metastatic nonseminoma testicular cancer are achieved with chemotherapy and subsequent surgery in cases with residual tumor. In Denmark, postchemotherapy retroperitoneal lumpectomy (RPLP) is performed in patients with residual tumors >1 cm. There is a need to clarify whether this surgical method provides acceptable treatment results. Our objective was to describe morbidity and oncological outcomes of postchemotherapy RPLP.

METHODS

This was a retrospective population-based multicenter study including patients with nonseminoma testicular cancer and postchemotherapy RPLP performed in Denmark between 1990 and 2015. A total of 219 patients were eligible, with median follow-up of 19 yr. Postoperative complications were evaluated according to the Clavien-Dindo classification. The cumulative incidence of recurrence inside or outside the borders of a bilateral surgical template, progression-free survival (PFS), and overall survival estimates were calculated using the Kaplan-Meier method.

KEY FINDINGS AND LIMITATIONS

After median follow-up of 19 yr, 31/219 patients (14%) experienced a surgical complication, of which 5% were Clavien-Dindo grade ≥III. In total, 37 patients experienced a recurrence. The 5-yr, 10-yr, and 20-yr cumulative risk of recurrence inside a bilateral template was 4.3%, 5.9%, and 5.9%, respectively. The 10-yr PFS rate was 83% and the 10-yr overall survival rate was 96%. The main limitation of the study is the retrospective design.

CONCLUSIONS AND CLINICAL IMPLICATIONS

With few patients experiencing a major postoperative complication and a 10-yr cumulative rate of 5.9% for recurrence inside a bilateral surgical template, postchemotherapy RPLP appears to be a safe alternative to template surgery for disseminated nonseminoma.

PATIENT SUMMARY

We looked at minimal surgery to remove tumor tissue remaining after chemotherapy in patients with testicular cancer. We found a low frequency of complications, tumor recurrence, and death.

The role of robotic retroperitoneal lymph node dissection in testicular cancer: a systematic review and meta-analysis

OBJECTIVE

To compare the safety and efficacy of robotic-assisted retroperitoneal lymph node dissection (RA-RPLND) versus non-robotic retroperitoneal lymph node dissection in testicular cancer.

METHODS

The statistical analysis software used Stata 17. The weighted mean difference (WMD) represents the continuous variable, and the dichotomous variable chooses the odds ratio, and calculates the 95% CI. This systematic review and cumulative meta-analysis was performed according to PRISMA criteria, and AMSTAR guidelines (assessing the methodological quality of systematic reviews). The Embase, PubMed, Cochrane Library, Web of Science, and Scopus databases were searched. The upper limit of the search time frame was February 2023, and no lower limit was set.

RESULTS

Seven studies involving 862 patients. Compared with open retroperitoneal lymph node dissection, RA-RPLND appears to have a shorter length of stay [WMD=-1.21, 95% CI (-1.66, -0.76), P <0.05], less estimated blood loss [WMD=-0.69, 95% CI (-1.07, -0.32), P <0.05], and lower overall complications [odds ratio=0.45, 95% CI (0.28, 0.73), P <0.05]. RA-RPLND appears to have more lymph node yields than laparoscopic retroperitoneal lymph node dissection [WMD=5.73, 95% CI (1.06, 10.40), P <0.05]. However, robotic versus open/laparoscopic retroperitoneal lymph node dissection had similar results in operation time, lymph node positivity rate, recurrence during follow-up, and postoperative ejaculation disorders.

CONCLUSION

RA-RPLND appears to be safe and effective for testicular cancer, but longer follow-up and more studies are needed to confirm this.

Perioperative complications and oncological outcomes of post-chemotherapy retroperitoneal lymph node dissection in patients with germ cell cancer at two high-volume university centres in Switzerland - a retrospective chart review

BACKGROUND

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an integral part of the management of patients with metastatic non-seminoma and residual masses >1 cm after chemotherapy.

AIMS

To assess perioperative complications and oncological outcomes at two major referral centres in Switzerland.

