Background: PMNSGCT represents one of the most challenging subsets of malignant germ cell tumors. PMNSGCT has a distinctly worse prognosis and is appropriately categorized as poor risk disease. A phase III intergroup study in patients with poor risk germ cell tumors, including PMNSGCT demonstrated equivalent survival in patients with Etoposide, Ifosfamide and Cisplatin (VIP) compared to standard Bleomycin, Etoposide and Cisplatin (BEP) regimen. We have demonstrated that the magnitude of post chemotherapy surgery required for PMNSGCT is higher with potential for serious pulmonary complications including post operative pulmonary failure and death. This retrospective study from 1978-2013 compares perioperative morbidity and mortality associated with Bleomycin (BEP) vs. non Bleomycin (VIP) containing regimens. Methods: From 1978-2013, 221 PMNSGCT patients (mean age, 29 years; ranging from 12- 50 years) who underwent post chemotherapy surgery were reviewed. Results: Of the 221 patients who underwent post chemotherapy surgery, 55 were treated with VIP and 166 with BEP chemotherapy. Among patients who received BEP, 83% had ≥ 3 cycles of Bleomycin. Both groups were well balanced in respect to the number of patients requiring pulmonary resection, extent of pulmonary resection and surgical approach. Post operative complications including acute respiratory failure and/or pneumonia (22 vs. 0, p value 0.004) and prolonged ventilator requirement > 48 hrs (30 vs. 2, p value 0.004) were significantly higher in patients who received BEP compared to VIP chemotherapy respectively . There were 11 post operative deaths reported- 10 patients with post operative respiratory failure and 1 death from pulmonary embolism. All deaths were in BEP chemotherapy group and 0 post operative deaths were reported in patients who received VIP chemotherapy (p value 0.05). Conclusions: Bleomycin containing chemotherapy regimens have traditionally been the standard of care for patients with poor-risk NSGCTs, including PMNSGCTs. Given the high rate of post-operative pulmonary failure after BEP, these results support our present policy of preferring VIP in PMNSGCT patients prior to major thoracic surgical procedures.