title: Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumor: a large single institution experience.
abstract: OBJECTIVE
  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.
  
  
  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.
authors.affiliation: The Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Elias S
authors.initials: ES
authors.lastname: Hyams
authors.forename: Phillip
authors.initials: P
authors.lastname: Pierorazio
authors.forename: Ornab
authors.initials: O
authors.lastname: Proteek
authors.forename: Myrna
authors.initials: M
authors.lastname: Sroka
authors.forename: Louis R
authors.initials: LR
authors.lastname: Kavoussi
authors.forename: Mohamad E
authors.initials: ME
authors.lastname: Allaf
mesh_terms: D000328:Adult; D006801:Humans; D010535:Laparoscopy; D008197:Lymph Node Excision / Q000379:methods*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009373:Neoplasms, Germ Cell and Embryonal / Q000473:pathology* / Q000601:surgery*; D012187:Retroperitoneal Space; D013736:Testicular Neoplasms / Q000473:pathology* / Q000601:surgery*; D055815:Young Adult