Complications of post-chemotherapy retroperitoneal lymph node dissection

The surgical morbidity rate of 603 patients who underwent lymphadenectomy after primary chemotherapy for clinical stages II and III testis cancer from 1982 to 1992 was reviewed. There were 144 complications in 125 patients (20.7%). The majority of patients (93%) had a tumor volume of greater than 5 cm. Five patients died 3 to 47 days postoperatively, for an operative mortality rate of 0.8%. Pulmonary complications were the most frequent cause of severe morbidity: 6 patients had the adult respiratory distress syndrome and 5 needed prolonged ventilation. The underlying cause was a combination of bleomycin induced pulmonary toxicity, and large volume retroperitoneal and pulmonary disease resected in these patients. Limiting inspired oxygen concentration and perioperative volume replacement are imperative to minimize bleomycin related pulmonary morbidity. Additional procedures, such as nephrectomy and colectomy, did not add to the morbidity rate. Among patients undergoing concomitant venacavectomy there was a higher occurrence of postoperative chylous ascites. Most of the other complications (gastrointestinal, lymphatic, neurological and renal) were temporary and treated conservatively. Perioperative management of the post-chemotherapy testis cancer patient is different from that of the patient undergoing primary retroperitoneal lymphadenectomy. The latter operation is usually performed in physically fit patients and the surgical template of dissection is of a smaller scale. Thus, the complications in this group are minor and without mortality. Specific technical considerations and difficulties are common to post-chemotherapy patients. Factors, such as large volume of disease, post-chemotherapy desmoplastic reaction and extensive retroperitoneal dissection, make these patients more prone to have complications. Decreased pulmonary, renal and nutritional reserves add to the surgical morbidity. Knowledge of possible pitfalls and their causes can avoid unnecessary operative complications.