Download Testicular Tumors: Chapter 30th

Surgery
of
Testicular Tumors
Chapter 30
Dr. Sundip Patel
4/1/2009
Epidemiology
Testicular Cancer
8000 New Cases yearly; 400 deaths yearly
Rising Incidence of Germ Cell Tumors, the most
common solid tumor in men 20-35 y/o
Great success story of current medicine
Management of Primary Tumors
 Painless scrotal masses often ignored (by patient)
Testicular cancers presenting as scrotal pain are
treated as epididymitis
Almost 20% of patients present with signs or
symptoms of metastatic disease such as back or
abdominal pain, weight loss, neck mass,
gynecomastia, or breast tenderness
Obtain careful H/P, AFP, BCG, LDH, scrotal U/S
Figure 30-1 Approach for radical inguinal orchiectomy. The incision is shown in the inset. The external oblique fascia is divided in line with its fibers down to the external
inguinal ring. (Adapted from Gottesman JE: Radical inguinal orchiectomy. In Crawford ED [ed]: Current Genitourinary Cancer Surgery. Philadelphia, Lea & Febiger, 1990,
p 319.)
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:49 AM)
© 2007 Elsevier
Figure 30-2 After the cord has been controlled with a tightened Penrose drain or rubber-shod clamp, the testis is mobilized out of the scrotum using blunt dissection.
(Adapted from Gottesman JE: Radical inguinal orchiectomy. In Crawford ED [ed]: Current Genitourinary Cancer Surgery. Philadelphia, Lea & Febiger, 1990, p 319.)
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Radical Orchiectomy
A radical orchiectomy with high ligation
of the spermatic cord at the level of the
internal ring is the first step in the
treatment of patients suspected of
harboring a testicular neoplasm.
Radical Orchiectomy - Steps
 General, spinal, or local anesthesia; outpatient
 A 5- to 7-cm oblique incision 2 cm above the pubic tubercle.
 Camper's and Scarpa's fascia are incised to the level of the external
oblique aponeurosis
 The ilioinguinal nerve is preserved. The spermatic cord is isolated
and occluded
 If a diagnostic biopsy or subtotal orchiectomy is planned, meticulous
draping off is necessary before opening the tunica vaginalis and
incising testicular parenchyma.
 Radical orchiectomy is completed by mobilizing the cord 1 to 2 cm
inside the internal ring and individually ligating the vas deferens and
the cord vessels between separate clamps
 The cord vessels are secured with silk ligatures, which can then be
used to identify the stump if a retroperitoenal lymph node dissection
(RPLND) is performed.
 The wound and scrotum are thoroughly irrigated, and hemostasis is
secured. A testicular prosthesis can be placed at this time.
 The external oblique aponeurosis is closed.
 Rest of wound is closed
Radical Orchiectomy - Complications
Bleeding / Hematoma most common
SCROTAL VIOLATION - Prior inguinal or
scrotal surgery could alter the normal
lymphatic drainage of the testis
Scrotal contamination and local recurrence
higher in this group
Scrotal Violation recs
 Patient who have undergone previous inguinal or scrotal
surgery have altered lympatic drainage
 In patients with low-stage seminoma, the radiation portals
should be extended to include the ipsilateral groin and
scrotum.
 In patients with low-stage nonseminomatous GCT (NSGCT), the
scrotal scar should be widely excised with the spermatic cord
remnant at the time of RPLND.
 Patients treated with full-dose platinum-based regimens should
have the cord stump removed at the time of RPLND; however,
given the relative absence of local relapse after systemic
treatment, extensive groin dissection or hemiscrotectomy is
not required
Partial Orchiectomy
Favorable selection criteria include
organ-confined disease with a mass
less than 20 mm, negative
postresection biopsies of the tumor
bed, and absence of intratubular germ
cell neoplasia in the remaining
testicular parenchyma. The procedure
is performed under conditions of cold
ischemia with great care to avoid tumor
spillage or contamination.
