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NON-RISK ADAPTED SURVEILLANCE IN STAGE I NONSEMINOMATOUS GERM CELL TUMOURS (NSGCT): IMPROVED RECENT OUTCOMES
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58
SPERM ANALYSIS AFTER ADJUVANT SINGLE-AGENT CARBOPLATIN THERAPY FOR STAGE I SEMINOMA
BILATERAL LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION
Leonhartsberger N., Stoehr B., Granig T., Bartsch G., Steiner H.
Steiner H., Bartsch G., Stoehr B., Granig T., Peschel R.
Medical University Innsbruck, Dept. of Urology, Innsbruck, Austria
Medical University Innsbruck, Dept. of Urology, Innsbruck, Austria
Introduction & Objectives: Radiotherapy has been considered as standard adjuvant treatment for clinical Stage I seminoma for long time. The introduction of cisplatinbased chemotherapy has improved patient recovery dramatically. Although it is well known that carboplatin is a drug that binds directly to DNA, which is the presumptive method for killing cells, the mechanism of action of carboplatin on spermatozoa is unclear. Long-term toxicity becomes an important issue in this young age group of patients, and fertility especially has long-lasting consequences for their sexuality and quality of life. We analyzed the long-term damage to gonadal function and evaluated fertility of patients with clinical stage I seminoma after high-dose chemotherapy.
Introduction & Objectives: The laparoscopic approach to RPLND has always been FULWLFL]HGIRUDYHU\VPDOOWHPSODWHDQGDQXQSURYHQRQFRORJLFDOHᚑFDF\DVDOOFOLQLFDO stage I patients found LN+ at RPLND received additional chemotherapy. Therefore, a ODSDURVFRSLFELODWHUDOSURFHGXUHKDVEHHQGHYHORSHGLQFOXGLQJSURVSHFWLYHLGHQWLᚏFDWLRQ and sparing of the sympathetic nerves.
Material & Methods: Thirty patients patients with clinical stage I seminoma were treated with two postoperative adjuvant courses of carboplatin (400mg/m2 body VXUIDFHDUHDVFKHGXOHGIRUGD\VDQG LQRXUKRVSLWDO0HDQDJHZDV\HDUV $OO SDWLHQWV KDG KLVWRORJLFDOO\ FRQᚏUPHG VHPLQRPD ZLWK UHVHFWLRQ PDUJLQV IUHH RI tumour. Adjuvant chemotherapy was started approximately 14 days after operation. All patients underwent semen analysis more than 12 months after chemotherapy with at OHDVWGD\VRIVH[XDOLQDFWLYLW\6SHUPHYDOXDWLRQIURPDQWHJUDGHHMDFXODWLRQLQFOXGHG sperm density, motility, volume and percentage of vital and abnormal spermatozoa. Data on gonadal function (serum hormone levels) were obtained, too. Results: No data were available on spermatogenesis before chemotherapy. Normal spermatogenesis after chemotherapy was observed in 16 of 29 patients (55,17%), SDWLHQWVUHPDLQHGROLJRVSHUPLF7KHIROORZXSSHULRGZDVVLPLODULQERWKJURXSV The mean sperm concentration in non-oligospermic patients was 45,25 million./ mL., in oligospermic patients 5,75 million/mL. Motility was reduced in both groups, QRQROLJRVSHUPLF SDWLHQWV VKRZHG FRPSDUHG WR LQ WKH ROLJRVSHUPLF JURXS 1R VLJQLᚏFDQW GLVRUGHU LQ YLWD ORJ\ DQG VSHUP PRUSKRORJ\ ZDV REVHUYHG Testosterone, FSH and LH levels were within normal range. Conclusions: Spermatogenesis recovers after carboplatin in most patients. Even before orchiectomy spermatogenesis is often impaired in men with testicular cancer. Therefore patients should also be informed about the risk of infertility and cryopreservation of semen before treatment.
