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 58months. The median operative time was 205min （range： 165-430min） and median estimated blood loss was 320ml （range： 100-1200ml）. 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.

A comprehensive evaluation of sexual and reproductive outcomes following robot-assisted retroperitoneal lymph node dissection for nonseminomatous germ cell tumor

Sexual disorders following retroperitoneal pelvic lymph node dissection(RPLND)for testis tumor can affect the quality of life of patients.The aim of the current study was to investigate several different andrological outcomes,which may be influenced by robot-assisted(RA)RPLND.From January 2012 to March 2020,32 patients underwent RA-RPLND for stage I nonseminomatous testis cancer or postchemotherapy(PC)residual mass.Modified unilateral RPLND nerve-sparing template was always used.Major variables of interest were erectile dysfunction(ED),premature ejaculation(PE),dry ejaculation(DE),or orgasm alteration.Finally,fertility as well as the fecundation process(sexual intercourse or medically assisted procreation[MAP])was investigated.Ten patients(31.3%)presented an andrological disorder of any type after RA-RPLND.Hypospermia was present in 4(12.5%)patients,DE(International Index of Erectile Function-5[IIEF-5]<25)in 3(9.4%)patients,and ED in 3(9.4%)patients.No PE or orgasmic alterations were described.Similar median age at surgery,body mass index(BMI),number of nodes removed,scholar status,and preoperative risk factor rates were identified between groups.Of all these 10 patients,6(60.0%)were treated at the beginning of our robotic experience(2012-2016).Of all 32 patients,5(15.6%)attempted to have a child after RA-RPLND.All of these 5 patients have successfully fathered children,but 2(40.0%)required a MAP.In conclusion,a nonnegligible number of andrological complications occurred after RA-RPLND,mainly represented by ejaculation disorders,but ED occurrence and overall sexual satisfaction deficit should be definitely considered.No negative impact on fertility was described after RA-RPLND.

Mesenteric metastases from mature teratoma of the testis:A case report

Metastatic spread of testicular cancer has been well documented,with 95% of cases involving para-aortic retroperitoneal lymph nodes.Mesenteric lymphatic basins do not lie within the canonical drainage pathway of the testes and represent a rare site of metastasis.Various mechanisms of spread to the mesentery have been described,including direct extension and haematogenous dissemination.We present a case of a previously-well 43-year-old man who presented with right scrotal discomfort and intermittent lower back pain,who was found to have mesenteric metastases from a non-seminomatous germ cell tumour of the testis.Managing lymphadenopathy that lies outside of standard resection templates remains a complex surgical challenge.Here we present the first case in the English medical literature with co-existing supradiaphragmatic axillary and mediastinal nodal disease.