METHODS

This was a retrospective chart review of 136 patients with non-seminoma who underwent PC-RPLND between 2010 and 2020 at the university hospitals of Bern and Zürich. Patient, treatment and tumour characteristics as well as the types and frequencies of intra- and postoperative complications were registered and compared using the chi-square test. Oncological outcomes consisted of the time and location of relapses as well as progression-free and overall survival, which were compared using the log-rank test.

RESULTS

Overall, 70 patients from Bern and 66 patients from Zürich were included; 5 patients had a previous retroperitoneal lymph node dissection (RPLND) (2 Bern, 3 Zürich). Vascular injuries were the most frequent intraoperative complication, occurring in 27/136 (19.9%) patients. Postoperative complications were observed in 42/136 (30.9%) patients, ileus being the most common. Perioperative mortality was 2.2%. A retroperitoneal mass ≥50 mm was significantly associated with intraoperative complications (p = 0.004) and increased resource demands (p = 0.021). Postoperative morbidity was higher according to age at post-chemotherapy retroperitoneal lymph node dissection ≥40 years (p = 0.028) and retroperitoneal mass ≥20 mm (p = 0.005). The median follow-up time was 37 months (interquartile range [IQR] 18-64 months). The median progression-free survival at 5 years was 76% (95% confidence interval [CI]: 64-85%) in Bern and 69% (95% CI: 54-80%) in Zürich (p = 0.464). The median overall survival at 5 years was 88% (95% CI: 76-94%) in Bern and 77% (95% CI: 60-87%) in Zürich (p = 0.335). Patients with progressive disease or a tumour marker increase before retroperitoneal lymph node dissection had significantly inferior progression-free and overall survival compared to non-progressing patients. The presence of teratoma in resected specimens did not confer inferior survival probabilities compared to necrosis only, whereas the presence of vital undifferentiated tumour conferred inferior progression-free and overall survival. Patients with a previous retroperitoneal lymph node dissection and patients operated for late relapses >2 years after chemotherapy also had significantly inferior progression-free and overall survival.

CONCLUSIONS

We found a relevant rate of severe perioperative complications at PC-RPLND at even experienced high-volume centres. The oncological outcomes at two major university urological centres in Switzerland were similar and determined by preoperative risk factors and intraoperative histology.

Robot-assisted retroperitoneal lymph node dissection for post-chemotherapy residual mass in testicular cancer: Long-term experience from a tertiary care centre

Objectives

To present our intermediate to long-term oncological and functional outcomes of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in post-chemotherapy (PC) residual mass in testicular cancers. To the best of our knowledge, this is the largest single-centre experience of RA-RPLND for in such setting.

Methods

Prospectively maintained database of carcinoma testis patients undergoing RA-RPLND from February 2012 to September 2021 was reviewed. Patient demographics, tumour stage and risk groups and chemotherapy details were recorded. Intraoperative details and post-operative complications were also noted. Pathological outcomes included were lymph node yield and histopathology report. Further, follow-up was done for recurrence and antegrade ejaculation status.

Results

Total of 37 cases were done for PC residual masses. International germ cell cancer collaborative group good, intermediate and poor risk proportion was 18 (48.6%), 14 (37.8%) and 5 (13.5%), respectively. Bilateral full template dissection, unilateral modified template dissection and residual mass excision was performed in 59.5% (22/37), 35.1% (13/37) and 5.4% (2/37) patients, respectively. The median size of the excised residual mass was 3.45 cm interquartile range (IQR 2-6 cm), with the largest being 9 cm. The median lymph nodal yield was 19. The most common histology was necrosis (n = 24, 65%), followed by teratoma (n = 11, 30%) and viable malignancy (n = 2, 5%). Antegrade ejaculation was reported in 32 patients (86.4%). After a median follow-up of 41 (IQR 14-64) months, only one patient had a recurrence.

Conclusions

RA-PC-RPLND is thus a safe, feasible and oncologically effective option for selected patients. With increasing experience, larger masses can also be dealt with efficiently.