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SYMPOSIUM
Year : 2010  |  Volume : 26  |  Issue : 1  |  Page : 102-107
 

Surgery for retroperitoneal relapse in the setting of a prior retroperitoneal lymph node dissection for germ cell tumor


1 Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, USA
2 Department of Urology, Weill College of Medicine, New York, USA

Date of Web Publication23-Mar-2010

Correspondence Address:
Joel Sheinfeld
Department of Urology, Weill College of Medicine, 353 East 68th Street, New York, NY 10021
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.60452

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   Abstract 

Recognition of the therapeutic role of retroperitoneal lymph node dissection (RPLND) in the setting of testicular germ cell tumors (GCTs) is of utmost importance. Although the histologic findings of RPLND provide diagnostic and prognostic information, the adequacy of initial RPLND is an independent predictor of clinical outcome. Despite the advent of effective cisplatin-based chemotherapy for testicular GCTs, patients who have undergone suboptimal surgery at the time of initial RPLND are compromised. Despite the initial enthusiasm surrounding anatomic mapping studies, the use of modified RPLND templates has the potential to leave a significant number of patients with unresected retroperitoneal disease. Teratomatous elements are particularly common. Patients with retroperitoneal relapse following initial RPLND should be treated with reoperative RPLND and chemotherapy and can expect long term survival rates nearing 70% when treated in tertiary centers by experienced surgeons.


Keywords: Recurrence, relapse, reoperative, retroperitoneal lymph node dissection, testicular cancer


How to cite this article:
Gotto GT, Carver BS, Sogani P, Sheinfeld J. Surgery for retroperitoneal relapse in the setting of a prior retroperitoneal lymph node dissection for germ cell tumor. Indian J Urol 2010;26:102-7

How to cite this URL:
Gotto GT, Carver BS, Sogani P, Sheinfeld J. Surgery for retroperitoneal relapse in the setting of a prior retroperitoneal lymph node dissection for germ cell tumor. Indian J Urol [serial online] 2010 [cited 2019 Sep 21];26:102-7. Available from: http://www.indianjurol.com/text.asp?2010/26/1/102/60452



   Introduction Top


Testicular cancer is generally regarded as highly curable even in the setting of advanced disease. This is in large part due to the advent of effective cisplatin-based chemotherapy. [1] Retroperitoneal lymph node dissection (RPLND) remains an integral component of the management of patients with testicular germ cell tumors (GCTs) in both the primary and post-chemotherapy settings. When combined with systemic chemotherapy, overall survival rates of greater than 90% can be expected. [2]

RPLND should always be pursued with therapeutic intent whether it is in the primary or post-chemotherapy setting. While pathologic findings following RPLND are important in the diagnosis and staging of patients with testicular GCTs, it cannot be overstated that this procedure can have a profound impact on clinical outcomes when properly performed. [3],[4] When patients relapse in the retroperitoneum after an inadequately performed RPLND even aggressive cisplatin-based chemotherapy protocols will not result in cure in all men. [4],[5],[6],[ 7] Every attempt should be made to resect all retroperitoneal disease at the time of initial RPLND and this goal may not be consistently achieved using restricted, modified templates described in the literature.

Patients who undergo an inadequate initial RPLND are at risk for relapse in the retroperitoneum. [7] There is a role for reoperative RPLND in these patients although oncologic outcomes are compromised when compared with patients who underwent initial RPLND with complete surgical resection. [4],[5],[6],[7] Although the use of modified surgical templates has been shown to aid in preservation of antegrade ejaculation, similar results can be achieved with a bilateral nerve-sparring procedure without compromising relapse-free survival. The adequacy of the surgical resection at the time of initial RPLND is an independent predictor of relapse-free survival in both low-stage and advanced nonseminomatous germ cell tumor (NSGCT). [4],[8]

This article will describe the patient population in which reoperative RPLND should be considered and will review sites of recurrence and histologic findings at the time of reoperative RPLND. The surgical morbidity and oncologic outcomes of reoperative RPLND will be addressed. Finally, this article includes a discussion on what puts patients at risk for retroperitoneal recurrence in the setting of a previous RPLND and how to avoid compromising relapse-free and cancer-specific survival at the time of initial RPLND.


