- Email: [email protected]
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective
european urology 54 (2008) 1004–1019
[47]
[48]
[49]
[50]
[51]
[52]
[53]
laparoscopic biopsy of sentinel lymph node in patients with clinical stage I testicular tumor. J Urol 2002; 168:1390–5. Holman E, Kovacs G, Fiasko T, et al. Hand-assisted laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular cancer. J Laparoendosc Adv Surg Tech A 2007;17:16–20. Davol P, Sumfest J, Rukstalis D. Robotic-assisted laparoscopic retroperitoneal lymph node dissection. Urology 2006;67:199. Weissbach L, Boedefeld EA, Horstmann-Dubral B. Surgical treatment of stage-I non-seminomatous germ cell testis tumor. Final results of a prospective multicenter trial 1982– 1987. Testicular Tumor Study Group. Eur Urol 1990;17: 97–106. Donohue JP, Foster RS. Retroperitoneal lymphadenectomy in staging and treatment. The development of nervesparing techniques. Urol Clin N Amer 1998;25:461–8. Eggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfield J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol 2007;177:937–43. Allaf ME, Bhayani SB, Link R, et al. Laparoscopic retroperitoneal lymph node dissection: duplication of the open technique. Urology 2005;65:575–7. Jewett MA, Kong YS, Goldberg SD, et al. Retroperitoneal lymphadenectomy for testis tumor with nerve sparing for ejaculation. J Urol 1988;139:1220–4.
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Paolo Fornara, M. Raschid Hoda Clinic for Urology and Kidney Transplantation Centre, University Medical School of Halle/Wittenberg, Halle, Germany [email protected] The present paper by Rassweiler et al is a review of the currently available literature on the evidence of laparoscopic retroperitoneal lymph node dissection (L-RPLND) in patients with clinical stage I nonseminomatous germ-cell tumour (NSGCT) [1]. A systematic search for randomised controlled trials or observational series was performed using three major medical literature databases, and results for >800 patients were analysed. The paper also contains a meta-analysis comparing L-RPLND with open retroperitoneal lymph node dissection (O-RPLND). Primary outcome parameters were disease-free survival and relapse rate. Secondary outcome parameters included perioperative mor-
1015
[54] Sebe P, Nouri M, Haab F, Doublet JD, Gattegno B, Thibault P. Metastasis to trocar after lymphadenectomy with retroperitoneal laparoscopy. Prog Urol 2001;11:307–9. [55] Williams SD, Stablein DM, Einhorn LH, et al. Immediate adjuvant treatment versus observation with treatment at relapse in pathological stage II testicular cancer. N Engl J Med 1987;317:1433–8. [56] Stephenson AJ, Bosl GJ, Motzer J, et al. Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection on outcome. J Clin Oncol 2005;23:2781–8. [57] Colleselli K, Poisel S, Schachtner W, Bartsch G. Nervepreserving bilateral retroperitoneal lymphadenectomy: anatomical study and operative approach. J Urol 1990; 144:293–8. [58] Albers P. Management of stage I testis cancer. Eur Urol 2007;51:34–44. [59] Rabbani F, Sheinfield J, Farivar-Mohensi H, et al. Lowvolume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse. J Clin Oncol 2001;17:2020–5. [60] Spermon JR, Witjes JA. The danger of postchemotherapy laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular cancer. J Endourol 2008; 22:1013–6. [61] Rassweiler J, Tsivian A, Kumar AV, et al. Oncological safety of laparoscopic surgery for urologic malignancy: experience with more than 1000 operations. J Urol 2003; 169:2072–5.
