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PubMed1994

[Paratesticular rhabdomyosarcoma].

The observation presented is based on one patient 18 years old who presents a paratesticular rhabdomyosarcoma stage I. A radical orchidectomy through on inguinal incision with high ligation of the spermatic cord was performed. We have omitted retroperitoneal lymph node dissection. The patient was treated by postoperative chemotherapy with V.A.C. during five weeks. Our patient remains disease free one year post-surgery, but after that, he presents suddenly a symptomatic bone metastasis of the thigh-bone and a massive metastatic pulmonary spreading, without retroperitoneal lymph nodes on the CT-scan. A multidisciplinary approach has considerably improved the prognosis of this tumor. Some reports suggest that routine retroperitoneal lymphadenectomy may be unnecessary for patients with no evidence of nodal involvement on CT-scan. The recent literature insists on problems cause by retroperitoneal lymph node involvement, but our clinical caused must induce us not to underestimate the potential of hematogenous spreading of this tumor.

Adolescent↗
PubMed1993

Monitoring of emission as direct intraoperative control for nerve sparing retroperitoneal lymphadenectomy.

An intraoperative test to identify emission relevant lumbar postganglionic nerves during nerve sparing retroperitoneal lymph node dissection is presented. The neurophysiological course of the ejaculation into the posterior urethra, the emission, is described. A retroperitoneal nerve sparing procedure was done for nonseminomatous testicular tumors bilaterally in 7 patients with pathological stage I disease and unilaterally in 4 with pathological stage IIa disease. While the isolated lumbar nerves were electrostimulated, the seminal vesicles and bladder neck were monitored by suprapubic transvesical sonography. Simultaneously, endoscopy of the posterior urethra was performed and time code was registered. Emission began with bladder neck closure, propulsive contraction of the seminal vesicles in the periphery and opening of the paracollicular region. Then, complete contraction of the seminal vesicles was associated with closure of the prostatic urethra and ended in the separate secretion from the ductuli prostatici and ejaculatorii. Descending from nerve L1 to L3, their importance for emission usually increased. For intraoperative monitoring of emission transvesical sonography alone is sufficient. In 2 patients this method allowed us to identify the relevant nerves within the retroperitoneal residual mass (fibrosis) after chemotherapy.

Adolescent↗
PubMed1992

Asymmetrical autonomic dysfunction of the feet after retroperitoneal surgery in patients with testicular cancer: 2 case reports.

We report on 2 patients with hyperhidrosis and decreased temperature of the leg on the unoperated side after unilateral retroperitoneal lymph node dissection. Both patients had a 4 to 5C difference in skin temperature of the feet, with the operated side being warm and dry compared to the nonoperated side. This condition is most likely due to a lesion of sympathetic fibers or ganglia located in close proximity to the retroperitoneal lymph nodes, resembling a unilateral lumbar sympathectomy. In addition, both patients had profuse sweating and a subjective feeling of coldness of the leg on the nonoperated side, which caused considerable discomfort. This latter phenomenon most likely represents a compensatory sympathetic hyperfunction due to the decreased sympathetic function in the other leg.

Adult↗
PubMed1984

[Bilateral primary germ cell tumors of the testis: report of two cases and review of the literature].

Bilateral germ cell tumors of the testis are not common. The contralateral tumor may develop simultaneously or sequentially. In both cases, bilateral involvement is postulated to represent two primary tumors. Case 1: A 47-year-old male was seen with a painless nodular mass in the right testis. Physical examination revealed hard swelling of both testes besides a nodule in the right testis. He underwent bilateral radical orchiectomy; and, microscopical both tumors proved to be seminoma. Although bipedal lymphangiography was negative for nodal metastases, postoperative irradiation to the pelvic and para-aortic lymph nodes was given to a total dose of 5,800 rad. The patient was alive 15 years after treatment for bilateral testicular tumors. Case 2: A 53-year-old male presented with painless left scrotal swelling. Physical examination showed not only an enlarged hard testis in the left scrotum but also a palpable hard mass in the right testis. Bilateral radical orchiectomy was performed and pathological examination revealed pure seminoma in both testes; a 1 cm mass in the right testis and almost completely replaced tumor in the left testis. Evaluation including retroperitoneal lymph node dissection revealed no metastatic disease. Postoperatively, the patient received 1,900 rad of irradiation to the retroperitoneal space. He is well one year after surgery and has no evidence of recurrence or metastasis. Previous reports of bilateral germ cell testicular tumors are reviewed and the incidence, age, predisposing factors, interval between the first and second tumors, histology, pathogenesis, prognosis, and management are discussed.

