Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective.

CONTEXT: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as standard tool in European Association of Urology (EAU) guidelines.

OBJECTIVE: To update the role of L-RPLND in patients with clinical stage I nonseminomatous germ cell tumour (NSGCT) compared to open retroperitoneal lymph node dissection (O-RPLND).

EVIDENCE ACQUISITION: A systematic literature search from 1992 to 2008 was performed in Medline, EMBASE, and Cochrane. The largest series from each group was considered. Comparative analysis was based on raw data of series published in 2000 and later.

EVIDENCE SYNTHESIS: Results of >800 patients treated by L-RPLND reported in 34 articles were analyzed. Lymph node dissection (LND) was based on modified templates, removing an average of 16 (5-36) lymph nodes. At experienced centres, complication rates were 15.6% (9.4-25.7), including 2% (0-5) retrograde ejaculation and 1.7% (0-6) reintervention. Operating room times are longer compared to O-RPLND (204 vs 186min). Five publications with a follow-up of 63 (36-89) mo include 557 patients. One hundred twenty-six of 140 (90%) patients with positive nodes (25%, range: 17-38) received adjuvant chemotherapy, resulting in a local relapse rate of 1.4% (0.7-2.3) with no in-field recurrence; rate of distant relapses was 3.3% (1.8-4.6), including one port-site metastasis; and rate of biochemical failure was 0.9% (0.7-2.3). Two of 14 patients with positive nodes (pN1) who did not receive adjuvant chemotherapy relapsed, both 8 mo after surgery, and were salvaged by chemotherapy. Compared with O-RPLND, there was no difference in relapse rates, percentage of patients receiving chemotherapy (29% vs 31%), chemotherapy (CTx) cycles per cohort (0.6), rate of salvage surgery (1.2% vs 1.5%), and patients with no evidence of disease (NED; 100% vs 99.7%).

CONCLUSIONS: L-RPLND offers similar staging accuracy and long-term outcome to O-RPLND. In a late series of experienced L-RPLND centres, there was a trend towards fewer complications. L-RPLND represents a valuable tool for experienced laparoscopic surgeons. Further studies must focus on the curative potential of the procedure in pathologic stage IIA.