STAGING
Stage I - disease confined to the testis,
Stage II - retroperitoneal metastases, and
Stage III - supradiaphragmatic or visceral
metastases.
In the TNMS system, vascular or
lymphatic invasion in the primary tumor is
classified in the T2 category and serum
tumor markers are included because of
their independent prognostic significance
THE RETROPERITONEUM AND GERM
CELL TUMORS
 GCTs share several features that have contributed
significantly to their successful management:
 (1) a germ cell origin, which is associated with responsiveness
to irradiation AND a potential for differentiation to histologically
benign teratoma
 (2) a rapid growth rate
 (3) frequent production of specific tumor markers such as
AFP and β-Hcg
 (4) usual occurrence in otherwise healthy young adults who
can tolerate the necessary therapy
 (5) a very predictable and systematic pattern of metastatic
spread from the primary site to the retroperitoneal lymph
nodes and, subsequently, to the lung and posterior
mediastinum
Lymphatics
 Lymphatic spread is common to all forms of GCTs
 However, in the case of choriocarcinoma, vascular dissemination
more often seen
 RIGHT TESTIS - The first of lymph nodes is located in
the interaortocaval area, followed by the precaval and
preaortic nodes’
 LEFT TESTIS - The para-aortic and preaortic lymph
nodes, followed by the interoartocaval nodes
 Contralateral spread is more common with right-sided
tumors and usually associated with large-volume
disease
 The lymphatic drainage of the epididymis is to the
external iliac chain, whereas that of the scrotum is to the
inguinal lymph nodes
Figure 30-3 Anatomic regions of the retroperitoneum.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Retro-Peritoneal Lymph Nodes and
Testicular Cancer
Retroperitoneal lymph node spread is
usually the first and often the only site of
metastatic disease
15% to 40% of patients are clinically
understaged, particularly in the
retroperitoneum
Untreated retroperitoneal lymph node
metastases are usually fatal
RETROPERITONEAL LYMPH NODE
DISSECTION
 Bilateral infrahilar RPLND is new current standard
 suprahilar dissections are usually performed for residual
hilar or suprahilar masses after cytoreductive
chemotherapy for advanced stage
 Loss of antegrade ejaculation most common morbidity
 advised to complete sperm banking before surgery
 Preservation R > L
 paravertebral sympathetic ganglia, postganglionic
sympathetic fibers T2-L4, and their convergence at the
hypogastric plexus are most crucial in the preservation of
antegrade ejaculation.
RETROPERITONEAL LYMPH NODE
DISSECTION - Technique
Transabdominal or a thoracoabdominal
approach
 Thoracoabdominal
Easier visualization and dissection of the
suprahilar lymphatic tissues and less risk of
postoperative small bowel obstruction
Figure 30-4 Surgical template for bilateral RPLND. IVC, inferior vena cava; SMA, superior mesenteric artery; IMA, inferior mesenteric artery.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-5 Surgical template for modified left-sided RPLND.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-6 Surgical template for modified right-sided RPLND.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Thoraco-Abdominal Approach - Steps
 Torqued position
 The operating table is hyperextended
 The incision starts obliquely over the eighth or ninth rib and curves
downward toward the pubic ramus
 A subperiosteal rib resection is performed, and the ipsilateral rectus muscle
is divided.
 The peritoneum and contents are mobilized from the undersurface of the
rectus sheath, and the diaphragm is divided and the pleura is entered
 The retroperitoneum is exposed to the level of the contralateral ureter. Full
bilateral RPLND can be carried out as described for the transabdominal
approach.
 The most common site of residual suprahilar disease is in the retrocrural
space
 The wound is closed by reapproximation of the diaphragm with silk sutures
and of the costal cartilage with Prolene. Chest tube drainage is established,
and the flank is closed
 COMPLICATIONS - Atelectasis, prolonged chest tube drainage, and
increased need for postoperative analgesia
Trans – Abdominal - Steps
 The falciform ligament is either divided between silk ligatures or excised en
bloc with the preperitoneal fat.