Material & Methods: From July 2004 until September 2007, 40 patients with nonseminomatous germ cell tumour (stage I: 19 pts, stage IIA marker negative: SDWLHQWV VWDJH ,,% DIWHU FKHPRWKHUDS\ SDWLHQWV XQGHUZHQW D WR SRUW transperitoneal laparoscopic bilateral RPLND. In stage I patients the contra lateral area below the inferior mesenteric artery was spared, in all other patients a complete bilateral template was cleared. Bilateral nerve-sparing technique was performed in all patients but 4 stage IIB patients with residual masses, in these patients only contralateral nerve-sparing was done out of oncological reasons. Results: Surgery was successfully completed in all patients, no conversion to open VXUJHU\ZDVQHFHVVDU\0HDQRSHUDWLYHWLPHIRUVWDJH,ZDVPLQ UDQJHದ DQGPLQXWHV UDQJHದ IRUVWDJH,,0HDQEORRGORVVZDVPO UDQJHದ 650). No intraoperative complication occurred. Postoperative complications were small asymptomatic lymphoceles in 11 pts and a large lymphocele requiring fenestration in 2 patients. Mean postoperative hospital stay was 4.9 days (range 4 - 6). Antegrade HMDFXODWLRQZDVSUHVHUYHGLQRISDWLHQWV2IDOOSWVZLWKRXWSULRUFKHPRWKHUDS\ (stage I and stage IIA marker negative) 18 pts had no tumour in the retroperitoneum, while in 5 pts active tumour was found in the RPLND specimen (N1). No adjuvant chemotherapy was administered. In 5 out of 17 post chemotherapy patients tumour was found in RPLND specimen (teratoma in 4 pts, active tumour in 1 pt). After a mean follow up of 16 months (range 1-40) 1 pulmonary recurrence occurred in a patient with negative retroperitoneal histology and this pt. was cured by cisplatin based chemotherapy. All other stage I and stage II patients are alive and free of disease. Conclusions: Bilateral nerve-sparing L-RPLND is technically feasible, the oncologic HᚑFDF\ RI WKLV DSSURDFK LV FXUUHQWO\ XQGHU HYDOXDWLRQ DQG ZLOO EHFRPH FOHDU DIWHU D longer follow up time.
59
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OPERATIVE MORBIDITY IN LAPAROSCOPIC RETROPERITONEAL LYMPH-NODE DISSECTION IN CLINICAL STAGE A NONSEMINOMATOUS TESTIS CANCER
NON-RISK ADAPTED SURVEILLANCE IN STAGE I NONSEMINOMATOUS GERM CELL TUMOURS (NSGCT): IMPROVED RECENT OUTCOMES
Castillo O.1, Rioja J.2, Sanchez-Salas R.1, Velasco A.1, Vidal I.1
Jewett M.1, Moore M.2, Warde P., Anson-Cartwright L., Kakiashvili D.1, Berthold D.2, Alison R.2, Duran I.2, Pond G.4, Sturgeon J.2
1
Clinica Santa Maria, Section of Endourology and Laparoscopic Urology, Dept. of Urology, Santiago de Chile, Chile, 2Clinica Universitaria de Navarra, Dept. of Urology, Pamplona, Spain Introduction & Objectives: Retroperitoneal lymph node dissection is an alternative treatment for clinical stage A non seminoma testicular cancer patients. This work shows the immediate results of a consecutive series of operated by a laparoscopic fashion Material & Methods: Surgical results of 118 patients with non seminoma testis cancer, with clinical stage A, operated in a consecutive manner. Surgical data was collected in a prospective way surgical technique has been described before, and basically consists in a transperitoneal access to, with a 4 trocars approach. 