Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Testicular Cancer: Radical or Modified Template Resection

BackgroundThe anatomical extent of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) has been discussed controversially for many years.ObjectiveTo evaluate the necessity of PC-RPLND with modified or radical template resection in patients with advanced nonseminomatous germ-cell tumors (NSGCT) and residual masses following systemic chemotherapy.Design, setting, and participantsThe charts of 152 consecutive patients who were treated at two tertiary referral centers were retrospectively reviewed.InterventionAll patients underwent PC-RPLND, with 54 and 98 patients undergoing a radical template resection and 98 patients undergoing a modified template resection. Modified template resection was performed if the location of the residual mass corresponded to the primary landing zone of testis cancer and the residual mass measured ≤5 cm in diameter. In all other cases a full bilateral PC-RPLND was chosen.MeasurementsThe following data were analyzed: location of the residual mass, extent of surgery, length of surgery, treatment-associated complications, nerve- sparing approach, adjunctive surgical procedures, postoperative morbidity, duration of hospital stay, early and late complications, relapse rates, cancer-specific survival rates, and overall survival rates.Results and limitationsOverall, 84 patients (55.2%) had necrosis/fibrosis, 45 (29.6%) had mature teratoma, and 23 (15.1%) had vital cancer in the surgical specimens. Antegrade ejaculation was preserved in 85% and 25% of patients undergoing modified and bilateral PC-RPLND (p = 0.02), respectively. Eight recurrences (5.2%) were observed after a mean follow-up of 39 mo (range 6–105 mo): one patient had an in-field relapse following modified PC-RPLND, and seven patients had recurrences outside the boundaries of full bilateral PC-RPLNDs. The 2-yr disease-free survival rates were 78.6% and 92.8% for bilateral and modified PC-RPLND, respectively. The limitations of this study were a short follow-up, a limited number of patients, and the retrospective nature of the study.ConclusionsFull bilateral PC-RPLND is the standard approach to extensive residual masses. In well-defined masses a modified template PC-RPLND does not interfere with oncologic outcome but decreases treatment-associated morbidity.