V-242 Presentación: Vídeo

Laparoscopic retroperitoneal lymphadenectomy with concurrent nephrectomy due to ureteric invasion
André, Margarida; Moreira, Luísa; Nikitakis, Filippos; Bolio, Fernando; Bollens, Renaud
Belgian Laparoscopic Urological Group

Introduction: Extragonadal germ cell tumors (EGCT) account for 1–5% of all germ cell tumors, comprising seminomas (30–40%) and nonseminomatous tumors (60–70%) in men. EGCT are usually seen in children or young adults, typically arising in midline locations.  In adults, the most common sites of primary EGCT are the mediastinum, retroperitoneum and cranium.

Results: We present a 34-year-old man with obesity, asthma and depression. On an abdominal CT scan a 6 cm left para-aortic mass, inferior to the renal pedicle, was found. CT guided biopsy was performed, revealing a non-seminomatous germ cell tumor. For further investigation he underwent a PET-FDG revealing only the left para-aortic mass. Testicle ultrasound was normal. Laboratory evaluation showed an elevated Alphafetoprotein (14000 mcg/L) and normal β-hCG and LDH. After discussion in multidisciplinary oncological meeting, four cycles of BEP were proposed. Abdominal CT 4 weeks after BEP revealed a residual left para-aortic mass with 4 cm. The case was again discussed and resection of the mass was proposed.

The patient was placed in right lateral decubitus. Four trocars were placed. The first step was identification of the kidney and the retroperitoneal mass. The mass was adherent to the surrounding tissues. On its lateral limit, we identified that the mass invaded the ureter, so a left nephrectomy was necessary to resect it. We proceeded to dissect the tissue surrounding the mass, releasing it from the aorta, medially, at first. After that, ligation of the renal pedicle was performed, followed by ligation of the ureter distally to the mass and dissection from the psoas muscle. The kidney was fully released and the surgical piece was removed using an organ bag. A passive drain was placed. Total surgery time: 1h45. Drain was removed after 2 days. Patient was discharged on the fourth day. Pathology confirmed a 4 cm non-seminomatous germ cell tumor, with clear margins.

Conclusion: EGCT are a rare entity that should raise suspicion for a burned-out testicular cancer. Regarding non-seminomatous germ cell tumor, when there is a residual mass > 1 cm, its resection is recommended, which often presents itself as a surgical challenge.