7KHFODVVLFDOOLPLWVIRUDUHWURSHULWRQHDOO\PSKQRGHGLVVHFWLRQPRGLᚏHGZLWKD nerve sparing technique. Results: Mean age was 29 years (range 15 to 44 years). The dissection was right in 64 cases and left in 54 cases. The average blood loss was 50 c.c. (Range 10 WRFF PHDQVXUJLFDOWLPHZDVPLQ 5DQJHWRPLQ DQGPHDQ in hospital stay was 41,4 hours (range 12 to 120 hours).Mean number of lymph QRGHVUHPRYHGZDV ,QWUDRSHUDWLYHFRPSOLFDWLRQVKDSSHQHGLQ patients (10,2%), 10 hemorrhage injuries (8,5%), 1 duodenal lesion (0,85%). In the periperative period 1 patient presented with acute pulmonary edema (0,85%). Of the 11 surgical lesions, 8 were solved laparoscopically fashion, and only three of them require conversion to open surgery. (1 lumbar vein tear, 1 burn lesion of KHLOLDFDUWHU\DQGFDYDYHLQLQMXU\EHFDXVHᚏUVWWURFDUSODFHPHQW 7KHUHZDV no mortality in these serie Conclusions: Laparoscopic retroperitoneal lymph node dissection is a valid alternative to the open approach, with an acceptable complication rate. At least in experienced hands the majority of them can be solved in a laparoscopic manner
1
Princess Margaret Hospital, University of Toronto, Dept. of Surgical Oncology, Toronto, Canada, 2Princess Margaret Hospital, University of Toronto, Dept. of Medical Oncology, Toronto, Canada, Princess Margaret Hospital, University of Toronto, Dept. of Radiation Oncology, Toronto, Canada, 4Princess Margaret Hospital, University of Toronto, Dept. of Biostatistics, Toronto, Canada Introduction & Objectives: Since 1981 the Princess Margaret Hospital testicular cancer group has used surveillance as the preferred management option for all patients (pts) with FOLQLFDOVWDJH,16*&7,QDUHSRUWRIWKHᚏUVWSWV>6WXUJHRQHWDO-&OLQ2QFRO @WKH UHODSVHUDWHZDVDQGWKHGLVHDVHVSHFLᚏF\HDUVXUYLYDO ,PSURYHPHQWVLQLPDJLQJ technique over time could cause stage migration with an overall lower relapse rate in this SDWLHQWSRSXODWLRQ:HFRPSDUHRXUH[SHULHQFHZLWKVXUYHLOODQFHRYHUGLᚎHUHQWWLPHSRLQWV Material & Methods: 7KUHHKXQGUHGDQGᚏYHSWVZLWKVWDJH,16*&7ZHUHSODFHGRQDQ DFWLYH VXUYHLOODQFH SURWRFRO EHWZHHQ 7KH\ ZHUH QRW VWUDWLᚏHG E\ ULVN DQG RQO\ received treatment on the event of a relapse. Recurrence rates, time to relapse, risk factors SUHGLFWLYH IRU UHFXUUHQFH GLVHDVH VSHFLᚏF DQG RYHUDOO VXUYLYDO ZHUH GHWHUPLQHG )RU WKH analysis by time period, pts were divided in two groups based on diagnosis date. (Initial=1981 >1 @DQG5HFHQW >1 @ Results: :LWKDPHGLDQIROORZXSRI\HDUVSWV UHODSVHG SWV LQWKHLQLWLDOJURXSDQG LQWKHUHFHQW$OOEXW UHODSVHVRFFXUUHGZLWKLQ 2 years after orchiectomy with a median time to relapse of 7 months. A multivariate analysis HVWDEOLVKHGO\PSKRYDVFXODULQYDVLRQ S DQGSXUHHPEU\RQDOFDUFLQRPD S DV LQGHSHQGHQWSUHGLFWRUVRIUHFXUUHQFH2YHUDOO SWVZHUHGHVLJQDWHGDVಫKLJK risk’ based on the presence of at least one of these factors. In the initial group 60/141 (42.6%) SWVZHUHKLJKULVNDQG UHODSVHGYHUVXV ORZULVN S ,QWKH UHFHQWJURXS SWVZHUHKLJKULVNDQG UHFXUUHGYHUVXV (11.7%) low-risk (p<0.001). There were 2 (0.7%) deaths due to testis cancer. The estimated \HDUGLVHDVHVSHFLᚏFVXUYLYDOZDV LQWKHLQLWLDOJURXSDQGLQWKHUHFHQWRQH Conclusions: ,QLWLDODFWLYHVXUYHLOODQFHLVDQHᚎHFWLYHVWUDWHJ\IRUWKHPDQDJHPHQWRIDOOVWDJH I NSGCT. A risk-adapted policy would have resulted in more than 60% of the patients being unnecessarily treated. The relapse rate has reduced over time, likely due to improvements in imaging causing stage migration.
