title: Excision of residual masses of metastatic germ cell tumours after chemotherapy: the role of extraperitoneal surgical approaches.
abstract: OBJECTIVE
  To evaluate the efficacy and safety of extraperitoneal surgical approaches for the removal of residual masses of metastatic germ cell tumours in men after chemotherapy.
  
  
  METHODS
  A series of 75 men (median age 32 years) with metastatic germ cell tumours of testicular (n = 63) or extragonadal (n = 12) origin, who had been treated with an intensive course of platinum-based chemotherapy, were found to have residual tumour masses. Extraperitoneal surgical approaches were used on 80 occasions to excise these masses. A thoraco-abdominal extraperitoneal approach (n = 71) was used for large masses and those with intrathoracic metastases while smaller retroperitoneal masses were removed through 12th rib (n = 5) or Rutherford-Morrison (n = 4) extraperitoneal approaches.
  
  
  RESULTS
  Complete macroscopic clearance of residual masses within the thorax and retroperitoneum was achieved in all cases. The median blood loss was 0.8 L and the median in-patient stay was 7 days. Complications included chest infection in four cases. Two patients died about 4 weeks after surgery, one from septic pericarditis and another after an epileptic fit secondary to brain metastases. Eleven patients have developed tumour recurrence, five of whom have died from disseminated disease. Hence the survival rate and disease-free survival rate are 91% and 83%, respectively, with a median follow-up of 22 months.
  
  
  CONCLUSIONS
  The thoraco-abdominal extraperitoneal surgical approach for retroperitoneal lymph node dissection after chemotherapy for testicular cancer is safe and has some advantages over anterior approaches, allowing synchronous removal of intrathoracic disease, improved access to nodes above and behind the renal vessels and more rapid post-operative recovery.
authors.affiliation: Department of Urology, Charing Cross Hospital, London, UK.
authors.forename: T J
authors.initials: TJ
authors.lastname: Christmas
authors.forename: A P
authors.initials: AP
authors.lastname: Doherty
authors.forename: G J
authors.initials: GJ
authors.lastname: Rustin
authors.forename: M J
authors.initials: MJ
authors.lastname: Seckl
authors.forename: E S
authors.initials: ES
authors.lastname: Newlands
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D018572:Disease-Free Survival; D005500:Follow-Up Studies; D006801:Humans; D008175:Lung Neoplasms / Q000556:secondary* / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D018365:Neoplasm, Residual; D011183:Postoperative Complications / Q000209:etiology*; D012186:Retroperitoneal Neoplasms / Q000556:secondary* / Q000601:surgery; D016019:Survival Analysis; D013724:Teratoma / Q000188:drug therapy* / Q000556:secondary / Q000601:surgery; D013736:Testicular Neoplasms / Q000188:drug therapy*