bidity and long-term complications. Despite longer operation room times, L-RPLND offered similar staging accuracy and long-term outcome to ORPLND. The postorchidectomy treatment for patients with clinical stage I NSGCT remains controversial because several therapeutic options, including surveillance, primary chemotherapy, and retroperitoneal lymph node dissection (RPLND), are available. The idea behind an adjuvant therapy after orchidectomy in low-risk patients is to treat possible occult metastasis, which could relapse if only surveillance is applied. Primary chemotherapy with a cisplatin, etoposide, and bleomycin (PEB) regimen has been proven to be as efficacious as O-RPLND. Both, however, are associated with side-effects or inherent morbidity of a large laparotomy incision. Due to the superior benefits of the minimally invasive nature of laparoscopic technique, L-RPLND has the potential to become the method of choice for patients requiring RPLND. The oncologic safety in terms of tumour control and the diagnostic accuracy of L-RPLND seem to be equal to the open procedure; however, the morbidity is significantly lower. Moreover, the functional and social convalescence and
1016
european urology 54 (2008) 1004–1019
quality of life has been reported to be better in patients receiving L-RPLND [2,3]. As pointed out by Rassweiler et al [1], the current potential for L-RPLND as a diagnostic and/or therapeutic tool is in clinical stage I NSGCT for cases in which no surveillance or chemotherapy are favoured by the patients. Regarding the curative role of RPLND (open or laparoscopic) in clinical stage IIA disease with low volume and in postchemotherapy stage IIA and IIB, some data from small-sized trials are available [4,5]. To clarify this issue, multicentre randomised trials with larger patient groups and longer follow-up are necessary and strongly encouraged. The use of laparoscopy was one of the most important steps in the progress of medicine in the 20th century. Laparoscopic radical nephrectomy is now considered the new gold-standard surgical treatment for benign renal masses as well as for localised renal cell carcinoma [6,7]. For radical prostatectomy, the laparoscopic approach provides promising results, which makes it likely to become the method of choice in the management of organconfined prostate cancer in the near future [8]. Nevertheless, laparoscopic techniques are associated with a learning curve. Hence, whenever reporting on laparoscopic methods (ie, L-RPLND), the adequate experience of the performing surgeon as well as that of the institution should be considered. For this purpose, hospital and surgeon case-load calculations to achieve optimum clinical outcome, already known from other surgical procedures, should also be applied to urologic laparoscopic procedures. As long as a high level of clinical evidence is not given for L-RPLND, only centres with adequate minimum case-load volume should be legitimate to perform this procedure.
References
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Peter Albers Du¨sseldorf University, Du¨sseldorf, Germany [email protected]
low-risk tumors (no vascular invasion) and chemotherapy for high-risk tumors [1]. In Canada, the options for this patient group include surveillance, even for patients with high-risk features, based on equal cancer-specific survival data of >98% [2]. In view of these management guidelines, the review of Rassweiler and colleagues [3] is important for this small subgroup of <10% of patients with NSGCT who (1) wish to be staged surgically; (2) have pure teratomatous tumors; and (3) are at high risk for recurrence, do not want to undergo surveillance, and have contraindications for chemotherapy. In these rare situations, the patient may choose between open and laparoscopic
Surgical staging in patients with clinical stage I nonseminomatous germ cell tumors (NSGCT) has become a rare recommendation. In Europe, the recommendation is for patients to undergo a risk-adapted treatment with surveillance for
[1] Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol 2008;54:1004–19. [2] Poulakis V, Skriapas K, De Vries R, et al. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006; 68:154–60. [3] Steiner H, Peschel R, Janetschek G, et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Urology 2004;63:550–5. [4] Weissbach L, Bussar-Maatz R, Flechtner H, Pichlmeier U, Hartmann M, Keller L. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment. Eur Urol 2000;37:582–94. [5] Neyer M, Peschel R, Akkad T, et al. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180–3. [6] Fornara P, Doehn C, Seyfarth M, Jocham D. Why is urological laparoscopy minimally invasive? Eur Urol 2000; 37:241–50. [7] Fornara P, Doehn C, Friedrich HJ, Jocham D. Nonrandomized comparison of open flank versus laparoscopic nephrectomy in 249 patients with benign renal disease. Eur Urol 2001;40:24–31. [8] Jurczok A, Zacharias M, Wagner S, Hamza A, Fornara P. Prospective non-randomized evaluation of four mediators of the systemic response after extraperitoneal laparoscopic and open retropubic radical prostatectomy. BJU Int 2007;99:1461–6.
