Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumor: a large single institution experience.

PURPOSE: Primary laparoscopic retroperitoneal lymph node dissection is done at our institution with therapeutic intent and it technically duplicates the open approach. Controversies associated with the procedure include the thoroughness of dissection, the high rate of chemotherapy exposure and the potential deleterious effects of pneumoperitoneum. We present our experience with laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors. MATERIALS AND METHODS: We queried the Johns Hopkins minimally invasive surgery database from 1995 to 2010 for patients with a clinical stage I nonseminomatous germ cell tumor undergoing laparoscopic retroperitoneal lymph node dissection. Demographic, perioperative, pathological and followup information was collected and analyzed. RESULTS: Of the 91 patients who underwent extended template laparoscopic retroperitoneal lymph node dissection during the study period 60 (66%) had lymphovascular invasion and 55 (60%) had greater than 40% embryonal carcinoma. Median estimated blood loss was 200 cc and mean length of stay was 2.1 days (range 1 to 4). Four patients (4.3%) experienced intraoperative complications and there were 4 open conversions (4.3%). Nine patients (9.8%) experienced postoperative complications. The mean lymph node count was 26.1 (range 7 to 72) and 28 patients (31%) had retroperitoneal metastasis. Followup was available for 55 patients at a median 38.0 months (range 12 to 168). No pN0 case recurred in the retroperitoneum but there were 5 systemic relapses in pN0 cases. Of the 21 patients with pN1 disease 14 elected chemotherapy and 7 elected surveillance. There was no relapse in either group. CONCLUSIONS: Laparoscopic retroperitoneal lymph node dissection appears to be safe, viable and effective for stage I nonseminomatous germ cell tumors. The lack of retroperitoneal recurrence in pN0-N1 cases supports the oncological efficacy of this approach. Its low morbidity and rapid convalescence compare favorably with those in open series.

Iatrogenic vascular lesions after minimally invasive partial nephrectomy: a multi-institutional study of clinical and renal functional outcomes.

OBJECTIVES: To report the first large multi-institutional experience, including clinical and renal functional outcomes after treatment of iatrogenic vascular lesions (eg, renal artery pseudoaneurysm, arteriovenous fistula). These lesions are uncommon after minimally invasive partial nephrectomy (MIPN) but can be associated with significant morbidity. METHODS: A retrospective review of MIPN was performed at 4 centers. Patients developing pseudoaneurysm or arteriovenous fistula in the postoperative period were identified. The demographic, disease, and perioperative details and data regarding the presentation and treatment of vascular lesions were collected. RESULTS: Of the 998 patients undergoing MIPN, 20 (2.0%) presented with iatrogenic vascular lesions (17 with pseudoaneurysm and 3 with arteriovenous fistula). The mean age was 55.9 years, the tumor size was 2.6 cm, and the body mass index was 30.8 kg/m(2). Twelve patients (60%) had >50% endophytic tumors, 7 patients (35%) had undergone collecting system repair, and the mean warm ischemia time was 26 minutes. All patients presented with gross hematuria at a mean of 14.5 days postoperatively. The diagnosis was made using urgent computed tomography scan in all cases. Selective embolization was performed in 16 patients; 2 required no intervention and had spontaneous resolution, and 2 had negative angiography findings. Four patients required transfusion during rehospitalization. Although 4 patients had categorical worsening of the glomerular filtration rate after MIPN, all patients had stable function acutely after angioembolization, and 3 patients had categorical glomerular filtration rate improvement through a mean follow-up of 20 months. No patients had recurrent hemorrhagic events. CONCLUSIONS: Iatrogenic vascular lesions occur in ∼2% of MIPN cases. Although a subset of patients will have resolution with observation only, most require angioembolization, with excellent clinical and renal function outcomes.