Age Factors↗
PubMed1996

Venous dissection injuries during laparoscopic urological surgery.

PURPOSE: The incidence of major venous dissection injuries during laparoscopic procedures is assessed and recommendations are made for management. MATERIALS AND METHODS: We evaluated our experience with all major intra-abdominal injuries occurring during 274 consecutive laparoscopic procedures performed within a 4-year period. Five patients (1.7%) had a total of 6 major vascular injuries, including gonadal vein avulsion in 1 case, lumbar vein avulsion in 1 and a tear in the inferior vena cava in 4. Two patients sustained inferior vena caval injuries during nephrectomy because of adhesions from previous surgery and 1 of them had 2 venacavotomies. RESULTS: All vascular injuries were venous and 5 of the 6 major vessel injuries were treated successfully endoscopically via intracorporeal suturing techniques. The injury requiring open repair was a gonadal vessel avulsion that occurred during retroperitoneal lymph node dissection early in our laparoscopic experience. Major vessel injuries were more likely to occur during complex laparoscopic procedures in patients who had undergone previous ipsilateral retroperitoneal surgery. CONCLUSIONS: In select situations new techniques can allow for safe endoscopic control and repair of venous injuries during laparoscopic surgery.

Adult↗
PubMed1985

Surveillance or lymph node dissection in clinical stage I non-seminomatous germinal testis cancer?

Surveillance following orchiectomy alone has gained popularity in the management of clinical stage I non-seminomatous germ cell tumours (NSGCT) of the testis. However, long-term follow-up of the retroperitoneal nodes can be difficult. We analysed the results of 71 consecutive patients followed for more than 1 year. Fifty men (70.5%) remain disease-free and 21 (29.5%) have relapsed. Relapses occurred 2 to 36 months after orchiectomy (median 6 months). Retroperitoneal nodes were involved in 12 cases (17%). In only one patient were retroperitoneal metastases diagnosed when smaller than 2 cm and in four they were diagnosed when larger than 5 cm. Furthermore, the late relapses occurred in the retroperitoneal nodes. After treatment of metastases, 69 patients (97%) are alive, disease-free and off therapy. As retroperitoneal relapses do not occur after a properly executed retroperitoneal lymph node dissection (RPLND) and ejaculation problems can be avoided with unilateral RPLND, it is suggested that RPLND can be used for clinical stage I NSGCT of the testis in experienced surgical centres, with the advantage of an easier follow-up.

Adolescent↗
PubMed1989

Vena caval resection in bulky metastatic germ cell tumors.

We describe the operative management and followup of vena caval resection in 12 patients with thrombosis of the inferior vena cava secondary to bulky metastatic (stage B3 or IIC) germ cell tumors. All patients received induction chemotherapy (10 platinum-based) followed by retroperitoneal lymph node dissection. The inferior vena cava was resected from just below the renal veins to the bifurcation of the iliac veins. Complete resection of retroperitoneal disease was accomplished in all patients. Five patients had postoperative complications, including 2 small bowel obstructions, 1 prolonged ileus and 2 persistent lymphatic leaks. Mean hospital stay was 37 days (range 27 to 49 days) versus 12 days (range 8 to 16 days) for noncomplicated recoveries. No long-term sequelae related to the vena caval resection have occurred with followup of 24 to 80 months. Seven patients are without disease, with a mean followup of 36 months (range 24 to 60 months). We conclude that en bloc vena caval resection for thrombosis of the vena cava allows for complete resection and simplifies the procedure with acceptable morbidity.

Adolescent↗
PubMed1975

Chylous ascites following retroperitoneal lymphadenectomy.