DOI: 10.1016/j.eururo.2008.08.023 DOI of original article: 10.1016/j.eururo.2008.08.022
[47]
[48]
[49]
[50]
[51]
[52]
[53]
laparoscopic biopsy of sentinel lymph node in patients with clinical stage I testicular tumor. J Urol 2002; 168:1390–5. Holman E, Kovacs G, Fiasko T, et al. Hand-assisted laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular cancer. J Laparoendosc Adv Surg Tech A 2007;17:16–20. Davol P, Sumfest J, Rukstalis D. Robotic-assisted laparoscopic retroperitoneal lymph node dissection. Urology 2006;67:199. Weissbach L, Boedefeld EA, Horstmann-Dubral B. Surgical treatment of stage-I non-seminomatous germ cell testis tumor. Final results of a prospective multicenter trial 1982– 1987. Testicular Tumor Study Group. Eur Urol 1990;17: 97–106. Donohue JP, Foster RS. Retroperitoneal lymphadenectomy in staging and treatment. The development of nervesparing techniques. Urol Clin N Amer 1998;25:461–8. Eggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfield J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol 2007;177:937–43. Allaf ME, Bhayani SB, Link R, et al. Laparoscopic retroperitoneal lymph node dissection: duplication of the open technique. Urology 2005;65:575–7. Jewett MA, Kong YS, Goldberg SD, et al. Retroperitoneal lymphadenectomy for testis tumor with nerve sparing for ejaculation. J Urol 1988;139:1220–4.
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Paolo Fornara, M. Raschid Hoda Clinic for Urology and Kidney Transplantation Centre, University Medical School of Halle/Wittenberg, Halle, Germany [email protected] The present paper by Rassweiler et al is a review of the currently available literature on the evidence of laparoscopic retroperitoneal lymph node dissection (L-RPLND) in patients with clinical stage I nonseminomatous germ-cell tumour (NSGCT) [1]. A systematic search for randomised controlled trials or observational series was performed using three major medical literature databases, and results for >800 patients were analysed. The paper also contains a meta-analysis comparing L-RPLND with open retroperitoneal lymph node dissection (O-RPLND). Primary outcome parameters were disease-free survival and relapse rate. Secondary outcome parameters included perioperative mor-
1015
[54] Sebe P, Nouri M, Haab F, Doublet JD, Gattegno B, Thibault P. Metastasis to trocar after lymphadenectomy with retroperitoneal laparoscopy. Prog Urol 2001;11:307–9. [55] Williams SD, Stablein DM, Einhorn LH, et al. Immediate adjuvant treatment versus observation with treatment at relapse in pathological stage II testicular cancer. N Engl J Med 1987;317:1433–8. [56] Stephenson AJ, Bosl GJ, Motzer J, et al. Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection on outcome. J Clin Oncol 2005;23:2781–8. [57] Colleselli K, Poisel S, Schachtner W, Bartsch G. Nervepreserving bilateral retroperitoneal lymphadenectomy: anatomical study and operative approach. J Urol 1990; 144:293–8. [58] Albers P. Management of stage I testis cancer. Eur Urol 2007;51:34–44. [59] Rabbani F, Sheinfield J, Farivar-Mohensi H, et al. Lowvolume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse. J Clin Oncol 2001;17:2020–5. [60] Spermon JR, Witjes JA. The danger of postchemotherapy laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular cancer. J Endourol 2008; 22:1013–6. [61] Rassweiler J, Tsivian A, Kumar AV, et al. Oncological safety of laparoscopic surgery for urologic malignancy: experience with more than 1000 operations. J Urol 2003; 169:2072–5.
