Additional Surgical Procedures and Perioperative Morbidity in Post-Chemotherapy Retroperitoneal Lymph Node Dissection for Metastatic Testicular Cancer in Two Intermediate Volume Hospitals - Beyond the Abstract

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important part of the treatment of disseminated testicular germ cell tumors. It is a challenging procedure with a relatively high rate of postoperative complications. An intraoperative additional surgical procedure (e.g. nephrectomy or inferior vena cava [IVC] resection) is necessary for approximately one-third of procedures.

Although most procedures are performed at low to intermediate volume institutions, most reports in the literature are from high-volume institutions. Previous studies have shown that the complication risk of PC-RPLND is associated with hospital volume. Still, reports from low and intermediate volume institutions are still scarce.

In this study, we present the perioperative morbidity of PC-RPLND in two intermediate volume hospitals. Our primary aim was to analyze whether the morbidity is comparable to what has been reported in the literature. In addition, we aimed to identify predictors of a high risk of perioperative morbidity.

A total of 124 patients who were treated with open PC-RPLND at two tertiary referral centers between 2001 and 2018 were included in this retrospective analysis. We determined perioperative morbidity by analyzing additional surgical procedures, intra-operative blood loss, and postoperative complications.

We found that an additional procedure was necessary for 33 patients (26.6%). The most commonly performed additional procedure was nephrectomy (9 patients; 7.3%), followed by IVC resection/reconstruction (8 patients; 6.5%). The risk of an additional procedure was higher in patients with IGCCCG intermediate/poor prognosis (odds ratio [OR] 3.56; 95% confidence interval [CI] 1.33–9.52) and residual tumor size > 5 cm (OR 3.53; 95% CI 1.39–8.93).

Intraoperative blood loss was significantly higher in patients with IGCCCG intermediate/poor prognosis (β = 0.177; p = 0.029), large residual tumor (β = 0.570; p < 0.001), an additional intervention (β = 0.342; p < 0.001) and teratoma on retroperitoneal histology (β = − 0.19; p = 0.014).

In all, 31 patients (25.0%) had a postoperative complication Clavien-Dindo grade ≥ 2. The most common complication was an infection managed by antibiotic therapy (14 patients; 11.3%). Two patients (1.6%) suffered from a postoperative complication grade 5. The risk of a postoperative complication was highest in patients undergoing an additional surgical intervention (OR 3.46; 95% CI 1.03–11.60; p = 0.044).

The rates of additional interventions and postoperative complications in our series were similar to what has been reported in reports from high-volume institutions. Patients with IGCCCG intermediate/poor prognosis with high-volume disease can be classified as high-risk patients. Extra attention to possible tumor ingrowth into adjacent organs and precautionary measures (e.g. postoperative stay at the intensive care unit) is warranted in these patients.

Written by: Richard P. Meijer, MD, PhD, FEBU, and Joost M. Blok, MD, PhD, Oncological Urologist, Associate Professor, UMC Utrecht Cancer Center, MS Urologische Oncologie, University Medical Center Utrecht, Utrecht, Netherlands

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