Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status

Urologic Oncology: Seminars and Original Investigations 22 (2004) 145–148

Seminar article

Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status Sam B. Bhayani, M.D., Mohamad E. Allaf, M.D., Louis R. Kavoussi, M.D.* Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA

Abstract The purpose of the study was to update the current status of laparoscopic retroperitoneal lymph node dissection in the treatment of clinical Stage I nonseminomatous germ cell testicular cancer. A literature search was conducted to evaluate laparoscopic retroperitoneal lymph node dissection (RPLND) in comparison to other modalities of treatment. All treatment modalities are effective in treating clinical Stage I nonseminomatous germ cell tumors. Morbidity is the major issue that may guide treatment decisions. Laparoscopic RPLND, in its therapeutic form, may replicate open RPLND with a minimally invasive approach. Laparoscopic RPLND is an effective alternative to traditional treatment options. © 2004 Elsevier Inc. All rights reserved. Keywords: Testis cancer; Lymphadenectomy; Retroperitoneal lymph node dissection; Germ cell tumor

Introduction Patients with clinical Stage I nonseminomatous germ cell testicular tumors (NSGCT) have several treatment options including surveillance, primary chemotherapy, and open retroperitoneal lymph node dissection (RPLND). Despite the efficacy of open RPLND, approximately 70% of patients have pathologically negative nodes, and derive no therapeutic benefit from surgery [1– 4]. Laparoscopic RPLND was developed to allow for the diagnostic and therapeutic benefits of open RPLND, without its inherent morbidity. Although skepticism still exists, proponents of laparoscopic RPLND are demonstrating that the technique duplicates open RPLND and may serve as a major option to treat clinical Stage I NSCGT [5]. Open RPLND has been under scrutiny as a treatment option for clinical Stage I NSGCT. As most patients are cured regardless of which treatment they choose, morbidity of the treatment becomes the major treatment issue. Although the long-term morbidity of open RPLND is minimal, the procedure relies on a large and cosmetically undesirable incision, with significant convalescence times and perma-

* Corresponding author. Tel.: ⫹1-410-502-7710; fax: ⫹1-410-5027711. E-mail address: [email protected] (L.R. Kavoussi). 1078-1439/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.urolonc.2004.01.006

nent physical scars. Primary chemotherapy, largely used in Europe, has equal efficacy as the open RPLND, and additionally will treat disease outside of the retroperitoneum [6]. However, long term side effects of primary chemotherapy remain, including cardiac toxicity, infertility and late hematological malignancy. Laparoscopic RPLND can be used as a staging or a therapeutic procedure. As 70% of patients undergoing open RPLND or chemotherapy are treated unnecessarily (as they have no metastases), a minimally morbid approach to staging the retroperitoneum is highly attractive. In European series, laparoscopic RPLND serves this purpose, and helps to delineate those who have metastases and require chemotherapy vs. those who may be more safely observed. In this form, laparoscopic RPLND is typically performed without retrocaval or retroaortic dissection, and is used to delineate pathological status [7]. As a therapeutic procedure, laparoscopic RPLND is also effective. Because the goal of the therapeutic procedure is to limit retroperitoneal relapse, all nodal tissue within the template is excised, including retroaortic and retrocaval tissue. This approach, currently used at our institution, limits relapses to outside the template, and may be offered as a singular primary treatment option, analogous to open RPLND. Patients with pathological Stage II disease can then be observed or treated with chemotherapy per their preference.

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Table 1 Treatment options for clinical stage I nonseminomatous germ cell tumors Treatment Surveillance

Typical recurrence 30%

Recurrence treated with

Success rate

Advantages

Disadvantages

3 cycles Chemotherapy

⬎95%

Chemotherapy or Surgery Chemotherapy

⬎95%

No patients treated unnecessarily No invasive procedures

Requires rigorous follow-up, 3 cycles chemotherapy significantly more toxic than 2 70% of patients treated unnecessarily

⬎95%

Accurate staging

Accurate Staging with advantages of laparoscopy Accurate staging with advantages of laparoscopy

70% patients treated unnecessarily with laparotomy incision, 30% of pIIa patients recur Patients with positive nodes receive 2 treatments (laparoscopy and chemo)

Primary chemotherapy

⬍5%

Open RPLND

⬍5%

Staging Lap RPLND with 2 cycles chemo for positive nodes Therapeutic lap RPLND

⬍5%

Chemotherapy or Surgery

⬎95%

⬍5%

Chemotherapy

⬎95%

Technique of laparoscopic RPLND

The technique varies somewhat among institutions. Our approach involves placement of 4 trocars in the midline [8]. All of the trocars are 10/12 mm ports, thus allowing easy introduction of the camera, clips, or stitches through any access point. The limits of the dissection of laparoscopic RPLND mirror what has been recommended for the open approach; on the right the boundaries are the ureter, the renal vessels, the aorta and the common iliac artery. On the left the boundaries are the ureter, the vena cava, the common iliac artery and the renal vessels. The inferior mesenteric artery is spared in both templates. Of note, if necessary the field can be extended. After gaining access, the colon is reflected and the retroperitoneum is exposed. The spermatic cord remnant is excised completely and the gonadal vein is dissected to the IVC or the left renal vein and excised with its lymphatic supply. The ureter is found as it crosses the iliac vessels. All lymphatic tissue between the ureter and the great vessels is excised. This includes the paraaortic tissue and the paracaval tissue on the left and right respectively. The interaortocaval nodes are removed in both templates. Nodal tissue is also removed behind the aorta or vena cava depending on the side of the template. Dissection of these areas usually requires division of the lumbar vessels with clips and complete mobilization of the great vessels. As such, the interaortocaval, retroaortic and retrocaval tissue can be carefully dissected without injury to the sympathetic chain or its branches. Bleeding can usually be controlled with clips, suturing, or direct compression on the injured structure. Tissue sealants or glues may also be selectively used. The specimens are placed into small removal sacs and extracted through a

Most patients have received chemotherapy because of philosophy of oncologists; without chemotherapy results should mirror open RPLND. More studies are needed

trocar site. Patients typically spend 2 days in the hospital, and resume usual activities within 2 weeks.

Efficacy of treatment options All treatments of clinical Stage I nonseminomatous testicular cancer are effective (Table 1), thus, the choice for treatment is ultimately dependent on patient preference and comfort with treatment modalities. Surveillance has the advantage of having no patients unnecessarily treated. The main disadvantage is the 3 cycles of chemotherapy involved for recurrence. Primary chemotherapy unnecessarily treats 70% of patients who garner no advantage since they harbor no metastases. These patients are exposed to real long term sequelae. Open RPLND has the same disadvantage of over treatment in 70% of patients and additionally patients have the lifelong cosmetic disadvantage of the open incision. Furthermore, 30% of patients with metastases will recur and require chemotherapy. Staging RPLND can address metastases with minimal long term morbidity, but requires 2 cycles of adjuvant chemotherapy. Therapeutic laparoscopic RPLND offers all the advantages of open RPLND, without the incision, but studies often include treatment with chemotherapy and randomized studies are lacking. Unfortunately, high volume centers treating testis cancer have been slow to adopt laparoscopic techniques and as such, comparing the efficacy of open RPLND to laparoscopic RPLND is difficult and requires indirect measures. These comparisons are confounded by surgical differences between the major centers performing RPLND, and by philosophical differences with regard to postoperative chemotherapy.