Eur Urol Suppl 2008;7(3):85
58
SPERM ANALYSIS AFTER ADJUVANT SINGLE-AGENT CARBOPLATIN THERAPY FOR STAGE I SEMINOMA
BILATERAL LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION
Leonhartsberger N., Stoehr B., Granig T., Bartsch G., Steiner H.
Steiner H., Bartsch G., Stoehr B., Granig T., Peschel R.
Medical University Innsbruck, Dept. of Urology, Innsbruck, Austria
Medical University Innsbruck, Dept. of Urology, Innsbruck, Austria
Introduction & Objectives: Radiotherapy has been considered as standard adjuvant treatment for clinical Stage I seminoma for long time. The introduction of cisplatinbased chemotherapy has improved patient recovery dramatically. Although it is well known that carboplatin is a drug that binds directly to DNA, which is the presumptive method for killing cells, the mechanism of action of carboplatin on spermatozoa is unclear. Long-term toxicity becomes an important issue in this young age group of patients, and fertility especially has long-lasting consequences for their sexuality and quality of life. We analyzed the long-term damage to gonadal function and evaluated fertility of patients with clinical stage I seminoma after high-dose chemotherapy.
Introduction & Objectives: The laparoscopic approach to RPLND has always been FULWLFL]HGIRUDYHU\VPDOOWHPSODWHDQGDQXQSURYHQRQFRORJLFDOHᚑFDF\DVDOOFOLQLFDO stage I patients found LN+ at RPLND received additional chemotherapy. Therefore, a ODSDURVFRSLFELODWHUDOSURFHGXUHKDVEHHQGHYHORSHGLQFOXGLQJSURVSHFWLYHLGHQWLᚏFDWLRQ and sparing of the sympathetic nerves.
Material & Methods: Thirty patients patients with clinical stage I seminoma were treated with two postoperative adjuvant courses of carboplatin (400mg/m2 body VXUIDFHDUHDVFKHGXOHGIRUGD\VDQG LQRXUKRVSLWDO0HDQDJHZDV\HDUV $OO SDWLHQWV KDG KLVWRORJLFDOO\ FRQᚏUPHG VHPLQRPD ZLWK UHVHFWLRQ PDUJLQV IUHH RI tumour. Adjuvant chemotherapy was started approximately 14 days after operation. All patients underwent semen analysis more than 12 months after chemotherapy with at OHDVWGD\VRIVH[XDOLQDFWLYLW\6SHUPHYDOXDWLRQIURPDQWHJUDGHHMDFXODWLRQLQFOXGHG sperm density, motility, volume and percentage of vital and abnormal spermatozoa. Data on gonadal function (serum hormone levels) were obtained, too. Results: No data were available on spermatogenesis before chemotherapy. Normal spermatogenesis after chemotherapy was observed in 16 of 29 patients (55,17%), SDWLHQWVUHPDLQHGROLJRVSHUPLF7KHIROORZXSSHULRGZDVVLPLODULQERWKJURXSV The mean sperm concentration in non-oligospermic patients was 45,25 million./ mL., in oligospermic patients 5,75 million/mL. Motility was reduced in both groups, QRQROLJRVSHUPLF SDWLHQWV VKRZHG FRPSDUHG WR LQ WKH ROLJRVSHUPLF JURXS 1R VLJQLᚏFDQW GLVRUGHU LQ YLWD ORJ\ DQG VSHUP PRUSKRORJ\ ZDV REVHUYHG Testosterone, FSH and LH levels were within normal range. Conclusions: Spermatogenesis recovers after carboplatin in most patients. Even before orchiectomy spermatogenesis is often impaired in men with testicular cancer. Therefore patients should also be informed about the risk of infertility and cryopreservation of semen before treatment.
