Laparoscopic retroperitoneal lymph node dissection combined with adjuvant chemotherapy for pathological stage II disease in nonseminomatous germ cell tumours: a 15-year experience.

OBJECTIVE: To present our 15-year experience of laparoscopic retroperitoneal lymph node dissection (LRPLND) combined with adjuvant chemotherapy (after RPLND) for patients with nonseminomatous germ cell tumour and positive nodes (pN+), evaluating the morbidity and long-term oncological outcome.

PATIENTS AND METHODS: Data for 87 patients with clinical stage I GCT were collected prospectively from 1992 to 2007. Primary diagnostic LRPLND was performed for pathological staging using a modified-template dissection. Patients with lymph node involvement had adjuvant chemotherapy, with two cycles of bleomycin, etoposide and cisplatin.

RESULTS: The mean (range) operative duration was 177 (68-360) min, and the hospital stay 6 (4-18) days. Positive nodes were identified in 24% of patients, who subsequently had adjuvant chemotherapy. After a mean (range) follow-up of 84 (1-186) months, distant relapse occurred in 9% of patients with pathological stage I (no adjuvant chemotherapy), including three patients with pulmonary metastases, two with retroperitoneal recurrence (outside the template field), two biochemical recurrences (alpha-fetoprotein elevated) and one port-site metastasis. No patients with pN+ disease relapsed. There were complications after surgery in 9% of patients, i.e. one pulmonary embolus, one lymphocoele, temporary ureteric stenting in two, ureteric stenosis requiring surgical repair in three and retrograde ejaculation in one patient. All patients remain disease-free.

CONCLUSIONS: After gaining experience, LRPLND has comparable operative times to contemporary open series, and low morbidity. The two retroperitoneal recurrences (2.5%) were outside the template field. No patients with pN+ had a recurrence, showing the efficacy of adjuvant chemotherapy. Our approach provides excellent oncological outcomes, avoiding intensive surveillance.