Current Status of Retroperitoneal Lymph Node Dissection and Testicular Cancer: When to Operate

Richard Foster, MD; Richard Bihrle, MD

Disclosures

Cancer Control. 2002;9(4) 

In This Article

Laparoscopic RPLND

With increasing use of laparoscopic techniques, several centers from around the world have begun to investigate the feasibility of laparoscopic RPLND.[16,17] As in other indications, these series have shown that there is a learning curve but that laparoscopic RPLND appears to be technically feasible. In these published series, sometimes variations on the open technique are employed. For instance, some investigators believe that dividing the lumbar arteries and veins is not necessary, and some feel that nerve-sparing techniques are similarly not mandatory. The presumed advantage of laparoscopic RPLND is a quicker return to full physical activity.

What is consistent in these varied series, however, is that when metastatic disease is found in the retroperitoneum adjuvant chemotherapy is universally given. Therefore, these laparoscopic series have not really tested the therapeutic capability of removing involved nodes. Instead, laparoscopy is used as a staging technique, with all patients found to have metastatic disease receiving either two or three courses of BEP. Predictably, the oncologic outcome is excellent since all patients with metastatic disease are given chemotherapy.

The rationale for such an approach is unclear. As noted, the morbidity of chemotherapy to a large degree relates to effects on spermatogenesis in the contralateral testis. If a patient is willing to accept this potential morbidity and treat metastatic disease with chemotherapy (as opposed to surgical removal), it is unclear why a patient would elect laparoscopic RPLND as a staging procedure and then receive two or three courses of chemotherapy. Since the results of surveillance are excellent, why would a patient who has no disincentive to receive chemotherapy simply elect surveillance and thereby avoid any sort of surgical procedure? Currently, patients at our institute who elect to treat any metastatic tumor with chemotherapy are followed on a surveillance regimen. Similarly, patients who want to avoid chemotherapy will be advised to undergo nerve-sparing RPLND followed by observation if metastatic disease is present.

If laparoscopic RPLND could be shown to have an equivalent therapeutic value as a conventional curative surgical procedure and if it had lower morbidity and a quicker return to full physical activity, there would be little reason to continue with open RPLND. However, since the "bar is set relatively high" for open RPLND in terms of its oncologic efficiency and long-term outcome, the standard in terms of therapeutic capability should be set at a similar height for a laparoscopic RPLND. Laparoscopic surgeons who wish to employ RPLND can test its therapeutic capability if, after a patient is found to be pathologic stage II at RPLND, no postoperative chemotherapy is given. Thereby, the therapeutic capability as a curative surgical procedure of laparoscopic RPLND would be tested. Whether this will be done remains unclear.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....