   Retroperitoneal Metastases in Testicular GCTS Top


Regardless of histologic subtype, testicular GCTs tend to spread through retroperitoneal lymphatics in a predictable fashion. This is felt to be the result of embryologic migration of the testis through the retroperitoneum where it acquires drainage from the lymphatics adjacent to the aorta and inferior vena cava. [9] It is uncommon to observe metastases to the lung and posterior mediastinum without concomitant retroperitoneal disease. [9],[10] Choriocarcinoma does show a higher rate of hematogenous spread, resulting in distant metastases without apparent retroperitoneal involvement, but still tends to follow a similar pattern to the other subtypes the majority of the time. [10]

Right-sided testicular GCTs tend to spread first to the interaortocaval region followed by the precaval and preaortic nodes. In contrast, the primary metastatic sites for left-sided tumors are the paraaortic and preaortic nodes. [9],[11],[12],[ 13] However, mapping studies have clearly established that multifocality and contralateral spread are more common with higher pathologic stage. This is particularly true for right-sided tumors. [10],[11],[12],[13] Subsequent spread through the retroperitoneum is typically in a cranial direction although caudal spread to the iliac, pelvic, and inguinal nodes can occur in the setting of bulky retroperitoneal disease. [10],[11],[12],[13]


   Retroperitoneal Lymph Node Dissection (RPLND) Top


The retroperitoneum is the initial, and often only, site of metastatic spread in up to 90% of patients with GCT. [10] It also represents the most common site for late relapse of both teratoma and viable GCT. [5],[7],[14] Despite improvements in radiographic imaging, up to 30% of patients who present initially with viable tumor in the retroperitoneum are clinically under staged. [10] Metastases to the brain, bone, and liver are typically late events and are typically seen only in association with bulky retroperitoneal disease. [9],[15],[16]

The indications for RPLND and the surgical template for dissection have changed significantly since its role was first established in 1948. [9] Bilateral suprahilar dissection was at one time the standard of practice. [9] With the advent of effective cisplatin-based chemotherapy, routine suprahilar dissection was abandoned due to its association with renovascular injury, pancreatic leak, and chylous ascites, which accounted for much of the surgical morbidity associated with RPLND. [9]

Retrograde ejaculation remained a significant risk even with bilateral infrahilar RPLND. The incidence of this complication is related to the extent of retroperitoneal dissection. [9],[17] A number of modified side-specific templates have been proposed with the objective of minimizing damage to the contralateral paravertebral sympathetic ganglia, postganglionic sympathetic fibers, and hypogastric plexus. [9] A common feature of most of these templates is a limited dissection below the inferior mesenteric artery (IMA) on the contralateral side. [9],[18],[19] However, antegrade ejaculation can be maintained with the application of nerve-sparing techniques in which these structures are prospectively identified, dissected and preserved, in the setting of a full bilateral template dissection. [9],[20],[21]


   Retroperitoneal Recurrence After RPLND Top


The issue of retroperitoneal relapse after RPLND is not commonly addressed in the literature. Its true incidence is likely underestimated due to

  • widespread use of postoperative cisplatin-based therapy
  • lack of standardized routine imaging following RPLND
  • limited follow-up periods in published series
Postoperative cisplatin-based chemotherapy eliminates occult micrometastatic disease in a significant proportion of patients. Most protocols for follow-up after RPLND include plain chest radiographs and serum tumor markers but not routine imaging of the retroperitoneum. When a relapse is detected, the patient is often treated with chemotherapy without imaging of the retroperitoneum to document the precise site of relapse. For this reason, many reports in the literature fail to report the site of recurrence. Finally, retroperitoneal relapse in the setting of a prior RPLND is commonly a late event which is likely missed in many published series due to insufficient follow-up. [9],[22],[23],[24] In patients with late relapse, the retroperitoneum is involved in 72% and 36% of patients present at least 10 years after an initial complete response. [7]

Relapse in the retroperitoneum in the setting of a prior RPLND results from suboptimal surgery in the vast majority of cases. Failure to completely resect retroperitoneal disease may be the result of technical errors or inappropriate modification of surgical templates. [23],[24],[25] Limited surgical volume and inexperience have been shown to compromise clinical outcomes in a variety of complex surgical procedures. [26],[27],[28] Given the relatively low incidence of testicular cancer, and declining use of primary RPLND, it is a challenge for many surgeons to maintain a high volume of cases. Even residency training programs struggle to maintain reasonable exposure to this procedure.

