Background: Resection of retrocrural disease in patients with metastatic germ cell tumors is a surgical challenge, especially in the post-chemotherapy setting. Herein, we present our experience with single-stage retrocrural metastasectomy and retroperitoneal lymph node dissection (RPLND). Methods: Using our IRB-approved testicular cancer database we identified patients who underwent one-stage retrocrural and retroperitoneal mass resection between September 1997 and December 2022. Clinical characteristics, surgical approach, peri-operative complications, and oncological outcomes of these patients were reviewed. Results: Among 400 patients who underwent RPLND for testicular cancer over the study interval, concurrent retrocrural resection was performed in 23 cases. Demographics and clinical features of the patients are shown in the table. All surgeries were performed in the post-chemotherapy setting, except one who underwent primary RPLND for seminoma. Surgical approach has evolved over time, including thoracoabdominal (TA) in 6 (all before 2010) and midline transabdominal (MA) in 17, including 3 midline extraperitoneal. There were 9 (39%) patients who required adjunctive procedures. Histology of retrocrural masses revealed viable tumor in 2 (embryonal carcinoma and seminoma), teratoma in 18 (including one with malignant transformation), and necrosis/fibrosis in 3. Pathologic concordance rate between retrocrural and retroperitoneal pathology was 83%. Median length of hospital stay was 5 days (9 vs. 3.5 for TA and MA, respectively). The 90-day complication rate was 43% (Clavien 3=17%), with a lower rate in patients undergoing MA vs. TA incisions (35% vs. 67%). With a median (IQR) follow-up of 24 (6-90) months, only one patient had retrocrural recurrence requiring re-resection, and no mortality was reported. Conclusions: The midline transabdominal is an effective approach for the concurrent retrocrural and retroperitoneal lymph node dissection in select patients with metastatic germ cell tumors. It is associated with a lower perioperative complication rate compared to the traditional thoracoabdominal approach.

IGCCCG: International Germ Cell Cancer Collaborative Group; IVC: inferior vena cava.