Material & Methods: From July 2004 until September 2007, 40 patients with nonseminomatous germ cell tumour (stage I: 19 pts, stage IIA marker negative: SDWLHQWV VWDJH ,,% DIWHU FKHPRWKHUDS\ SDWLHQWV XQGHUZHQW D WR SRUW transperitoneal laparoscopic bilateral RPLND. In stage I patients the contra lateral area below the inferior mesenteric artery was spared, in all other patients a complete bilateral template was cleared. Bilateral nerve-sparing technique was performed in all patients but 4 stage IIB patients with residual masses, in these patients only contralateral nerve-sparing was done out of oncological reasons. Results: Surgery was successfully completed in all patients, no conversion to open VXUJHU\ZDVQHFHVVDU\0HDQRSHUDWLYHWLPHIRUVWDJH,ZDVPLQ UDQJHದ DQGPLQXWHV UDQJHದ IRUVWDJH,,0HDQEORRGORVVZDVPO UDQJHದ 650). No intraoperative complication occurred. Postoperative complications were small asymptomatic lymphoceles in 11 pts and a large lymphocele requiring fenestration in 2 patients. Mean postoperative hospital stay was 4.9 days (range 4 - 6). Antegrade HMDFXODWLRQZDVSUHVHUYHGLQRISDWLHQWV2IDOOSWVZLWKRXWSULRUFKHPRWKHUDS\ (stage I and stage IIA marker negative) 18 pts had no tumour in the retroperitoneum, while in 5 pts active tumour was found in the RPLND specimen (N1). No adjuvant chemotherapy was administered. In 5 out of 17 post chemotherapy patients tumour was found in RPLND specimen (teratoma in 4 pts, active tumour in 1 pt). After a mean follow up of 16 months (range 1-40) 1 pulmonary recurrence occurred in a patient with negative retroperitoneal histology and this pt. was cured by cisplatin based chemotherapy. All other stage I and stage II patients are alive and free of disease. Conclusions: Bilateral nerve-sparing L-RPLND is technically feasible, the oncologic HᚑFDF\ RI WKLV DSSURDFK LV FXUUHQWO\ XQGHU HYDOXDWLRQ DQG ZLOO EHFRPH FOHDU DIWHU D longer follow up time.
59
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OPERATIVE MORBIDITY IN LAPAROSCOPIC RETROPERITONEAL LYMPH-NODE DISSECTION IN CLINICAL STAGE A NONSEMINOMATOUS TESTIS CANCER
NON-RISK ADAPTED SURVEILLANCE IN STAGE I NONSEMINOMATOUS GERM CELL TUMOURS (NSGCT): IMPROVED RECENT OUTCOMES
Castillo O.1, Rioja J.2, Sanchez-Salas R.1, Velasco A.1, Vidal I.1
Jewett M.1, Moore M.2, Warde P., Anson-Cartwright L., Kakiashvili D.1, Berthold D.2, Alison R.2, Duran I.2, Pond G.4, Sturgeon J.2
1
Clinica Santa Maria, Section of Endourology and Laparoscopic Urology, Dept. of Urology, Santiago de Chile, Chile, 2Clinica Universitaria de Navarra, Dept. of Urology, Pamplona, Spain Introduction & Objectives: Retroperitoneal lymph node dissection is an alternative treatment for clinical stage A non seminoma testicular cancer patients. This work shows the immediate results of a consecutive series of operated by a laparoscopic fashion Material & Methods: Surgical results of 118 patients with non seminoma testis cancer, with clinical stage A, operated in a consecutive manner. Surgical data was collected in a prospective way surgical technique has been described before, and basically consists in a transperitoneal access to, with a 4 trocars approach. 