Nerve-sparing lymphadenectomy in stage 1 testicular tumors: GATA Haydarpaşa Hospital experience

Evre 1 testis tümörlerinde sinir koruyucu lenfadenektomi: GATA Haydarpaşa deneyimi

Abstract

Introduction: Nowadays, patients with clinical stage 1 non-seminomatous germ cell tumor can expect a potential survival up to 100 %. Although in the beginning, retroperitoneal lymph node dissection has been the mainstay for the management of these patients, with the introduction of cisplatinum and the improvement of the imaging techniques, surveillance and prophylactic primary chemotherapy were also established as equally effective treatment alternatives. The achievement of these excellent results has prompted many investigators to seek a refinement in treatment that maintains survival while reducing morbidity. In order to reduce the morbidity of the retroperitoneal lymph node dissection, surgeons have defined predilection areas for the retroperitoneal lymph node involvement, according to their surgical records. At the same time it was also determined that the great majority of patients with clinical stage 1 disease undergoing RPLND actually had pathologically organ confined disease. As a result, many centers initiated surveillance trials where close clinical observation replaced surgical exploration as the initial management. In addition, a number of centers began trials using short courses of early adjuvant chemotherapy for patients with a high risk of relapse. With the introduction of the nerve-sparing lymphadenectomy, the infertility rate due to RPLND was reported to be only occasional. We report our experience with the first 18 patients on whom we have performed nerve sparing RPLND. Material and Methods: From 1998 to September 2002, 18 nerve sparing RPLND's were performed on patients having referred with a clinical stage 1 non- seminomatous germ cell tumor. The patients were 21 to 27 years old (mean: 23). 14 patients had their tumor on the right testis, while 4 subjects had a left testicular tumor. After the midline incision is performed, an incision is made in the posterior peritoneum from the cecum to the area of the inferior mesenteric vein and the Bookwalter retractor was placed for a good and stable exposure of the retroperitoneum. A right or left modified lymphadenectomy was performed and only the nerves of the right side were spared in both the right and left sided tumors, because of the relative complexity of the procedure on the left side. Following the procedure, a retroperitoneal drain was left and kept for a couple of days. Results: No major complications occurred in any of the patients. All patients have kept then- antegrade ejaculation, except our first case and another patient operated on at the first year. Conclusion: RPLND remains an appealing method of management in clinical stage 1 non-seminomatous germ cell tumors, especially when the loss of emission and ejaculation are eliminated. Local conditions of our country, where cost and compliance issues are in favor of a surgical approach, make it further appealing.

Özet

Klinik Evre-1 nonseminomatöz germ hücreli tümörlerde, sinir koruyucu lenfadenektomi, evreleme ve tedaviye katkısı, tedavi sonrası izlemin kolay ve ucuz olması nedeniyle çok mantıklı bir seçenektir. Son 4 yılda kliniğimize başvuran 18 hastaya modifiye sinir koruyucu lenfadenektomi uygulandı. Hiçbir komplikasyonla karşılaşılmadı ve ilk yıl ameliyat olan 2 olgu dışında tüm hastalarda ameliyat sonrası antegrad ejakülasyon korundu. Bu yaklaşım seçeneği, diğer seçeneklerle, özellikle ülke koşulları dikkate alınarak kıyaslandı ve olguların önemli bir kısmında en uygun yöntem olacağı düşünüldü.