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All laparoscopic RPLNDs are not equal. In the Austrian series, laparoscopic RPLND the clinical Stage I patient is performed as a staging tool, and nodes are not routinely removed posterior to the lumbar vessels. The rationale for performing this more limited RPLND relies on the lack of an isolated retrocaval or retroaortic positive node based on pathological analyses of the authors’ series [7]. Furthermore, as the procedure is performed as a staging procedure, the goal is to identify patients who require chemotherapy, and then treat those with positive nodes. In the Johns Hopkins experience, the procedure has evolved. Initially, the procedure was aborted if multiple positive nodes were found, as chemotherapy would be instituted in these cases [9]. As technological advances in instrumentation, suturing, and hemostasis have evolved, a traditional approach is the norm. Currently, an exact replication of the open template is performed on all patients with clinical Stage I NSGCT, with complete excision of retroaortic and retrocaval tissue, thus rendering the procedure both a staging and therapeutic procedure. Despite the more complete lymphatic excision of therapeutic laparoscopic RPLND, it is the philosophy of some medical oncology departments to routinely give 2 cycles of chemotherapy in all patients with positive nodes at lymphadenectomy, rather than risk the chance of recurrence and progression and later treatment with a higher dose of chemotherapy. It is unknown if the long term sequelae with a modified chemotherapy regimen is similar to that seen with traditional 3 cycles. Despite this philosophy, from a surgical perspective, the replication of the open template should be performed to maintain established oncological principles, particularly if a patient with pathological Stage IIa disease should choose observation rather than adjuvant treatment. In the largest US center the traditional philosophy of the oncologists has been to treat with adjuvant chemotherapy. This has elicited one major concern: is the laparoscopic RPLND an adequate “clean-out” of the retroperitoneum or is the chemotherapy masking retroperitoneal nodes which were missed? This question can easily be answered with another method to compare the open and laparoscopic RPLND: examination of the patients with pathological Stage I disease. If the laparoscopic RPLND were inadequate, certainly patients would be misdiagnosed with pathological Stage I disease, and the positive lymph nodes in the retroperitoneum would be missed, thus leading to a retroperitoneal recurrence. This supposition has not occurred, as no retroperitoneal recurrences have been reported in the Hopkins series or more recent data from the University of Washington [5,10]. Despite the indirect efficacy of laparoscopic RPLND, a randomized direct comparison to open RPLND is theoretically the best approach to establish equal efficacy. Such a comparison has not been performed with other accepted laparoscopic procedures such as tubal ligation, cholecystec-

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tomy, gastric fundoplication, adrenalectomy, nephrectomy or nephroureterectomy. With these procedures, it has been apparent that the laparoscopic approach differs from the open approach primarily with regard to access of the abdomen, and intrabdominal manipulations are similar, if not exact. The oncological community has not assessed laparoscopic RPLND with these same standards, but ultimately, as more centers offer therapeutic laparoscopic RPLND, the procedure will replace the open procedure as a new standard to treat clinical Stage I NSGCT.

Complications of laparoscopic RPLND The major complication reported during laparoscopic RPLND is hemorrhage [5,9]. Early in the experience of the procedure hemorrhage necessitated conversion to an open procedure and occasionally blood transfusion. These complications reflect a different era of laparoscopic surgery, in which instrumentation, suturing technology, and hemostatic aids were not available. Currently, techniques have been developed to deal with potential hemorrhage. Lymphocele formation is also a complication, more commonly seen in early experience. As with open surgery, this can be avoided with careful clipping of lymphatic channels. Retrograde ejaculation has been reported at a rate similar to that seen with open RPLND [5].

Conclusions Laparoscopic RPLND for the treatment of clinical Stage I NSGCT has evolved into an excellent alternative to traditional modes of therapy. The procedure can replicate the advantages of open RPLND without the morbidity of a large incision. Although all treatment modalities are effective in low stage NSGCT, laparoscopic RPLND offers a minimally invasive approach to the disease. Further studies comparative studies of primary chemotherapy, open RPLND, and laparoscopic RPLND are needed from high volume centers to further elucidate differences in therapy.

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[5] Bhayani SB, Ong A, Oh WK, et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003;62(2):324 –7. [6] Jones RH, Vasey PA. Part I: testicular cancer-management of early disease. Lancet Oncol 2003;4(12):730 –7. [7] Janetschek G, Peschel R, Hobisch A, et al. Laparoscopic retroperitoneal lymph node dissection. J Endourol 2001;15(4):449–53; discussion 453–5.

[8] Bischoff JT, Kavoussi LR. Atlas of laparoscopic retroperitoneal surgery. Philadelphia: W.B. Saunders, 2000. [9] Nelson JB, Chen RN, Bishoff JT, et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular tumors. Urology 1999;54(6):1064 –7. [10] Porter J. Laparoscopic retroperitoneal lymph node dissection. In: Smith’s textbook of endourology, 2nd ed (in press).