Laparoscopic RPLND vs. Open RPLND

[Molars]

I've had open RPLND scheduled to occur on 12/15. I've been very apprehensive about the surgery, but for me it is something that needs to be done. I've read a little about laparoscopic RPLND, what I've read suggests that it's too new of a proceedure. I wanted to pursue all avenues just to be sure. So I contacted Dr. James Porter in Seattle and Dr. Luis Kavoussi in Baltimore about laparoscopic RPLND. These guys are the most experienced lap RPLND surgeons in the country. They have convinced my to have the RPLND done laparoscopically as according to them there is absolutely no difference between lap and open RPLND... provided the surgeon is experienced with the lap technique. I've canceled my open RPLND at USC set for 12/15 and scheduled lap RPLND in Seattle with Dr. Porter on the same day. I love all the information I've gotten from this forum but am surprised by the bias towards open RPLND. Why is this? I've heard that a reason for the bias in the medical community stems from the fact that none of the testicular cancer "experts" are minimally invasive surgeons (lap RPLND), yet none of the minimally invasive surgeons are testicular cancer experts. I have a feeling that its only a matter of time before laparoscopic RPLND becomes the standard of care. What do you think about this?

[Scott]

On this forum, I think we are "cautious about" rather than "biased against" laparoscopic RPLND. (As you know, I had L-RPLND myself.)

[Mom]

If my son needed the RPLND, we would have taken him to Baltimore for the Lap. It is all about the comfort level of the surgeon. There are very few doctors who do enough regular RPLNDs to trust so doctors proficient in doing L-RPLNDs are going to be few and far between. My husband went through the full RPLND 25 years ago and even though he turned out fine, we would have wanted our son to have the less intrusive surgery. As long as you haven't chosen a doctor who is going to practice on your body, I think you have made the right decision. You should maybe do that no fat diet that has been recommended. Hang in there and please keep posting. Dianne

[Molars]

Thanks Mom, Scott.

You both mirror my feelings and are correct in that there are very few surgeons who do the lap RPLND. Drs. Porter and Kavoussi are the top two in the country. My doctor seemed a little reluctant about the lap RPLND, or maybe a bit disappointed that he wasn't going to do the open RPLND. But after talking with both Dr. Porter and Dr. Kavoussi, I'm very confident in my decision to do the lap. I decided on Dr. Porter simply because he was able to do it this Thursday, Dr. Kavoussi's first available date was Jan 10th. Since I've already met my insurance deductible, having it done this year saves me $1500. Oh yeah, don't want to give the cancer a chance to spread beyond the surgical borders if it is still present.

Scott, you are very dedicated to this forum as you answer EVERY thread. You are an animal!!! Thanks for all you hard work.

Ryan

[Dave V]

Having had one myself , I also would support your decision to do the LAP. Good luck.

[matthias]

Molars,

with a NSGCT Stage I, one could wonder why you want any RPLND at all, to begin with. Other than that, thanks for blazing the trail on lap-RPLND...as I (and many other) warriors do by choosing surveillance. Here is my war face: .

P.S.: Of course, you have a rather challenging tumor make-up: best wishes, and I am sure you are doing the right thing under your scenario.

[Scott]

Thanks for all you hard work.

It's "the obligation of the cured," and I'm happy to do my part. Fortunately, we've got a very strong community going here!

[Don]

I would also tend to beleive that the lap-RPLND may be the replacement for the open procedure unless their are large tumors or teratoma masses that have to be removed(as in Justinand my cases). Only knowing of a few people that have had the lap done my questions are :
1) Roughly how many of Lap procedures are done in comparison to the open version?
2) Is the recovery time quicker and chances for infection lower due to the small incisions?
3) Are the Surgeons able to do as complete of a observation of the Lymph nodes,tissue and surrounding organs with the Lap as opposed to the Open?
4) Are there any different side affects with the Lap?
5)Where do the surgeons have to draw the line as to who is or isn't a good canidate for the Lap??
Just curious !!!!!!! DON

[danebert]

As one who was concidering the lap. He is my two cents. I had a post chemo residual mass measuring in at 2cm. I called Kauvoussi. (sp?) and he deemed me the perfect canidate for the lap procedure so I set the date. I figured I would get a second opinion from Dr. Foster ( had performed over 1300 RPLND's) and Dr. EInhorn ( first to use Cisplatin in TC and the reason many of us here are even alive) of Indiana University. Dr. Foster said the data wasnt there to support the efficacy of the lap RPLND. Einhorn agreed. But what really swayed my opinion ( I eventually got the open RPLND with Foster), was when Einhorn said if it was his child, He would recomend the open procedure. First,with the open procedure, vascular injuries can be controled easier. Afterall you are cutting around the vena cava. Second, a CT doesn't visualize everything. The open procedure visualizes more of the retroperitoneium, and thus, enables the DR to explore more. The last thing you want is a little teratoma left behind. Although rare, this teratoma can degenerate into a scarcoma, or other cancer that ins't curable like a germ cell tumor.

[danebert]

Sorry about the spelling.

Also, one last thing. Kavoussi, published a study including his patient population. The complication rate was very high. IN addition, the long term follow-up wasn't there. If you read the study, you will see that the doctors recommended the use of adjuvant chemo after any positive findings at RPLND for stage II TC, therefore thequestioning the efficacy of the surgery themselves.