7KHFODVVLFDOOLPLWVIRUDUHWURSHULWRQHDOO\PSKQRGHGLVVHFWLRQPRGLᚏHGZLWKD nerve sparing technique. Results: Mean age was 29 years (range 15 to 44 years). The dissection was right in 64 cases and left in 54 cases. The average blood loss was 50 c.c. (Range 10 WRFF PHDQVXUJLFDOWLPHZDVPLQ 5DQJHWRPLQ DQGPHDQ in hospital stay was 41,4 hours (range 12 to 120 hours).Mean number of lymph QRGHVUHPRYHGZDV ,QWUDRSHUDWLYHFRPSOLFDWLRQVKDSSHQHGLQ patients (10,2%), 10 hemorrhage injuries (8,5%), 1 duodenal lesion (0,85%). In the periperative period 1 patient presented with acute pulmonary edema (0,85%). Of the 11 surgical lesions, 8 were solved laparoscopically fashion, and only three of them require conversion to open surgery. (1 lumbar vein tear, 1 burn lesion of KHLOLDFDUWHU\DQGFDYDYHLQLQMXU\EHFDXVHᚏUVWWURFDUSODFHPHQW 7KHUHZDV no mortality in these serie Conclusions: Laparoscopic retroperitoneal lymph node dissection is a valid alternative to the open approach, with an acceptable complication rate. At least in experienced hands the majority of them can be solved in a laparoscopic manner
1
Princess Margaret Hospital, University of Toronto, Dept. of Surgical Oncology, Toronto, Canada, 2Princess Margaret Hospital, University of Toronto, Dept. of Medical Oncology, Toronto, Canada, Princess Margaret Hospital, University of Toronto, Dept. of Radiation Oncology, Toronto, Canada, 4Princess Margaret Hospital, University of Toronto, Dept. of Biostatistics, Toronto, Canada Introduction & Objectives: Since 1981 the Princess Margaret Hospital testicular cancer group has used surveillance as the preferred management option for all patients (pts) with FOLQLFDOVWDJH,16*&7,QDUHSRUWRIWKHᚏUVWSWV>6WXUJHRQHWDO-&OLQ2QFRO @WKH UHODSVHUDWHZDVDQGWKHGLVHDVHVSHFLᚏF\HDUVXUYLYDO ,PSURYHPHQWVLQLPDJLQJ technique over time could cause stage migration with an overall lower relapse rate in this SDWLHQWSRSXODWLRQ:HFRPSDUHRXUH[SHULHQFHZLWKVXUYHLOODQFHRYHUGLᚎHUHQWWLPHSRLQWV Material & Methods: 7KUHHKXQGUHGDQGᚏYHSWVZLWKVWDJH,16*&7ZHUHSODFHGRQDQ DFWLYH VXUYHLOODQFH SURWRFRO EHWZHHQ 7KH\ ZHUH QRW VWUDWLᚏHG E\ ULVN DQG RQO\ received treatment on the event of a relapse. Recurrence rates, time to relapse, risk factors SUHGLFWLYH IRU UHFXUUHQFH GLVHDVH VSHFLᚏF DQG RYHUDOO VXUYLYDO ZHUH GHWHUPLQHG )RU WKH analysis by time period, pts were divided in two groups based on diagnosis date. (Initial=1981 >1 @DQG5HFHQW >1 @ Results: :LWKDPHGLDQIROORZXSRI\HDUVSWV UHODSVHG SWV LQWKHLQLWLDOJURXSDQG LQWKHUHFHQW$OOEXW UHODSVHVRFFXUUHGZLWKLQ 2 years after orchiectomy with a median time to relapse of 7 months. A multivariate analysis HVWDEOLVKHGO\PSKRYDVFXODULQYDVLRQ S DQGSXUHHPEU\RQDOFDUFLQRPD S DV LQGHSHQGHQWSUHGLFWRUVRIUHFXUUHQFH2YHUDOO SWVZHUHGHVLJQDWHGDVಫKLJK risk’ based on the presence of at least one of these factors. In the initial group 60/141 (42.6%) SWVZHUHKLJKULVNDQG UHODSVHGYHUVXV ORZULVN S ,QWKH UHFHQWJURXS SWVZHUHKLJKULVNDQG UHFXUUHGYHUVXV (11.7%) low-risk (p<0.001). There were 2 (0.7%) deaths due to testis cancer. The estimated \HDUGLVHDVHVSHFLᚏFVXUYLYDOZDV LQWKHLQLWLDOJURXSDQGLQWKHUHFHQWRQH Conclusions: ,QLWLDODFWLYHVXUYHLOODQFHLVDQHᚎHFWLYHVWUDWHJ\IRUWKHPDQDJHPHQWRIDOOVWDJH I NSGCT. A risk-adapted policy would have resulted in more than 60% of the patients being unnecessarily treated. The relapse rate has reduced over time, likely due to improvements in imaging causing stage migration.
Eur Urol Suppl 2008;7(3):85