 The small bowel is reflected to the right, and an incision is made in the
posterior peritoneum medial to the inferior mesenteric vein
 This incision is continued cephalad to the ligament of Treitz and is extended
superiorly and medially to the duodenojejunal flexure, allowing for superior
mobilization of the fourth portion of the duodenum and pancreas.
 The proper plane of dissection is the avascular plane between the inferior
mesenteric vein and the left gonadal vein. This maneuver further defines a
thick condensation of fibrovascular tissue (ligament of Treitz) and several
large lymphatic trunks, which should be divided between silk sutures
 Alternatively, to gain adequate exposure in the area of the left renal hilum,
particularly with large postchemotherapy masses, the inferior mesenteric
vein can be doubly ligated and divided
 The incision is continued lateral to the right gonadal vein
 The duodenum is then kocherized.
 It is important to ligate or clip the numerous lymphatic vessels in this area to
minimize postoperative lymphatic complications
Figure 30-7 Incision of the posterior parietal peritoneum. The incision extends from the ligament of Treitz along the left side of the root of the small bowel mesentery to
the ileocecal region (1). It may be extended superiorly and medially to the duodenojejunal flexure and inferolaterally around the cecum and ascending colon. The left leaf
of the incised posterior peritoneum is defined (2).
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-8 Development of the left leaf of the incised posterior peritoneum in the avascular plane between the inferior mesenteric vein (IMV) and the left gonadal vein.
The colonic mesentery lies anteriorly and the para-aortic space and Gerota's fascia lie posteriorly. LRV, left renal vein; SMA, superior mesenteric artery.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-9 The retroperitoneal space has been exposed. The duodenum has been kocherized; its second, third, and fourth portions have been reflected superiorly along
with the pancreas and superior mesenteric artery (SMA). The entire right colon has been mobilized and exteriorized. LRV, left renal vein; IMV, inferior mesenteric vein;
IVC, inferior vena cava; IMA, inferior mesenteric artery.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-10 Division of attachments between the undersurface of the duodenum and pancreas and the anterior surface of the left renal vein (LRV). It is important to clip
or ligate the numerous lymphatic channels in this area. Prominent lacteals in the vicinity of superior mesenteric artery (SMA) are often seen. IMV, inferior mesenteric
artery; IVC, inferior vena cava.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
CAUTION!!
20% of patients will have accessory renal
arteries
2% to 3% of patients will have a retroaortic
left renal vein
Important to recognize a retroaortic left
renal vein because it may be inadvertently
mistaken for a lumbar vein and ligated or
the pancreas and SMA may be injured
Lymphadenectomy










Attention is initially directed to the left renal vein, and the renal perivascular lymphatic tissue is mobilized inferiorly.
Aadrenal, spermatic, and lumbar branches are tied.
The dissection along the anterior surface of the left renal vein continues to the right until the anterior surface of
the IVC is encountered, and the first anterior "split" is then performed. The split and roll technique is illustrated in
Figure 30-11.
The right gonadal vein is ligated at the vena cava. Lymphatic tissue can then be rolled off the IVC laterally and
medially as the dissection proceeds inferiorly. Lumbar veins are dissected, doubly ligated with 3-0 silk, and
divided.
At this point, nerve-sparing techniques can be performed if clinically indicated
The anterior split on the surface of the aorta should then be carried inferiorly to the bifurcation of the common iliac
arteries.
The origin of the IMA is identified. If necessary, this artery can be sacrificed
The gonadal arteries should be ligated early to prevent the subadventitial hematoma that may result if they are
avulsed. Following the anterior aortic split, lymphatic tissue is retracted medially and laterally and lumbar arteries
are dissected
The right and left renal arteries are skeletonized, and the lymphatic tissue is separated from the psoas fascia and
anterior spinous ligament, which are the posterior limits of dissection. Great care should be taken to control lumbar
vessels as they pass into the posterior body wall near the sympathetic chains to avoid possible injury to
sympathetic innervation in attempting to control problematic bleeding.Throughout the procedure it is important to
ligate or clip the cut ends of lymphatic vessels, particularly in the region of the right renal artery, where large
tributaries to the cisternae chyli are located.
