In our study comparing O-PCLND and L-PCLND long-term oncological outcome was excellent for both surgical techniques. There were no statistical significant differences between the two cohorts with respect to intraoperative complications. L-PCLND patients were less likely to receive surgical drains. There has been a trend towards a shorter operative time and hospital stay following L-PCLND. To overcome possible confounding factors, like the relatively small number of patients, the retrospective nature of the study and the differences in median residual tumor diameter of the two cohorts, we performed a subgroup analysis of patients with tumor diameters of ≤7
cm. This analysis confirmed the less frequent placement of surgical drains, the shorter duration of drainage and hospital stay. However, despite these efforts, the O-PCLND group was relatively small and the majority of patients had residual tumors larger than 3
cm. Therefore, a sample selection bias might have significantly influenced the results (Table
). Further confounding factors could be differences in IGCCCG categories and extend of follow-up, the imbalanced distribution of residual tumor diameters and histological subtypes. Therefore, a precise statistical comparison with reliable conclusions remains challenging. Overall this is a descriptive series of patients undergoing PCLND for metastatic testis cancer and some patients were managed in an inhomogeneous fashion. Some of the surgical procedures were not performed according to established treatment guidelines.
Table 7 Subgroup analysis of residual tumors ≤7cm
The results obtained for our L-PCLND patients are comparable to those published previously [17
]. In 2009 Calestroupat and colleagues reported their experience with 26
L-PCLND patients. Median residual tumor diameter was 3.4
cm, while the conversion rate and the transfusion rate were 11.5% and 3.8%, respectively. Median operative time (183 min) was relatively short with a median hospital stay of 5
days. Grade 3/4 complications occurred in 7.6% of cases. The authors concluded that a high level of surgical expertise is needed to successfully perform a L-PCLND. Although L-PCLND has been restricted to patients with small residual tumors in the study of Calestroupat et al., their conversion rate, transfusion rate and the number of Grade3/4 complication were higher compared to our observations [18
In a series of 49
L-PCLND patients with residual tumor sizes between 2-5
cm Janetschek and co-workers reported a mean operative time of 226 min and a mean postoperative hospital stay of 3.5
days. Overall, complication rate was low. All bleeding complications were managed laparoscopically and no blood transfusion was necessary. Interestingly, L-PCLND was only applied to patients with clinical stage IIb disease, thereby partly explaining these favourable intra- and postoperative results [17
The largest L-PCLND series of 59 patients was published by Albqami from Linz, Austria. A mean operative time of 234 min, a conversion rate of 0%, a mean estimated blood loss of 165
ml and a mean hospital stay of 3.8
days were reported. During a 5
year follow-up two patients relapsed [19
In 2008 Steiner et al. demonstrated the feasibility of a bilateral L-PCLND with the preservation of sympathetic nerves in 42 patients (stage IIB n
19). No conversion to O-PCLND was necessary; mean operative time was 323 min, no intraoperative complications were reported. Antegrade ejaculation was reported for 85.7% of patients. After a mean follow up of 17.2
months no disease recurrence was observed. Unfortunately, there were no exact tumor diameters and locations reported in this study [20
]. Comparison to our data is therefore challenging.
Overall, none of the above mentioned studies directly compared L-PCLND patients with a contemporary O-PCLND cohort.
For O-PCLND patients with initial tumor masses larger than 5
cm local relapse rates of 10% are reported in the literature [21
]. However, for extended retroperitoneal teratoma the local disease recurrence rates following surgery might be up to 25% [22
]. In a recent series of 73 patients with small residual tumors (mean diameter 4
cm) Luz et al. reported an overall complication rate of 27% and found viable tumor in 22% of patients [23
]. In 2007, Carver et al. demonstrated that O-PCLND patients with a residual teratoma had a 10-year recurrence-free survival of 80%. The residual tumor size and the IGCCCG risk classification were independent predictors of disease recurrence [24
]. These findings are in contrast to our findings: We did not identify surgical technique, IGCCCG risk score, clinical stage or residual tumor diameter as predictors of disease recurrence or OS. This observation could reflect the significant differences of patient characteristics in Carvers cohort compared to our study, especially with respect to the fraction of L-PCLND patients with good prognosis and small residual tumors.
Subramanian et al. published a detailed analysis of 98 O-PCLND patients. Median blood loss was 1000
ml with a consecutive transfusion rate of 42%. Median operating time was 305 min and the median hospital stay 6
days. Overall, intraoperative complication rate was 12%, grade III complications were reported in 6% of cases, 1% each for grade IV and V. Antegrade ejaculation was preserved in 41% of patients. Unfortunately, similarly to other publications no data on tumor diameters were reported which limits comparability to our data [13
Reviewing O-PCLND series Heidenreich and co-workers concluded that in advanced NSGCTs, a complete resection should be performed for all residual masses irrespective of tumor size, location or histology, thereby providing an excellent long-term disease-free survival of 95% [9
]. For smaller tumors, a modified template resection was recommended [11
Despite the advances in laparoscopic surgery at highly specialized urological centers, L-PCLND still represents an evolving technique. Patient counselling and decision making on surgical technique used largely depends on the surgeon’s experience, tumor characteristics and the patient’s condition.
One of the major drawbacks in obtaining evidence on this important issue is the fact that comparison of the data published in the literature is challenging due to a number of reasons: firstly different eras, in which interventions were performed [25
] and secondly different reporting systems of complications. To overcome these issues partly, we incorporated the recently introduced Clavien classification into our study [12
]. Unfortunately, most of the previous studies did not use this evidence based classification, thereby precluding a sufficient comparison.