bidity and long-term complications. Despite longer operation room times, L-RPLND offered similar staging accuracy and long-term outcome to ORPLND. The postorchidectomy treatment for patients with clinical stage I NSGCT remains controversial because several therapeutic options, including surveillance, primary chemotherapy, and retroperitoneal lymph node dissection (RPLND), are available. The idea behind an adjuvant therapy after orchidectomy in low-risk patients is to treat possible occult metastasis, which could relapse if only surveillance is applied. Primary chemotherapy with a cisplatin, etoposide, and bleomycin (PEB) regimen has been proven to be as efficacious as O-RPLND. Both, however, are associated with side-effects or inherent morbidity of a large laparotomy incision. Due to the superior benefits of the minimally invasive nature of laparoscopic technique, L-RPLND has the potential to become the method of choice for patients requiring RPLND. The oncologic safety in terms of tumour control and the diagnostic accuracy of L-RPLND seem to be equal to the open procedure; however, the morbidity is significantly lower. Moreover, the functional and social convalescence and
1016
european urology 54 (2008) 1004–1019
quality of life has been reported to be better in patients receiving L-RPLND [2,3]. As pointed out by Rassweiler et al [1], the current potential for L-RPLND as a diagnostic and/or therapeutic tool is in clinical stage I NSGCT for cases in which no surveillance or chemotherapy are favoured by the patients. Regarding the curative role of RPLND (open or laparoscopic) in clinical stage IIA disease with low volume and in postchemotherapy stage IIA and IIB, some data from small-sized trials are available [4,5]. To clarify this issue, multicentre randomised trials with larger patient groups and longer follow-up are necessary and strongly encouraged. The use of laparoscopy was one of the most important steps in the progress of medicine in the 20th century. Laparoscopic radical nephrectomy is now considered the new gold-standard surgical treatment for benign renal masses as well as for localised renal cell carcinoma [6,7]. For radical prostatectomy, the laparoscopic approach provides promising results, which makes it likely to become the method of choice in the management of organconfined prostate cancer in the near future [8]. Nevertheless, laparoscopic techniques are associated with a learning curve. Hence, whenever reporting on laparoscopic methods (ie, L-RPLND), the adequate experience of the performing surgeon as well as that of the institution should be considered. For this purpose, hospital and surgeon case-load calculations to achieve optimum clinical outcome, already known from other surgical procedures, should also be applied to urologic laparoscopic procedures. As long as a high level of clinical evidence is not given for L-RPLND, only centres with adequate minimum case-load volume should be legitimate to perform this procedure.
References
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Peter Albers Du¨sseldorf University, Du¨sseldorf, Germany [email protected]
low-risk tumors (no vascular invasion) and chemotherapy for high-risk tumors [1]. In Canada, the options for this patient group include surveillance, even for patients with high-risk features, based on equal cancer-specific survival data of >98% [2]. In view of these management guidelines, the review of Rassweiler and colleagues [3] is important for this small subgroup of <10% of patients with NSGCT who (1) wish to be staged surgically; (2) have pure teratomatous tumors; and (3) are at high risk for recurrence, do not want to undergo surveillance, and have contraindications for chemotherapy. In these rare situations, the patient may choose between open and laparoscopic
Surgical staging in patients with clinical stage I nonseminomatous germ cell tumors (NSGCT) has become a rare recommendation. In Europe, the recommendation is for patients to undergo a risk-adapted treatment with surveillance for
[1] Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol 2008;54:1004–19. [2] Poulakis V, Skriapas K, De Vries R, et al. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006; 68:154–60. [3] Steiner H, Peschel R, Janetschek G, et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Urology 2004;63:550–5. [4] Weissbach L, Bussar-Maatz R, Flechtner H, Pichlmeier U, Hartmann M, Keller L. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment. Eur Urol 2000;37:582–94. [5] Neyer M, Peschel R, Akkad T, et al. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180–3. [6] Fornara P, Doehn C, Seyfarth M, Jocham D. Why is urological laparoscopy minimally invasive? Eur Urol 2000; 37:241–50. [7] Fornara P, Doehn C, Friedrich HJ, Jocham D. Nonrandomized comparison of open flank versus laparoscopic nephrectomy in 249 patients with benign renal disease. Eur Urol 2001;40:24–31. [8] Jurczok A, Zacharias M, Wagner S, Hamza A, Fornara P. Prospective non-randomized evaluation of four mediators of the systemic response after extraperitoneal laparoscopic and open retropubic radical prostatectomy. BJU Int 2007;99:1461–6.
DOI: 10.1016/j.eururo.2008.08.023 DOI of original article: 10.1016/j.eururo.2008.08.022