Postoperative tachycardia is common due to sympathetic discharge.
Figure 30-11 A to G, Sequentially, this diagram shows the "split and roll" technique that allows for en bloc removal of the nodal package. The lumbar vessels must be
divided twice, first at the wall of the great vessels and again as they enter the foramina alongside the vertebral bodies.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-12 Nerve-sparing technique with soft vascular tapes around the right postganglionic branches of the sympathetic chains as they course in an oblique fashion
toward the hypogastric plexus. Their relationship to the great vessels, lumbar veins, and root of the inferior mesenteric artery (IMA) is shown. SMA, superior mesenteric
artery.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Nerve Sparing
 Candidates include patients with clinical stage I and lowvolume stage II NSGCT undergoing primary RPLND, as
well as a carefully selected subset of patients
undergoing post-chemotherapy lymphadenectomy
 The most important aspect in performing nerve-sparing
RPLND is the prospective identification and preservation
of relevant sympathetic nerves
 (1) the sympathetic chains bilaterally
 (2) the postganglionic sympathetic nerves arising from the
sympathetic chains
 (3) the hypogastric plexus, which is the anastomosing network of
nerve fibers anterior to the lower aorta
Figure 30-12 Nerve-sparing technique with soft vascular tapes around the right postganglionic branches of the sympathetic chains as they course in an oblique fashion
toward the hypogastric plexus. Their relationship to the great vessels, lumbar veins, and root of the inferior mesenteric artery (IMA) is shown. SMA, superior mesenteric
artery.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-5 Surgical template for modified left-sided RPLND.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Figure 30-6 Surgical template for modified right-sided RPLND.
Downloaded from: Campbell-Walsh Urology (on 1 April 2009 03:50 AM)
© 2007 Elsevier
Antegrade Ejaculation
 Antegrade ejaculation - L3 and L4 ganglia.
 Nerve fibers often exit in close proximity to
lumbar vessels, and great care must be taken in
ligating them to avoid injury
 The lymphadenectomy then proceeds as just
described within the appropriate template.
Again, when performing nerve-sparing RPLND,
dissection on the aorta should be done only after
the nerve fibers have been isolated and
protected.
 Proper nerve-sparing techniques result in
greater than 95% rates of antegrade ejaculation.
Laparoscopic Key Points
 Undergo preoperative sperm banking
 To reduce the risk of chylous ascites, patients are started
on a low-fat diet 2 weeks before surgery
 Patients undergo a mechanical bowel preparation the
afternoon before surgery and take only clear liquids until
midnight
 Broad-spectrum antibiotics are administered before
starting the operation
 Sequential antiembolic pneumatic boots are placed on
the lower extremities
 Nasogastric tube, Foley catheter, patient is placed in a
modified lateral position (60 degrees) with elevation of
the ipsilateral side
Treatment Options for Low-Stage GCTs
 Clinical Stage I NSGCT – RPLND
 Clinical Stage IS ("Marker Only" Disease)page 948
page 949Patients with persistently elevated serum
tumor markers after radical orchiectomy but
negative CT scans of the chest, abdomen, and pelvis
should undergo primary cisplatin-based
chemotherapy because systemic disease is usually
present
 Clinical Stage II NSGCT
 RPLND or cisplatin-based chemotherapy
 1. Extent of disease, 2. Serum tumor marker status, 3. Presence or
absence of tumor-related back pain
KEY POINTS – LOW STAGE NSGCT
 1. If tumor markers fail to normalize after radical orchiectomy
 cisplatin-based induction chemotherapy, regardless of radiographic
findings.