A case of postoperative chylous ascites accumulation after retroperitoneal lymph node dissection is reviewed. Although uncommon, this complication is distressing and because of the close proximity of the cisterna chyli to the renal pedicles it may be encountered with any retroperitoneal procedures involving this area. Avoidance of the complication by specific identification and ligation of these structures appears to be the best treatment. Several forms of operative and non-operative therapy have been noted and survival rates in the iatrogenic form of chylous ascites appear to be good based on a limited series of cases.

Adult↗
PubMed1977

Advances in the management of non-seminomatous germinal tumours of the testis.

Experience in the management of 146 consecutive patients with non-seminomatous tumours of the testis has led to a plan of management based on retroperitoneal lymph node dissection as the primary treatment modality, with use of adjuvant therapy dependent on pathological findings. Chemotherapy has proved to be the most important adjuvant with postoperative radiation therapy reserved only for patients with extensive retroperitoneal metastatic disease. 3-year crude survival for patients with all stages of disease was 78% and in those in whom the disease was confined to below the diaphragm the survival rate was 85%.

Humans↗
PubMed1997

Current concepts about testicular cancer.

In the past 20 years, testicular cancer, which occurs in the young, has become a curable malignancy; 90% of the patients treated will achieve long-term survival. However, there is a significant morbidity associated with the management of the disease process. The literature was reviewed concerning the current treatment strategies and prognosis, as well as the long-term sequelae of the various diagnostic and therapeutic procedures. Surveillance has become a key element in the management of patients with a primary (stage I) testicular non-seminoma. Although approximately 25% of these patients will relapse, 100% survival can be achieved with cisplatin in combination with etoposide and bleomycin (BEP). Patients with a disseminated non-seminoma are usually treated with 4 courses of BEP; an 80% survival rate can be achieved. The long-term effects of chemotherapy include Raynaud's phenomenon, acral paraesthesia, hyperlipidaemia, nephrotoxicity, infertility and hormonal disturbances. Retroperitoneal lymph node dissection or resection of residual disease following chemotherapy are associated with a low mortality and morbidity rate, ejaculatory dysfunction excepted. However, with specific modifications in technique (e.g. nerve-sparing) antegrade ejaculation can be preserved in the majority of patients. Radiotherapy is used in stage I and II seminoma. With the conventional dose of 25-30 Gy to the retroperitoneal and ipsilateral iliac lymph nodes, temporary dysfunction of the germ and Leydig cells of the remaining testis may occur by scatter radiation. Patients with advanced seminoma are treated with cisplatin-based chemotherapy. To date, testicular cancer patients can receive appropriate curative treatment with acceptable acute toxicity, depending on the therapy given. The detrimental effects of late toxicities require careful study and follow-up. However, little attention is paid currently to quality of life aspects, in particular the impact of the disease and its treatment on general well-being, including sexual function.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1998

Retroperitoneoscopy: experience with 200 cases.

PURPOSE: A retroperitoneal access is commonly used for open urological procedures. Since the introduction of the balloon dissecting technique by Gaur this anatomical route has also been used for laparoscopic surgery. We present our experience with retroperitoneoscopy in 200 cases. MATERIALS AND METHODS: From December 1992 to October 1997 a total of 200 retroperitoneoscopic procedures were performed in 197 patients 4 to 82 years old, comprising 78 nephrectomies, 50 renal cyst resections, 14 nephropexies, 11 ureterolyses, 8 retroperitoneal lymph node dissections, 8 renal biopsies, 6 adrenalectomies, 6 heminephrectomies, 6 pyeloplasties, 5 ureterolithotomies, 6 ureterocutaneostomies and 2 others. Of the patients 38 (19%) and 22 (11%) had undergone previous abdominal surgery, and kidney and ureter operations, respectively. Dissection of the retroperitoneal space was enabled by the use of a balloon catheter in 14, balloon trocar system in 93 and finger dissection technique in 93 cases. RESULTS: We classified 76 procedures (38%) as simple (renal biopsy, renal cyst resections, ureterocutaneostomy), 102 (51%) as difficult (adrenalectomy, nephrectomy, nephropexy) and 22 (11%) as very difficult (pyeloplasty, heminephrectomy, lymphadenectomy). There was a significant learning curve during the first 50 cases reflected by longer operating time, and higher complication, conversion to open surgery and open reintervention rates (14, 10 and 6%, respectively). In addition to the learning curve, mean operating time depended on the difficulty of the procedure, averaging 45 to 100 minutes for a simple, 95 to 185 for a difficult and 185 to 240 for a very difficult retroperitoneoscopy. In the last 50 cases the complication, conversion and reintervention rates (2, 4 and 2%, respectively) were acceptable for routine clinical application. CONCLUSIONS: After experience with more than 200 cases of retroperitoneoscopy the access technique has been significantly simplified. The procedure is standardized, safe and reproducible.