A review of operative log reports from 2000 through 2004 by the Accreditation Council for Graduate Medical Education Residency Review Committee for Urology revealed that the average number of RPLNDs performed by residents graduating in the United States in 2004 during their entire residency training was four. Roughly half of these residents acted as the primary surgeon in two or less RPLNDs and as first assistant in one or less. [29] The bottom tenth percentile were not involved in a single RPLND as primary surgeon or first assistant. [29]


   Modified Surgical Templates for RPLND Top


Modified templates for RPLND are based on anatomic mapping studies by Ray and Whitmore, Donohue and Weissbach. [11],[12],[13] The findings of these studies suggest that certain regions are at lower risk for metastases according to the side of testicular involvement. [11],[12],[13] The basic premise for modified templates is resection of the ipsilateral lymph nodes between the renal vessels and the bifurcation of the common iliac artery, with contralateral dissection limited or omitted. In the case of left-sided primary tumors, interaortocaval dissection is variably performed depending on the template. [9]

The limitations of modified templates were first addressed by Jewett and Torbey in 1988. [30] The mapping studies on which modified templates are based have been shown to underestimate the true extent of retroperitoneal involvement. There are several reasons for this. First, true rates of recurrence outside the modified template cannot be assessed without adequate follow-up. Node-negative patients were followed for a median of only 22 months in the Weissbach study during which time three retroperitoneal relapses were noted. [13] The studies by Ray and Whitmore and Donohue reported no follow-up at all. [11],[12] Second, despite being the only mapping study with any patient follow-up, the Weissbach study randomized patients with pathologic stage IIB disease to either two or four cycles of cisplatin-based chemotherapy which precludes accurate assessment of retroperitoneal relapse. [13] Third, variability in surgical technique and adherence to the modified template likely influenced the results of the Weissbach study which included patients from 50 surgeons in 46 different centers. [13] Finally, renal and renovascular anatomic variants, including variable insertion and branching of the right gonadal vein, may influence lymphatic drainage of the testis resulting in metastatic deposits outside a modified template.

Two recent publications from MSKCC examined rates of extra-template disease in patients undergoing either primary or post-chemotherapy RPLND. [18],[31] Eggener et al. evaluated 191 clinical stage I-IIA NSGCT patients who underwent full bilateral primary RPLND and were found to be node-positive. The incidence of node-positivity outside of five commonly referenced modified templates ranged from 3% - 23%. [18] Carver et al. evaluated 269 patients with viable GCT or teratoma at the time of post-chemotherapy RPLND for advanced NSGCT and found that, depending on the limits of the modified template, 7-32% had viable extra-template disease. [31] Neither study found a difference in the histologic distribution of extra-template disease compared to in-template disease. [31]

Eggener et al. found that in patients with metastatic extra-template disease, the most commonly involved sites outside of modified right-sided templates were the pre-aortic (100%) and para-aortic (68-100%) regions. [18] Interestingly, a study by Leibovich et al, in 2002 identified these two regions as the sole sites of positive nodes in 28 of 607 patients (5%) with right-sided NSGCT who underwent RPLND at Indiana University. [32] Eggener et al. identified the inter-aortocaval region as the most commonly involved site outside of modified left-sided templates with positive nodes found at this site in 88% of patients with extra-template disease. [18] Indeed, masses in the left para-aortic and/or hilar regions accounted for 50-53% of retroperitoneal masses resected at the time of reoperative RPLND in series from MSKCC and from Cespedes and Peretsman. [4],[22] Another reason for inadequate resection at this site is difficulty in achieving adequate exposure which requires pancreatic mobilization and meticulous dissection of the left renal vessels. [4],[9]


   Clinical Implications of an Uncontrolled Retroperitoneum Top


RPLND must be performed with therapeutic intent. Even in the setting of primary RPLND, those patients with retroperitoneal relapse have compromised survival. As depicted in [Figure 1]A, 5-year cancer-specific survival (CSS) dropped from 99% to 86% for 22 patients who underwent redo-RPLND at MSKCC. [4] This decrease in survival occurred despite the fact that 20 of the 22 patients (90%) received two to four cycles of cisplatin-based chemotherapy as adjunctive therapy following primary RPLND (one patient) or because of incomplete resection (nine patients) or clinical relapse (10 patients) prior to undergoing reoperative RPLND. Cisplatin-based chemotherapy will not reliably compensate for an incomplete RPLND performed without therapeutic intent. Completeness of resection is also an independent predictor of CSS in the setting of late retroperitoneal relapse. A second study by Sharp et al. from MSKCC found that five-year CSS was 79% vs. 36% for patients with and without a complete resection performed at the time of late retroperitoneal relapse. [7]

Completeness of resection at the time of reoperative retroperitoneal surgery has been also been shown to be a significant and independent factor in the prognosis of patients with residual retroperitoneal disease. [4],[7],[8] Rates of disease progression have been shown to increase as much as 4-fold in patients with incompletely resected residual metastases. [7],[33],[34],[35]

Two independent publications from Indiana University and MSKCC evaluated relapse and survival rates in patients undergoing either primary PC-RPLND or reoperative PC-RPLND. [4,8] Donohue et al. report relapse rates for primary PC-RPLND versus reoperative PC-RPLND of 20.6% and 51.6%, respectively. Survival rates dropped from 84% in the primary group to 55% in the reoperative group. [8] Similarly, McKiernan et al. from MSKCC reported a drop in CSS from 90 to 56%. [4] These results are shown in [Figure 1]B.

The three most important prognostic factors for patients requiring reoperative surgery are serum tumor marker status at the time of reoperation, histologic findings at surgery, and completeness of resection. [4],[7],[36],[37] In the study by McKiernan et al. patient survival at two years, post-reoperative RPLND was reported at only 52% for patients with elevated serum tumor markers at the time of surgery in contrast to those with normal markers who had survival rates approaching 80%. [4] With regards to histologic findings at the time of reoperative RPLND, there was significant variation in CSS for patients with fibrosis or resected teratoma (80%), viable GCT (44%), and teratoma with malignant transformation (20%). [4] The study by Sharp et al. from MSKCC found that in patients with late relapse specifically, a symptomatic presentation and multifocal disease were the only independent predictors of reduced CSS in a multivariable model, with hazard ratios of 4.9 and 3.0, respectively. [7]

The most common histologic finding at the time of reoperative retroperitoneal surgery following either primary RPLND or PC-RPLND is teratoma. Mc Kiernan reported that in patients with retroperitoneal recurrences following primary RPLND or PC-RPLND, teratoma was identified at the time of initial resection in 45% and 59% of patients, respectively. [4] Despite its benign histologic appearance, teratoma can recur locally and undergo malignant transformation. Therefore, complete resection is of all retroperitoneal teratoma is imperative. Late relapse from unresected teratoma has been reported in several series and the true incidence of this event is likely underreported because of inadequate follow-up. [9],[23],[38] Mass effects from growing teratoma may lead to invasion and/or obstruction of surrounding structures.

Malignant transformation with sarcomatous and/or carcinomatous elements has been reported. [9] A study by Loehrer et al. reported late recurrence in 19% of patients with teratoma identified at the time of initial RPLND. [38] The majority of these relapses occurred within the retroperitoneum suggesting incomplete resection at the time of initial RPLND and malignant transformation was identified in a subset of patients. [38] Malignant transformation was responsible for two deaths following late retroperitoneal relapse of teratoma in a study by Holzik et al. [39] Survival for patients with teratoma with malignant transformation discovered at the time of reoperative RPLND is exceptionally poor at only 20%. [4]


   Complications of Reoperative RPLND Top


Achieving a complete resection at the time of reoperative RPLND is critical to avoid a repeat retroperitoneal recurrence and optimize oncologic outcomes including relapse-free and cancer-specific survival. Several groups have published on the morbidity associated with reoperative retroperitoneal surgery. Reoperative surgery is considered more challenging because of desmoplastic reaction and adhesions related to extravasation of blood and/or lymphatic fluid at the time of prior surgery and chemotherapy. This can result in difficulty with identification of planes and can lead, for example, to subadventitial vascular dissection and the need for vascular grafting. [40] Sacrificing adjacent organs (kidney, bowel, spleen) and/or graft replacement of a great vessel may be necessary. [9],[35]

A small study published by Waples and Messing in 1993 reported on morbidity following reoperative retroperitoneal surgery in nine patients. Mean anesthetic time was 9.5 hours with a mean estimated blood loss of 6.3 liters. Five patients (56%) had significant perioperative complications including common bile duct injury, chylous ascites, and major vascular injury resulting in lower extremity amputation. [41]

More recently, in 2003, two separate publications reported on the experiences with reoperative RPLND at MSKCC and MD Anderson. [4],[40] McKiernan reported an overall complication rate of 27% in 61 patients operated on at MSKCC. [4] The most common complications included lymphocele (4), ileus (3), wound infection (2), SBO (2), ureteral injury (2) and renal infarction (1). [4] There was one death due to pulmonary embolus. [4] Sexton et al. reported on 21 patients who underwent reoperative RPLND at M.D. Anderson. Intraoperative complications were reported in 29% of patients. Postoperative complications, including prolonged ileus and chylous ascites, were reported in 48%, and, again, there was a single death attributed to pulmonary embolus. [40] The morbidity of reoperative retroperitoneal surgery is minimized when performed in dedicated tertiary centers by experienced surgeons. [4],[8],[9],[40]


   Conclusions Top


While RPLND does provide both diagnostic and prognostic information, it is first and foremost a therapeutic procedure. Failure to recognize this may lead to suboptimal surgery putting patients at risk for late relapse and compromised clinical outcomes. While reoperative surgery in combination with cisplatin-based chemotherapy can salvage nearly 70% of patients with retroperitoneal relapse after a suboptimal RPLND, inadequate initial resection of retroperitoneal metastases has been shown to be a an independent adverse prognostic variable in NSGCT. There is significant limitation to the anatomic mapping studies used to justify the use of modified surgical templates and, at present, no modification of the standard bilateral RPLND template will result in reliable resection of all retroperitoneal disease in either the primary or post-chemotherapy setting.

In addition, nerve-sparing techniques at the time of bilateral RPLND result in rates of antegrade ejaculation similar to those seen with modified templates. Common features of retroperitoneal relapse after RPLND include a predilection for the left para-aortic region and the increased prevalence of teratomatous elements. Both reoperative and, arguably, primary RPLND or PC-RPLND should be performed in tertiary centers by experienced surgeons in an effort to reduce perioperative morbidity and improve oncologic outcomes.



 
   References Top

1.Sheinfeld, J. Treatment of patients with testis cancer: Introduction. Urol Oncol 2005;23:222.  Back to cited text no. 1      
2.Sheinfeld, J. The role of adjunctive postchemotherapy surgery for nonseminomatous germ-cell tumors: Current concepts and controversies. Semin Urol Oncol 2002;20:262.  Back to cited text no. 2      
3.Carver, BS, Sheinfeld, J. Therapeutic efficacy of laparoscopic RPLND: Unproved and untested. Am J Urol Rev 2004;2:427.  Back to cited text no. 3      
4.McKiernan JM, Motzer RJ, Bajorin DF, Bacik J, Bosl GJ, Sheinfeld J. Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor: Clinical presentation, patterns of recurrence, and outcome. Urology 2003;62:732.  Back to cited text no. 4  [PUBMED]    
5.Baniel J, Foster RS, Gonin R, Messemer JE, Donohue JP, Einhorn LH. Late relapse of testicular cancer. J Clin Oncol 1995;13:1170-6.  Back to cited text no. 5  [PUBMED]    
6.Baniel J, Foster RS, Einhorn LH, Donohue JP. Late relapse of clinical stage I testicular cancer. J Urol 1995;154:1370-2.  Back to cited text no. 6  [PUBMED]    
7.Sharp DS, Carver BS, Eggener SE, Kondagunta GV, Motzer RJ, Bosl GJ, et al. Clinical outcome and predictors of survival in late relapse of germ cell tumor. J Clin Oncol 2008;26:5524-9.  Back to cited text no. 7  [PUBMED]    
8.Donohue JP, Leviovitch I, Foster RS, Baniel J, Tognoni P. Integration of surgery and systemic therapy: Results and principles of integration. Semin Urol Oncol 1998;16:65.  Back to cited text no. 8  [PUBMED]    
9.Sheinfeld J, McKiernan JM, Bosl GJ. Surgery for testicular tumors. In: Campbell's Urology. In: Walsh PC, Retik AB, Vaughan ED Jr, editors. Philadelphia: WB Saunders; 2000. p. 2920-44.   Back to cited text no. 9      
10.Stephenson AJ, Sheinfeld J. The role of retroperitoneal lymph node dissection in the management of testicular cancer. Urol Oncol 2004;22:225.  Back to cited text no. 10  [PUBMED]    
11.Ray B, Hajdu SI, Whitmore WF Jr. Distribution of retroperitoneal lymph node metastases in testicular germinal tumors. Cancer 1974;33:340.  Back to cited text no. 11  [PUBMED]    
12.Donohue JP, Zachary JM, Maynard BR. Distribution of nodal metastases in nonseminomatous testis cancer. J Urol 1982;128:315.  Back to cited text no. 12  [PUBMED]    
13.Weissbach L, Boedefeld EA. Localization of solitary and multiple metastases in stage II nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I. J Urol 1987;138:77.  Back to cited text no. 13  [PUBMED]    
14.George DW, Foster RS, Hromas RA, Robertson KA, Vance GH, Ulbright TM, et al. Update on late relapse of germ cell tumor: A clinical and molecular analysis. J Clin Oncol 2003;21:113-22.  Back to cited text no. 14  [PUBMED]    
15.Johnson DE, Appelt G, Samuels ML, Luna M. Metastases from testicular carcinoma: Study of 78 autopsied cases. Urology 1976;8:234-9.  Back to cited text no. 15  [PUBMED]    
16.Bredael JJ, Vugrin D, Whitmore WF Jr. Autopsy findings in 154 patients with germ cell tumors of the testis. Cancer 1982;50:548.  Back to cited text no. 16  [PUBMED]    
17.Lange PH, Narayan P, Fraley EE. Fertility issues following therapy for testicular cancer. Semin Urol 1984;2:264.  Back to cited text no. 17  [PUBMED]    
18.Eggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfeld J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol 2007;177:937-42; discussion 942-3.  Back to cited text no. 18  [PUBMED]    
19.Sheinfeld J, Herr HW. Role of surgery in management of germ cell tumor. Semin Oncol 1998;25:203.  Back to cited text no. 19  [PUBMED]    
20.Jewett MA, Kong YS, Goldberg SD, Sturgeon JF, Thomas GM, Alison RE, et al. Retroperitoneal lymphadenectomy for testis tumor with nerve sparing for ejaculation. J Urol 1988;139:1220.  Back to cited text no. 20  [PUBMED]    
21.Donohue JP, Foster RS, Rowland RG, Bihrle R, Jones J, Geier G. Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation. J Urol 1990;144:287-91; discussion 291-2.  Back to cited text no. 21  [PUBMED]    
22.Cespedes RD, Peretsman SJ. Retroperitoneal recurrences after retroperitoneal lymph node dissection for low-stage nonseminomatous germ cell tumors. Urology 1999;54:548.  Back to cited text no. 22  [PUBMED]    
23.Sheinfeld J. Risks of the uncontrolled retroperitoneum. Ann Surg Oncol 2003;10:100.  Back to cited text no. 23  [PUBMED]    
24.Carver BS, Sheinfeld J. Germ cell tumors of the testis. Ann Surg Oncol 2005;12:871.  Back to cited text no. 24  [PUBMED]    
25.Sheinfeld J. Laparoscopic retroperitoneal lymph node dissection: Description of the nerve-sparing technique (Editorial). Urology 2002;60:343.  Back to cited text no. 25      
26.Ho V, Heslin MJ, Yun H, Howard L. Trends in hospital and surgeon volume and operative mortality for cancer surgery. Ann Surg Oncol 2006;13:851-8.  Back to cited text no. 26  [PUBMED]    
27.Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. J Am Med Assoc 1998;280:1747-51.  Back to cited text no. 27      
28.Konety BR, Dhawan V, Allareddy V, Joslyn SA. Impact of hospital and surgeon volume on in-hospital mortality from radical cystectomy: Data from the health care utilization project. J Urol 2005;173:1695.  Back to cited text no. 28  [PUBMED]    
29.Lowrance WT, Cookson MS, Clark PE, Smith JA Jr, Chang SS. Assessing retroperitoneal lymphadenectomy experience in United States urological residency programs. J Urol 2007;178:500-3; discussion 503.  Back to cited text no. 29  [PUBMED]    
30.Jewett MA, Torbey C. Nerve-sparing techniques in retroperitoneal lymphadenectomy in patients with low-stage testicular cancer. Semin Urol 1988;6:233.  Back to cited text no. 30  [PUBMED]    
31.Carver BS, Shayegan B, Eggener S, Stasi J, Motzer RJ, Bosl GJ, et al. Incidence of metastatic nonseminomatous germ cell tumor outside the boundaries of a modified postchemotherapy retroperitoneal lymph node dissection. J Clin Oncol 2007;25:4365-.  Back to cited text no. 31  [PUBMED]    
32.Leibovitch BS, Foster RS, Mosharafa AA. Unusual sites of metastasis in low stage testis cancer. J Urol 2002;167:683A.  Back to cited text no. 32      
33.Stenning SP, Parkinson MC, Fisher C, Mead GM, Cook PA, Fossa SD, et al. Postchemotherapy residual masses in germ cell tumor patients: Content, clinical features, and prognosis. Cancer 1998;83:1409-19.  Back to cited text no. 33  [PUBMED]    
34.Sheinfeld J. Commentary on retroperitoneal surgery following induction chemotherapy for advanced NSGCT. Am J Urol Rev 2003;1:267.  Back to cited text no. 34      
35.Nash PA, Leibovitch I, Foster RS, Bihrle R, Rowland RG, Donohue JP. En bloc nephrectomy in patients undergoing post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous testis cancer: Indications, implications and outcomes. J Urol 1998;159:707-10.  Back to cited text no. 35  [PUBMED]    
36.Fox EP, Weathers TD, Williams SD, Loehrer PJ, Ulbright TM, Donohue JP, et al. Outcome analysis for patients with persistent nonteratomatous germ cell tumor in postchemotherapy retroperitoneal lymph node dissections. J Clin Oncol 1993;11:1294-9.  Back to cited text no. 36  [PUBMED]    
37.Murphy BR, Breeden ES, Donohue JP, Messemer J, Walsh W, Roth BJ, et al. Surgical salvage of chemorefractory germ cell tumors. J Clin Oncol 1993;11:324-9.  Back to cited text no. 37  [PUBMED]    
38.Loehrer PJ Sr, Hui S, Clark S, Seal M, Einhorn LH, Williams SD, et al. Teratoma following cisplatin-based combination chemotherapy for nonseminomatous germ cell tumors: A clinicopathological correlation. J Urol 1986;135:1183-9.  Back to cited text no. 38  [PUBMED]    
39.Lutke Holzik MF, Hoekstra HJ, Mulder NH, Suurmeijer AJ, Sleijfer DT, Gietema JA. Non-germ cell malignancy in residual or recurrent mass after chemotherapy for nonseminomatous testicular germ cell tumor. Ann Surg Oncol 2003;10:131-5.  Back to cited text no. 39  [PUBMED]    
40.Sexton WJ, Wood CG, Kim R, Pisters LL. Repeat retroperitoneal lymph node dissection for metastatic testis cancer. J Urol 2003;169:1353-6.  Back to cited text no. 40  [PUBMED]    
41.Waples MJ, Messing EM. Redo retroperitoneal lymphadenectomy for germ cell tumor. Urology 1993;42:31.  Back to cited text no. 41  [PUBMED]    


    Figures

  [Figure 1]

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