 2. Bilateral RPLND is the standard template for patients with
pathologic stage II NSGCT.
 3. Nerve-sparing techniques involve preservation of both
sympathetic chains, the postganglionic sympathetic fibers, and the
hypogastric plexus.
 4. Incidence of teratoma in the retroperitoneum after primary RPLND
in patients with pathologic stage II NSGCT is approximately 20% to
30%.
 5. Incompletely resected patients with pathologic stage II NSGCT, or
those with any clinical evidence of disease (elevated β-hCG and/or
AFP, lung nodules, retrocrural adenopathy) after primary RPLND,
require cisplatin-based induction chemotherapy
 6. The therapeutic impact of L-RPLND remains unknown.
Surgery for High-Stage Germ Cell
Tumors
Surgery for High-Stage Germ Cell Tumors
- The initial treatment of patients with
advanced GCT is cisplatin-based
combination chemotherapy
NONSEMINOMATOUS GERM CELL
TUMORS
 Increased serum concentrations of AFP and β-hCG after
primary cisplatin-based chemotherapy are often characterized
by unresectable, viable GCT; and second-line "salvage"
chemotherapy is usually recommended for these
nonresponders
 Whereas most clinicians agree that surgical exploration is
indicated for patients with normal tumor markers and residual
radiographic abnormalities, at the present time there are no
standard guidelines for observation rather than adjunctive
surgery
 The patient's prognosis is related to serum marker level at the
time of RPLND, prior treatment burden, and the pathologic
findings of the resected specimen and completeness of
resection
 However, if viable GCT is present at any site but all disease is
completely resected, two additional cycles provide survival
benefit in this subset of patients
Teratoma
 Significant advantages in complete resection
1. Teratomas may grow, obstruct, or invade adjacent
structures and become unresectable
2. There is the risk of malignant transformation, that is,
the development of non-germ cell malignant elements
such as sarcoma or carcinoma
3. Teratoma is associated with late recurrence
 Teratoma may be found in the retroperitoneum
despite its absence in the orchiectomy specimen
Teratoma cont.
 Multiple studies show that approximately 20% of patients predicted to
have necrosis/fibrosis will harbor either teratoma or viable GCT.
 No single criterion or combination of criteria predict a negative
pathology with sufficient accuracy to eliminate the risk of residual
teratoma or viable GCT and thus obviate PC-RPLND .
 Decision to recommend post-chemotherapy surgery depends on the
frequency of viable GCT, the biologic potential of teratoma, and the
morbidity of the RPLND.
 If viable GCT is present, it is partially drug resistant and will progress
if left unresected. The cure rate of recurrent GCT to ifosfamide-based
salvage regimens is approximately 25%.
 Conversely, if viable GCT is completely resected, and two additional
cycles of cisplatin-based chemotherapy are given, cure rates between
50% and 70% are possible.
 As noted earlier, unresected teratoma may grow rapidly ("growing
teratoma syndrome"), invade local structures, become unresectable,
or undergo malignant transformation.
Natural Progression
 Finding of necrosis/fibrosis alone in the resected
retroperitoneal specimen is usually associated
with a good long-term prognosis
 Late Relapse
Late recurrence of GCT of the testis is defined as
relapse after a disease-free interval of at least 2 years in
the absence of a second primary testicular tumor – 24%
Late relapses of GCT are usually refractory to
chemotherapy
High-Risk Post-Chemotherapy NSGCT
Patients
 GROUP 1 - Patients undergoing PC-RPLND after
salvage chemotherapy
•
Patients with advanced GCT who experience relapse or fail to achieve a complete response to standard
cisplatin-based chemotherapy and receive either conventional-dose salvage therapy or high-dose
chemotherapy regimens with bone marrow or stem cell support (lower rates of complete resect)
 GROUP 2 – “Desperation" PC-RPLND is done in patients with an elevated
serum tumor marker (AFP or β-hCG) at the time of surgery
 GROUP 3 - Patients deemed to have unresectable disease do very
poorly, with 17 of 19 (90%) patients experiencing relapse
and only 4 (21%) survivors
 GROUP 4 - “Redo" PC-RPLND - patients who have undergone a
prior attempt at PC-RPLND who present with
recurrence in the surgical field. The importance of
complete initial post-chemotherapy surgery cannot
be overemphasized.