Adolescent↗
PubMed1994

Predictive parameters of biologic behavior of early stage nonseminomatous testicular germ cell tumors.

BACKGROUND: Thirty percent of patients presenting with clinical stage A nonseminomatous testicular germ cell tumors in fact have pathologic stage B disease. This pilot study was performed to determine whether DNA content and cell cycle analysis by flow cytometry and single-cell cytophotometry can improve clinical staging in these patients. METHODS: The orchiectomy specimens of 102 patients with clinical stage A disease were analyzed retrospectively using histopathologic classification, flow cytometry, and single-cell cytophotometry. All patients had undergone retroperitoneal lymph node dissection. RESULTS: The multivariate analysis in this group of patients resulted in the following model: If the primary tumor consisted of 100% embryonal carcinoma, the patient was classified as high risk for retroperitoneal metastasis. If the patient was found to have less than 100% embryonal carcinoma in the primary tumor, the percent of aneuploid tumor cells in S-phase as identified by flow cytometry was most predictive for pathologic stage. Using this approach, 91% of all patients with pathologic stage B, and 77% of the patients with pathologic stage A were correctly classified; test efficiency was 82%. CONCLUSIONS: These results demonstrate an improvement in clinical staging in this group of patients. This paradigm, developed from retrospective analysis, will be tested prospectively in consecutive patients to determine if it is clinically useful.

Aneuploidy↗
PubMed1995

Adult primary pure teratoma of the testis. The Indiana experience.

BACKGROUND: Pure testicular teratoma in adults is a relatively rare malignant tumor with the ability to invade and metastasize. Pure teratoma generally is believed to be less aggressive and less likely to progress, to present in lower stages, and to have better survival rates then other forms of germ cell tumor. Consequently, clinical stage A patients with pure testicular teratoma commonly have been considered to be managed best by surveillance. METHODS: A computerized database search identified 41 patients presenting to Indian University with pure teratoma in the orchiectomy specimen. These patients were further subdivided into four groups based on clinical stage, as follows: Group I, 18 patients with clinical Stage A disease; Group II, 4 patients with clinical Stages A-B1 disease based on questionable computed tomography findings; Group III, 3 patients with clinical Stage B1 disease; Group IV, 16 patients with advanced stage (B3-C) disease. The experience with these patients was reviewed. RESULTS: The overall risk of lymph node metastasis in retroperitoneal lymph node dissection (RPLND) and the risk of relapse after RPLND for patients with low stage pure testicular teratoma (groups I-III) were 40 and 16%, respectively. In patients with clinical Stage A teratoma, the risk of retroperitoneal metastasis in RPLND was 16.7% and the relapse rate was 11.1%. In addition, nearly 37% of referred patients with pure teratoma presented with advanced disease. CONCLUSIONS: These data provide additional confirmation of the metastatic potential of pure testicular teratoma. The proper management of the adult clinical stage A patient with primary pure teratoma of the testis should not necessarily differ from the management of any other histologic type of nonseminomatous testicular tumor. Accordingly, histologic diagnosis of pure teratoma should not mandate surveillance. Instead, patients must be given adequate information regarding management options, as are all other patients presenting with clinical Stage A nonseminoma.

Adolescent↗
PubMed1989

Lymph node metastasis and retroperitoneal lymphadenectomy in ovarian cancer.

While clinicians are devoting themselves to the study of the behaviour of ovarian cancer as well as to the search for more effective therapeutic modalities, little attention has been paid to an important route of metastasis in this group of diseases: retroperitoneal spread through the lymphatic pathway. The purpose of this report is to present a 5-year experience of a prospective study on lymph node metastasis in patients with ovarian cancer through retroperitoneal lymphadenectomy at the Peking Union Medical College Hospital. From June 1982 through May 1987, retroperitoneal lymph node dissection was performed in 105 cases of ovarian cancer. Seventy-seven (73.3%) were histologically diagnosed as cancer of epithelial origin, and 28 (26.7%) as germ-cell tumours. The overall incidence of retroperitoneal positive nodes was 54.3% (57/105). The incidence of positive pelvic nodes was 46.7% (49/105), and that of positive para-aortic nodes was 37.5% (30/80). In 69 patients who underwent systemic lymphadenectomy, 39 were found to have glandular involvement; in these 39 patients both aortic and pelvic nodes were positive in 19 cases (48.7%), aortic nodes were positive and pelvic nodes negative in 7 cases (18.0%), and pelvic nodes were positive and aortic nodes negative in 13 cases (33.3%). Preoperative lymphography was performed in 30 cases. The positive and negative correspondence rates with the pathological findings were both 83.3%. In 38 cases in which the primary cancer originated in the left ovary, 17 (44.7%) were found to have positive pelvic nodes, whereas in 25 cases with primary cancer arising in the right ovary only 2 (8%) had metastasis of the ipsilateral pelvic nodes. The lymph nodes obtained from 22 patients with positive nodes and sufficient preoperative chemotherapy were carefully examined under the microscope for the effects of the drugs. Some cellular degeneration of the lymph node metastasis was observed in only one of the 15 cases of epithelial cancer, and no response at all was noted in three cases of immature teratoma. Cellular degeneration accompanied by extensive necrosis was demonstrated in the metastatic tumours of the lymph nodes in all four cases of endodermal sinus tumour. Seventy-two patients were followed-up for at least 2 1/2 years. The rate of complete remission was 46.7% (14/30) in patients with negative nodes, but only 33.3% (14/42) in those with positive nodes. However, the difference was not statistically significant.

Antineoplastic Combined Chemotherapy Protocols↗
PubMedDate not supplied

Management of lymphatic fistulas by total parenteral nutrition.

Lymphatic fistula is a rare surgical complication, which mainly occurs after cervical or retroperitoneal lymph node dissection and which frequently requires a surgical repair. A small series of nine postoperative lymphatic fistulas treated conservatively with total parenteral nutrition (TPN) is reported. All the patients were malnourished at the beginning of the TPN, and all exhibited an objective improvement of their nutritional status after completion of the treatment. Due to the interruption of the enteral alimentation or to the nutritional repletion, spontaneous closure of the fistula was achieved in eight of nine patients treated with TPN longer than 1 week. The authors conclude that whenever the immediate surgical repair is not recommended, or it is not successful, a 2- to 3-week course of TPN may be used with the chance of spontaneous healing. In any case, patients conservatively treated by TPN can undergo a delayed operation with minimal risk because of the improved nutritional status.

Chylothorax↗
PubMed1993

Redo retroperitoneal lymphadenectomy for germ cell tumor.

Redo retroperitoneal lymph node dissection (RPLND) for the treatment of germ cell tumors (GCTs) is an uncommonly performed procedure. We report on 9 patients who underwent redo RPLND at the University of Wisconsin (UW) between January 1988 and December 1990. Indications for redo RPLND include: residual retroperitoneal mass after initial RPLND and chemotherapy, normal alpha-fetoprotein (AFP) and beta subunit of human chorionic gonadotropin (B-HCG), otherwise negative metastatic workup, and evidence that the mass is resectable. Overall, 6 of 9 patients are alive with no evidence of disease at a mean follow-up of thirty-two months. Preoperative evaluation, histopathology, morbidity, and technical aspects of this procedure, which is a critical part of the management of GCT, are reviewed.

Adult↗
PubMed1988

Treatment of the residual retroperitoneal mass after chemotherapy for advanced seminoma.

Although resection of the residual retroperitoneal mass after chemotherapy for nonseminomatous testicular cancer is standard practice, controversy exists as to the appropriate management of the residual mass after chemotherapy for advanced seminoma. A literature review suggests that 15 to 25 per cent of such masses will contain residual cancer, suggesting that retroperitoneal lymph node dissection is appropriate in these patients.

Adult↗