ENDOUROLOGY & LAPAROSCOPY

Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience
Steiner H, Peschel R, Janetschek G, Holtl L, Berger AP, Bartsch G, Hobisch A
Department of Urology, University of Innsbruck, Innsbruck, Austria
Urology 2004; 63: 550-5

• Objectives: To evaluate the feasibility, morbidity, and long-term oncologic efficacy of laparoscopic retroperitoneal lymph node dissection (L-RPLND) in patients with nonseminomatous germ cell tumor (NSGCT).
• Methods: L-RPLND was performed 188 times in 185 patients; 114 procedures were performed for Stage I NSGCT and 6 procedures for tumor marker-negative clinical Stage IIA disease. In the case of positive lymph nodes, adjuvant cisplatin-based chemotherapy was administered. After chemotherapy, L-RPLND was performed for retroperitoneal Stage IIA (10 patients), IIB (43 patients), and IIC lesions (15 patients).
• Results: The mean operative time was 256 minutes for Stage I and 243 minutes for Stage II; the conversion rate was 2.6%. The mean blood loss was 159 mL in patients with Stage I and 78 mL in those with Stage II disease. Active tumor was found in 19.5% of patients with Stage I lesions and in 50% of patients with tumor marker-negative clinical Stage IIA disease. After chemotherapy, active tumor was found in 1 patient with Stage IIC disease and mature teratoma in 38.2% of patients. The mean postoperative hospital stay for those with Stage I and II disease was 4.1 and 3.7 days, respectively. Antegrade ejaculation was preserved in 98.4% of patients. The mean follow-up was 53.7 months for those with Stage I and 57.6 months for those with Stage II disease. All but 6 patients have remained free of relapse, and no patient died of tumor progression.
• Conclusions: The rate of tumor control after L-RPLND and the diagnostic accuracy of L-RPLND were equal to the open procedure, and the morbidity was significantly lower. Therefore, L-RPLND for Stage I and low-volume retroperitoneal Stage II disease can be performed at centers with experience in urologic laparoscopy and oncology.
  
  
• Editorial Comment
  With the recent explosion of interest in laparoscopic prostatectomy and laparoscopic partial nephrectomy, with virtually every paper stating that these procedures should be performed only by those with “advanced laparoscopic experience,” the challenge of laparoscopic retroperitoneal lymph node dissection (L-RPLND) is often overlooked. I agree with the authors that a left-sided L-RPLND for Stage I nonseminomatous germ cell tumor (NSGCT) is the best way to start off. The left-sided template is smaller, the aorta is more forgiving, and the midline does not need to be crossed. There is controversy about the right-sided template, however. For those who feel that the right-sided dissection should be carried all the way to the contralateral renal hilum, completing this dissection laparoscopically without repositioning is difficult. It would have been nice if the authors had given us data on operative time, complications, and conversions for right vs. left procedures - I would guess that the right-sided ones were more challenging and dangerous. Disagreements about extent of the template aside, the authors’ data are very reassuring as to the completeness of the dissection for Stage I disease. Of 91 patients with negative dissections, only one suffered a retroperitoneal recurrence. This suggests that the dissection by the authors is thorough. Certainly, their data regarding complications and conversions are excellent. L-RPLND should be considered an excellent option when there is “advanced laparoscopic experience.”

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA