Surgical Management of Retrocrural Disease in Germ Cell Tumors: Outcomes and Evolution of Practice.

Residual retrocrural disease in testis cancer following chemotherapy is a surgical challenge. We sought to assess the outcomes and evolution with surgical management of residual retrocrural disease.

We identified 2,788 testicular cancer patients from 1990-2010 who underwent retroperitoneal surgery for metastatic testicular cancer at our institution. Patients who also underwent post-chemotherapy staged or concurrent retrocrural dissections were stratified for analysis. Surgical approach, clinical characteristics, additional procedures, complications and outcomes were evaluated.

Retrocrural dissection was performed in 211 patients. Histology of retrocrural disease demonstrated teratoma in 72%, necrosis in 15.2%, active germ cell cancer in 8.1%, and malignant transformation in 2.4%. Our preferred surgical approach to the retrocrural space has evolved over time, earlier approaches from 1990-1995 favored a single thoracoabdominal incision (17, 25%), midline transabdominal incision (22, 32.4%), or with a concurrent or staged thoracotomy (29, 42.6%). A transabdominal/transdiaphragmatic (TATD) approach at the time of midline retroperitoneal lymph node dissection has been utilized more frequently in 55% of contemporary cases, decreasing the need for thoracotomies. Patients undergoing a transabdominal/transdiaphragmatic approach had fewer complications (p=0.006), required fewer associated procedures (p=0.001), and a shorter length of stay (5 vs. 6 days, p=0.184).

Metastatic testis cancer to the retrocrural space is surgically challenging however complete resection is needed to maintain an expected excellent oncologic outcome. Coordination between urologic and thoracic surgeons for an individualized approach is important. We have found that a transabdominal/transdiaphragmatic approach where appropriate, has resulted in fewer complications.

The Journal of urology. 2020 Nov 12 [Epub ahead of print]

Sean Q Kern, Clint Cary, Hristos Z Kaimakliotis, Jose Pedrosa, Timothy Masterson, Richard Bihrle, Richard Foster, Kenneth Kesler

Department of Urology, Indiana University School of Medicine., Department of Thoracic Surgery, Indiana University School of Medicine.

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