Introduction

Testicular cancer is the most common cancer in patients aged 20 to 40 years and its incidence is rising. About two thirds of the non-seminoma germ cell tumors (NSGCTs) present with regional or distant metastasis. Adjuvant chemotherapy and retroperitoneal lymph node dissection (RPLND) may be necessary in the setting of advanced disease. RPLND is a technically challenging surgery and the laparoscopic approach is usually reported in high-volume centers. In this video, we present a case of laparoscopic RPLND (L-RPLND) for left side retroperitoneal metastasis of a NSGT.

Case Presentation

We present a case of a 23 years old male, without prior relevant medical history, who was referred to our institution after a left orquiectomy which revealed a mixed non-seminomatous germ cell tumor, mostly embrionary carcinoma, with 10-15% yolk sac tumor and <5% teratoma, pT1. After surgery AFP and HCG levels were normal, but LDH was elevated 3.7x. The CT scan showed para-aortic lymph nodes with 62 mm of maximum width. The patient was staged pT1N3M0, S2, stage IIIB, intermediate risk group. He underwent 4 cycles of BEP with imagiological response but with residual para-aortic lymph nodes with 22 mm maximum width. He was proposed to a L-RPLND. The patient was positioned in right lateral decubitus and a 12mm port was inserted superior and lateral to the umbilicus. Two 5 mm ports were placed superiorly in a triangular shape. Another 12 mm port was placed at the level of the iliac. The descending colon was mobilized. The left ureter and left gonadal vein were dissected. Lymph node dissection was performed with the following limits: lateral – left gonadal vein, medial – aortic artery, superior – left renal vein, inferior – level of ureter crossing in common iliac vessels. Lumbar veins were coagulated with advanced bipolar energy. No adverse events took place. Estimated blood loss was 100 mL and the patient was discharge after 3 days. The histology revealed 29 lymph nodes with 11 showing germ cell tumor metastasis. No residual para-aortic mass was detected in the following CT.

Conclusion

The laparoscopic approach is feasible in the setting of patients with advanced retroperitoneal lymph node disease who respond to chemotherapy. It is associated with faster patient recovery and shorter hospital stay. Nevertheless, it requires a surgeon with extensive laparoscopic experience to ensure oncological outcomes.