One-stage approach for retroperitoneal and mediastinal metastatic testicular tumor resection

Background. Eight percent of nonseminomatous germ cell tumors of the testis are associated with postchemotherapy residual masses in both the retroperitoneum and the posterior mediastinum. We describe a transabdominal transdiaphragmatic approach that allows simultaneous resection of these masses. Methods. After standard retroperitoneal lymph node dissection through a midline laparotomy, an incision parallel to the right crus of the diaphragm was made and extended anteriorly through the muscular portion. Excellent exposure of the lower posterior mediastinum was obtained. Masses located higher than vertebra T8 were resected by extending this incision anteriorly and performing a partial sternal division. A complete median sternotomy can be done to allow subcarinal dissection, as well as pulmonary or anterior mediastinal mass resection. Results. Between 1993 and 1999, 18 patients had simultaneous resection of retroperitoneal and posterior mediastinal masses with this approach. There were no perioperative deaths; 3 patients had minor postoperative complications. After a median follow-up of 3.2 years, the overall 5-year survival rate was 92%, and the 5-year disease-free survival rate was 87%. Conclusions. The transdiaphragmatic approach to the posterior mediastinum is less aggressive than the thoracoabdominal approach. It is safe and effective for simultaneous resection of postchemotherapy testicular nonseminomatous germ cell tumors located in the retroperitoneum and posterior mediastinum.