Retroperitoneale Lymphadenektomie bei testikulären Keimzelltumoren: Indikationen, Komplikationen und spezielle Fragestellungen

Zusammenfassung

Die retroperitoneale Lymphadenektomie ist integraler Bestandteil der stadienadaptierten Therapie von testikulären Keimzelltumoren. Verschiedene Ansätze der retroperitonealen Lymphadenektomie werden auf Basis unterschiedlicher Indikationen durchgeführt.

Die nervschonende retroperitoneale Lymphadenektomie als primäre Therapieoption bei nicht seminomatösen Keimzelltumoren im klinischen Stadium I sollte risikoadaptiert erfolgen. Geringfügige perioperative Komplikationen wie Wundinfekte, Lymphozelen und paralytischer Ileus treten bei in etwa 14 % der Patienten auf. Schwerwiegendere Komplikationen wie chylärer Aszites und Lungenarterienembolien treten bei ca. 5,4 % der Patienten auf. Die häufigste Langzeitkomplikation ist hierbei das Auftreten einer Retrograden Ejakulation. Der Erhalt der antegraden Ejakulation kann jedoch bei weit über 90 % der Patienten erreicht werden.

Die postchemotherapeutische retroperitoneale Lymphadenektomie ist integraler Bestandteil der multimodalen Therapie bei retroperitonealen Residualbefunden. Bei residuellen Befunden > 3 cm beim fortgeschrittenen Seminom dient das FDG PET als zuverlässige Entscheidungshilfe zur Durchführung einer retroperitonealen Lymphadenektomie.

Bei ca. 30 % der Patienten mit nicht seminomatösen Keimzelltumoren finden sich residuelle retroperitoneale Tumorbefunde. Diese sollten unabhängig von der Größe der Befunde bei negativen Serumtumormarkern oder Serumtumormarkern im Plateau komplett reseziert werden. Die postchemotherapeutische retroperitoneale Lymphadenektomie stellt einen herausfordernden Eingriff dar und sollte primär an ausgewiesenen Zentren durchgeführt werden. Bei bis zu 25 % der Patienten ist im Rahmen der postchemotherapeutischen retroperitonealen Lymphadenektomie die Resektion umgebender Strukturen indiziert. Eine Beteiligung der aorta abdominalis liegt in 6 – 10 % der Fälle vor, eine Beteiligung der vena cava in ca. 2 % der Fälle. Komplikationsraten liegen bei der postchemotherapeutischen retroperitonealen Lymphadenektomie höher als bei der primären nervschonenenden Lymphadenektomie mit signifikant höherem intraoperativen Blutverlust und signifikant höherer Transfusionsrate. Mit einer Wahrscheinlichkeit von 2 – 7 % tritt chylärer Aszites nach postchemotherapeutischer retroperitonealer Lymphadenektomie häufiger auf. Jedoch kann auch im Rahmen der postchemotherapeutischen Lymphadenektomie bei bis zu 85 % der Erhalt der antegraden Ejakulation erreicht werden. Entscheidend für den Erhalt der antegraden Ejakulation und einer Verbesserung der Morbidität insgesamt ist auch hier das nach Möglichkeit das Anstreben eines nervsparenden Vorgehens durch Anpassung der Felder.

Abstract

Retroperitoneal lymph node dissection is an integral part of the stage-adapted therapy of germ cell tumours. Different approaches of retroperitoneal lymph node dissection are performed based on various indications.

Nerve-sparing retroperitoneal lymph node dissection as a primary therapy option in non-seminomatous germ cell tumours in clinical stage I disease should be performed using a risk-adapted approach. Minor complications like infections of operative wounds, lymphoceles and paralytic ileus are described in about 14 % of patients, major complications like chylous ascites and pulmonary artery embolism in 5,4 % of patients. The most common long-term complication is retrograde ejaculation. Antegrade ejaculation rates of over 90 % can be achieved with a nerve-sparing attempt.

Post-chemotherapy retroperitoneal lymph node dissection is an integral part of the multimodality treatment of retroperitoneal residual masses after chemotherapy. For residual masses with a diameter of > 3 cm in advanced seminoma patients, FDG-PET is a reliable indicator for decision-making on retroperitoneal lymph node dissection.

Residual retroperitoneal tumour masses appear in about 30 % of patients with non-seminomatous germ cell tumours. These masses should be resected completely, irrespectively of their size, in patients with negative tumour markers or plateauing tumour markers. Post-chemotherapy lymph node dissection is a challenging procedure and should be performed at referral centres. In 25 % of patients, resection of adjunctive organs is necessary in post-chemo lymph node dissection. Affection of abdominal aorta is described in 6 – 10 % of all cases, affection of inferior vena cava in about 2 % of cases. Post-chemo lymph node dissection is associated with a higher complication rate than nerve-sparing primary retroperitoneal lymph node dissection, including a significantly higher intraoperative blood loss and a significantly higher transfusion rate. With rates of 2 – 7 %, chylous ascites occurs more often in post-chemo retroperitoneal lymph node dissection. Antegrade ejaculation can be preserved in up to 85 % of patients. To preserve antegrade ejaculation and reduce morbidity, a nerve-sparing approach and template reduction in post-chemo retroperitoneal lymph node dissection is crucial and should be performed when possible.

Schlüsselwörter

Retroperitoneale Lymphadenektomie - Testikuläre Keimzelltumore - Komplikationen

Keywords

testicular germ cell cancer - complications - retroperitoneal lymph node dissection

Publication History

Article published online:
17 June 2020

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