11-Year Experience with Midline Extraperitoneal Retroperitoneal Lymph Node Dissection for Germ Cell Tumors

Purpose:A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has been associated with decreased morbidity compared to transperitoneal approach. We aimed to review our 11-year experience in patients with germ cell tumors (GCT) who underwent EP-RPLND at a single institution.Methods:All patients with GCT who underwent EP-RPLND between 2010 to 2021 were reviewed. Surgical, peri-operative, and oncologic outcomes were reported. A logistic regression model was developed to evaluate variables predictive of early discharge. Oncologic outcomes included recurrence free survival (2-year RFS) and recurrence patterns, which were analyzed according to pathology.Results:Overall, 237 patients underwent EP-RPLND, of which 72% were in the post-chemotherapy (PC) setting. Median follow-up was 16.7(IQR 3.9-39.6) months. Median size of retroperitoneal disease was 2.8 (1.8-5.4)cm, of which 16 cases were > 10 cm. There were no cases of postoperative ileus or readmission due to small bowel obstruction. Median hospital stay was 2(IQR 1-3) days. From 2020 to 2021, 73% of patients were discharged on POD1 and 89% by POD2. Thirty-one complications occurred, including 4% grade III-IV. In the primary setting, 2-year RFS for seminoma and NSGCT were 0.93 (95% CI 0.84-1.00) and 0.85 (95% CI 0.72-1.00); respectively. In the PC setting, 2-year RFS for seminoma and NSGCT were 0.88 (95% CI 0.74-1.00) and 0.88 (95% CI 0.81-0.95); respectively. Overall, only 7 patients had in-field recurrence.Conclusions:Midline EP-RPLND is safe, associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and post-chemotherapy settings, with low rates of in-field relapse.