Anatomical retroperitoneoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors: Initial operative experience

To introduce the technique of anatomical retroperitoneoscopic retroperitoneal lymph node dissection (ARRPLND) was performed in 12 consecutive patients with a clinical stage I nonseminomatous germ-cell tumor (NSGCT) between February 2008 and October 2010. All procedures were performed using a modified template nerve-sparing approach. The retroperitoneal space was adequately expanded using double gasbags. After the retroperitoneal fat was cleared, two relatively bloodless planes were entered consecutively to expose the lymph node and permit dissection. Dissection proceeded first in the plane between the anterior renal fascia and posterior peritoneum, and secondly in the avascular plane between the posterior renal fascia and transversalis fascia. The proximal spermatic vein was clipped at the initial stage. En bloc resection of the lymph tissue and fat between the anterior renal fascia and posterior renal fascia were performed. Three patients (25%) had pathologic stage IIA disease and received adjuvant chemotherapy. No recurrence was observed during follow-up ranging from 26 to 58 months. The median operative time was 205 min (range: 165-430 min) and median estimated blood loss was 320 ml (range: 100-1200 ml). There were two intraoperative complications (Clavien grade II) and one open conversion due to perforation of the peritoneum. Postoperative complications (Clavien I) developed in three patients. Normal antegrade ejaculation recovered by 1 month following the operation. Our preliminary results indicate that ARRPLND is technically feasible and associated with satisfactory clinical outcomes for clinical stage I NSGCT. Further studies are necessary to evaluate this technique.