[Kev332]

I know that when I discussed the lap RPLND with my Urologist back before I got the open RPLND, I believe he said that LAP RPLNDs are for patients who have a specific lymph node or nodes that is/are enlarged etc. But that if you are having the RPLND as a precautionary measure, the open is more beneficial since its easier to see whats there..

[danebert]

When they see 1 or 2 enlarged nodes, it is correct to assume there are more.
In my case they saw 1 enlarged node on CT scans, but I had three involved.

[Scott]

My CT scan showed only one enlarged node, and it was the only one found positive when I had L-RPLND. I'm back on surveillance and will only have chemotherapy in case of another recurrence.

As for giving chemotherapy after L-RPLND finds active cancer, that's no longer done routinely. See this link, at which Dr. Kavoussi says, "I think that the dissection has evolved to the point that it is the exact same dissection that one can do open, and that is a personal opinion, and, as I said, there need to be prospective studies. We have at our institution, as I stated, been advising patients for low volume stage 2 disease not to undergo chemotherapy."

Also, jrednib's 4/19/2005 post includes opinions he collected from several experts.

[danebert]

Ironically, I visited with Dr. Einhorn shortly after the aformentioned posting ( the one scott refered to), and asked him questions related to this specifc post. More specifically the quote from the post "He has no issues with L-RPLND" in regards to Dr. Einhorns opinion with L-RPLND. THis is the farthest thing from the truth. He spend about 20 minutes explaining his reservations with that approach. IN addition, I see no mention of Dr. Foster in the post. His is, afterall, the leading doctor when it come to surgically treating testicular cancer. He spent almost an hour explaining the difference and inferiority of the procedure.
Yes scott, you may have had one node enlarged and only one positive node found. But your case is anything but typical. First, you had no teratoma found at RPLND. Second, although diagnosed with non seminoma, you had a (re)occurance of Seminoma.(RPLND is a rare procedure used in the treatment of seminoma) However the most important issue here is over oncologic efficacy, which has not yet been proved to date in the small, SMALL, series of patients undergoing L-RPLND. THere is far too much selection bias with the L_RPLND, and the follow up is too short. Remember, the issue at hand is a late relapse of teratoma due to the failure of surgical irradication. If it is necrosis, the you could argue no benifit to undergoing the RPLND at all. If there is viable cancer found at RPLND post - chemotherapy then additional cycles of chemotherapy are administered.
One must also address the issue of L-RPLND in stage I disease. Historically, chemo was given after a positive finding. Recently, this view has changed, but lacks true long term follow up. To date there has not been a single randomized trial comparing the oncological efficacy of the L-RPLND to the open RPLND.
Dr Kavoussi as well as other doctors who perform the L-RPLND are technical surgeons not vascular surgeons. You must also address the issue of complication rates which are far higher with the lap procedure, more specifically vascular injuries. Again I refer you to Dr. Kavoussi's study. If one refers to Scotts specific example. His convalesence period was far longer then that of a person undergoing the open procedure.(incld. hospitalizations for complications)
When I spoke with Dr. Kavoussi, he said I would be out of the hospital in 2 days, Dr. Foster said I would be out in three after the open procedure. No NG tubes with either surgery. I was able to eat soild foods within 2 days of the open RPLND. Pain was minimal with the open RPLND, yet I can't compare it to an L_RPLND becuse I havn't had one. Within 2 weeks I returned to all normal activities except heavy lifting which can't be done for a while after the L-RPLND procedure.
however, the issue here is cancer, not pain or hospital stay. The L-RPLND hasn't been proven as effective as the open procedure. Why risk it for such minimal gain. At the very least, withhold opinion untill long term studies are out. Ask Dr. Sheinfeld of MSK ( Memorial Sloan Kettering ) or Dr. Foster of IU. THey will both tell you the same. Mayo isn't on the top of the list nor is Kavoussi or John Hopkins when it comes to treating testicular cancer. The L_RPLND hasn't been proven in long term studies. CHeck over at TCRC for more info or e-mail Doug, who runs the site. Beleive me he knows as much as anybody.

Finally, I will leave you with an example of the pitfalls of accepting a new treatment too early. In the mid 1990's Drs decided to test out a drug called Carboplatinum for metastatic TC. It is similar to Cisplatin but has a lower toxcicity profile. Similar to the L-RPLND vs. RPLND.( Similar procedure with less problems) Well, after a few studies, they were very optimistic, considering its routine use in good risk metasatic disease. However, the study was limited and no long term follow-up was avalible. Upon closer inspection they found that Cisplatin was far superior to Carboplatinum. More men died on the Carboplatinum and more relapsed. Not to sound extreme, but these issues and others surround new and promising treatment in a disease. Outside of a clinical trial, L-RPLND shouldn't be used in the stage I or in the post chemotherapy setting, as stated by the top experts at the top hospitals!!

And that isn't as Kavoussi said "a personal opinion" Its is the opinion of the greater medical community.

[Scott]

We agree on many points, danebert.

1. There's insufficient long-term data to prove that laparoscopic RPLND is as effective as open surgery.

2. My case is atypical, and if I could have known in advance that I had seminoma instead of teratoma, I wouldn't have had surgery. (My readmission to the hospital for complications isn't really relevant, though, since chylous ascites can occur with either open or laparoscopic surgery.)

Do you have a link to the study you cited? I'd like to read it.