Post-Chemotherapy RPLND
 Large retroperitoneal tumors and severe desmoplastic reaction
make PC-RPLND one of the most difficult and dangerous
operations undertaken by urologists – rec. referral centers
 The standard bilateral RPLND should be performed.
 Resection of a residual mass without RPLND is inappropriate
 The left para-aortic region is the most common site of local
recurrence prompting reoperation
 Post-chemotherapy thoracotomy
 yields important prognostic information
 therapeutic in most patients with resected teratoma and a subset
of patients with viable cancer.
KEY POINTS: HIGH-STAGE GERM
CELL TUMORS
▪The initial treatment for patients with advanced GCT is cisplatin-based combination
chemotherapy
▪Post-chemotherapy pathologic findings in patients with advanced NSGCT after induction
therapy are approximately as follows: necrosis, 50%; teratoma, 40%; viable
carcinoma, 10%
▪Post-chemotherapy pathologic findings in patients with advanced NSGCT following
salvage therapy are approximately as follows: necrosis, 10%; teratoma, 40%; viable
carcinoma, 50%
▪Variables and statistical models to predict necrosis in the retroperitoneum after induction
therapy have approximately a 30% error
▪Teratomatous elements may be found in the retroperitoneum despite their absence in
the orchiectomy specimen
▪Teratoma may grow and obstruct or invade local structures, undergo malignant
transformation, and may result in late relapse
▪Bilateral RPLND is the standard template in the post-chemotherapy NSGCT setting;
resection of residual mass alone is an unacceptable alternative
▪Histologic discordance between different sites (e.g., retroperitoneum, thorax, neck) after
post- chemotherapy resection is found in approximately 30% of cases.
Post Chemo Surgery - Complications
 Higher rate
 Due to..
Large-volume residual disease
desmoplastic reaction
prior exposure to bleomycin
more extensive RPD increase technical demands of the
procedure
 Incidence of chylous ascites is 2% to 3%
Asymptomatic lymphoceles require no treatment
Post Chemo Surgery – Complications
cont..
 Pulmonary



atelectasis
Pneumonia
acute respiratory distress syndrome
 Infectious Complications



Superficial wound infections
Urinary tract infections = <1%.
Clostridium difficile

Incidental appendectomy is contraindicated
 Vascular Complications
 Renovascular injury = 2% to 3% of cases
•
Hypertension
 Minor injury of the great vessels
 Neurological Complications
 Peripheral nerve injury <1%
 Spinal cord ischemia with aortic mobilization = <1%
 Gastrointestinal Complications
 Ileus may be associated with mechanical obstruction or, less commonly, with retroperitoneal
hematoma, pancreatitis, urinary extravasation, mesenteric hematoma, and bowel infarction
 SBO = 2% to 3%
 Pancreatitis
 Sacrifice of the IMA is common and is rarely associated with any lower gastrointestinal
complication.
SEMINOMA
 Perioperative morbidity is higher than for
NSGCT
Due to despmoplastic reaction and teratoma unlikely
 Residual masses less than 3 cm should be
managed with observation
Residual masses larger than 3 cm remains
controversial
 FDT PET scan
 negative PET scan usually implies freedom from
disease
FERTILITY
Cytotoxic chemotherapy has been shown
to have long-term deleterious effects on
Leydig cell function
Platinum-based chemotherapy regimens
cause both Leydig and Sertoli cell
dysfunction
nadir in spermatogenesis is reached in 10 to 14
months
Cryopreservation of sperm is recommended
before chemotherapy for testicular cancer