Hiester Andreas, Nini Alessandro, Fingerhut Anna, Große Siemer Robert, Winter Christian, Albers Peter, Lusch Achim
Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany.
Front Surg. 2019 Jan 17;5:80. doi: 10.3389/fsurg.2018.00080. eCollection 2018.
Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays a crucial role in treatment of metastatic non-seminomatous germ cell cancer. To evaluate the functional outcome regarding the preservation of ejaculatory function comparing a bilateral vs. unilateral template resection in PC-RPLND patients. In addition, oncological safety and perioperative complications of the unilateral template resection was compared to the full bilateral one. Between 2003 and 2018, 504 RPLNDs have been performed in 434 patients. The database of consecutive patients was queried to identify 171 patients with PC-RPLND after 1st line chemotherapy for a non-seminoma with or without bilateral template resection. Re-Do's, late relapse, salvage patients, and thoraco-abdominal approaches were excluded. Indication for a template resection was a unilateral residual mass mainly <5 cm as published (1). Descriptive statistics were used to report preoperative features, postoperative outcomes and patterns of recurrence, on the overall population and after stratification for the type of resection (bilateral vs. unilateral). Kaplan-Meier analyses were used to describe recurrence- and cancer-specific mortality-free survival rates at different time points. Overall, 90 and 81 patients underwent unilateral and bilateral radical resection, respectively. Median size of residual mass was 7 cm for bilateral and 4 cm for unilateral template resection. Clinical stage II and III were present in 31 and 69% of patients, respectively. Median follow-up was 14.5 months (IQR 3.3-37.6). The 1- and 2-year recurrence-free survival rates were 91 and 91%, and 77 and 72% for patients treated with unilateral template and bilateral resection, respectively ( = 0.0078). Median time to recurrence was 9.5 and 9 months in template and bilateral resection group, respectively. Adjunctive procedures were performed in 56 patients (33%) and were significantly more frequent in the bilateral resection group (43 vs. 23%, = 0.006). The overall high-grade complication rate (Clavien-Dindo ≥ III) was 6, 3, and 9% in unilateral template and bilateral resection group, respectively ( = 0.6). The rate of preservation of antegrade ejaculation was significantly higher in the unilateral group. Antegrade ejaculation in patients undergoing unilateral template resection with a residual mass <5 cm can be preserved at a much higher rate. Moreover, this surgical procedure is oncologically safe in terms of mid-term recurrence and CSM-free survival rates. This data undermines the growing evidence of limited PC-RPLND being justifiable in strictly unilateral residual mass <5 cm. This data has to be confirmed with a longer follow-up regarding in-field and retroperitoneal recurrences.
化疗后腹膜后淋巴结清扫术（PC-RPLND）在转移性非精原细胞瘤性生殖细胞癌的治疗中起着关键作用。为了评估PC-RPLND患者中双侧与单侧模板切除在保留射精功能方面的功能结局。此外，将单侧模板切除的肿瘤学安全性和围手术期并发症与全双侧切除进行了比较。2003年至2018年期间，对434例患者进行了504例RPLND。查询连续患者的数据库，以识别171例接受一线化疗治疗非精原细胞瘤且有或无双侧模板切除的PC-RPLND患者。排除再次手术、晚期复发、挽救性治疗患者和胸腹联合入路。模板切除的指征是如已发表的那样主要<5 cm的单侧残留肿块(1)。使用描述性统计报告总体人群以及按切除类型（双侧与单侧）分层后的术前特征、术后结局和复发模式。采用Kaplan-Meier分析描述不同时间点的无复发生存率和癌症特异性无死亡率生存率。总体而言，分别有90例和81例患者接受了单侧和双侧根治性切除。双侧模板切除的残留肿块中位大小为7 cm，单侧为4 cm。临床II期和III期患者分别占31%和69%。中位随访时间为14.5个月（四分位间距3.3-37.6）。单侧模板切除和双侧切除治疗的患者1年和2年无复发生存率分别为91%和91%，以及77%和72%（P = 0.0078）。模板切除组和双侧切除组的复发中位时间分别为9.5个月和9个月。56例患者（33%）进行了辅助手术，双侧切除组明显更频繁（43%对23%，P = 0.006）。单侧模板切除组和双侧切除组的总体高级别并发症发生率（Clavien-Dindo≥III级）分别为6%、3%和9%（P = 0.6）。单侧组顺行射精保留率明显更高。残留肿块<5 cm的单侧模板切除患者顺行射精保留率可以更高。此外，就中期复发和无癌症特异性死亡率生存率而言，该手术在肿瘤学上是安全的。该数据削弱了越来越多的证据，即严格单侧残留肿块<5 cm时有限的PC-RPLND是合理的。关于野内和腹膜后复发，该数据必须通过更长时间的随访来证实。
