Introduction: A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has demonstrated significantly decreased morbidity compared to a transperitoneal approach. We aimed to review our 10-year experience in patients with germ cell tumors (GCT) who underwent EP-RPLND at USC.
Methods: All patients with GCT who underwent EP-RPLND between 2010 and 2021 were reviewed. All patients were considered for EP-RPLND except for men undergoing aortic resection, extensive retrocrural dissection, or intraperitoneal resection. Perioperative and long-term outcomes were analyzed including recurrence rates and patterns. Ileus was defined as nausea/vomiting requiring nasogastric decompression. Mann-Whitney U and Chi-square tests were used for univariate analysis, with p<0.05 considered significant.
Results: Overall, 172 patients underwent EP-RPLND, of which 73% were performed in the post-chemotherapy (PC) setting. Median size of radiologic retroperitoneal disease was 3.2 cm (IQR 2 – 5.4), of which 12 cases were >10 cm. Median number of lymph nodes resected was 29 (IQR 17–39). There were no cases of postoperative ileus, and median hospital stay was 2 (IQR 1-3) days (Table 1). In the PC group, 23% underwent adjunct procedures including: vascular reconstruction (10), cavectomy (9), nephrectomy (8), ureteral resection (3), retrocrural dissection (2), suprahilar dissection (1), neck dissection (2), iliac vessel resection (2), & bone biopsy (1). Twenty three patients experienced 24 (13.5%) 90-d complications. In patients who underwent nerve-sparing, 86.9% maintained antegrade ejaculatory function. Out of 18 patients who experienced disease recurrence at a median of 4.4 mo, 4 were in-field recurrences (Table 2).
Conclusions: Midline extraperitoneal approach for RPLND in GCT is safe, associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and post-chemotherapy settings, even when adjunct procedures are necessitated.
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