Retroperitoneoscopic para-aortic lymph node sampling in bladder rhabdomyosarcoma

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Journal of Pediatric Urology (2010) 6, 185e187

CASE REPORT

Retroperitoneoscopic para-aortic lymph node sampling in bladder rhabdomyosarcoma Simon Blackburn, Naima Smeulders, Antony Michalski, Abraham Cherian* Departments of Urology and Oncology, Great Ormond Street Hospital NHS Trust, Great Ormond Street, London WC1N 3JH, United Kingdom Received 8 June 2009; accepted 9 July 2009 Available online 13 August 2009

KEYWORDS Retroperitoneoscopy; Para-aortic lymph node; Rhabdomyosarcoma; Bladder; Prostate; Pediatric

Abstract Determining lymph node involvement is an important step in the pre-treatment evaluation of non-metastatic rhabdomyosarcoma. We describe retroperitoneoscopy for paraaortic lymph node biopsy in a 4-year-old boy with embryonal rhabdomyosarcoma of the bladder with pelvic and para-aortic lymph node enlargement on magnetic resonance imaging. This technique affords access to the para-aortic region with minimal dissection, permitting quick recovery and early commencement of chemotherapy. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Case report A 4-year-old boy presented with haematuria. Ultrasound revealed a lobulated mass arising from the bladder base. MRI demonstrated a lesion in the bladder/prostate region with enlarged lymph nodes in the pelvis and along the left side of the aorta between the inferior mesenteric artery and the aortic bifurcation (Fig. 1). No other intra-abdominal disease was seen. Computed tomography (CT) of the chest, radionuclide bone scanning and bone marrow biopsies did not demonstrate metastases. Cystoscopic biopsy

* Correspondence to: Abraham Cherian, Department of Paediatric Urology, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, United Kingdom. Tel.: þ44 (0)207 405 9200; fax: þ44 (0)207 813 8260. E-mail address: [email protected] (A. Cherian).

diagnosed embryonal rhabdomyosarcoma. For accurate staging of the tumour, the enlarged nodes were biopsied. After laparoscopic transperitoneal biopsy of the pelvic lymph nodes, the para-aortic nodes were accessed using a retroperitoneoscopic technique (Video 1). The patient was turned prone and a 5-mm port was inserted in the left loin at the lateral border of erector spinae. The Gaur balloon technique [1] was used to create a working space between the psoas muscle and the lower pole of the left kidney. Two further 5-mm ports were placed at the tip of the 12th rib and at the iliac crest. Displacement of the kidney anteriorly revealed the pulsatile abdominal aorta medially (Fig. 2i). Blunt dissection exposed the aorta from the renal hilum to the aortic bifurcation (Fig. 2ii). A single prominent lymph node was excised from above the aortic bifurcation (Fig. 2iii) and extracted in a glove finger. Histology demonstrated reactive changes in the paraaortic lymph node; rhabdomyosarcoma was confirmed in

1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.07.008

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S. Blackburn et al.

Figure 1 Coronal T2 weighted MRI scan. Enlarged lymph nodes (LN) are seen along the left border of the aorta (A) between the level of the inferior mesenteric artery and aortic bifurcation.

the pelvic node. On the third postoperative day ifosfamide, vincristine and D-actinomycin chemotherapy was commenced, followed, in time, by tumour excision and external beam pelvic radiotherapy. The patient was well 6 months after surgery, having completed all therapy.

Discussion Involvement of nodes beyond the regional lymph nodes, including para-aortic nodes, is defined as metastatic disease and necessitates different chemotherapy as well as radiotherapy [2]. The absence of regional lymph node involvement in a child who subsequently has a complete surgical resection of the primary tumour eliminates the need for radiotherapy [2]. Confirming lymph node status is, therefore, critical to staging and treatment of embryonal rhabdomyosarcoma of the bladder/prostate. Histological assessment is important; Hermans et al. demonstrated that 58% of retroperitoneal lymph nodes enlarged on CT in paratesticular rhabdomyosarcoma were disease free on microscopy [3]. Paediatric urologists are familiar with Gaur’s retroperitoneoscopic approach, which he initially described for a range of indications, including para-aortic lymph node punch-biopsy in adults with filarial and tuberculous disease [1]. This is the first report of this technique in a child with bladder/prostate rhabdomyosarcoma. It is important to differentiate this technique from the laparoscopic transperitoneal approach to the retroperitoneum, which requires much more dissection, including intestinal mobilization, with more potential complications [4]. In a porcine model of minimally invasive surgery, adhesion formation was lower after retroperitoneal than transperitoneal dissection, and was postulated to reduce enteritis after radiotherapy [5]. Certainly, for open pre-therapy surgical staging, radiation-induced complications and mortality are increased after laparotomy compared to retroperitoneotomy [6].

Figure 2 Intra-operative photographs. (i) The patient is prone. The kidney has been displaced anteriorly. The visual field is bordered superiorly by the psoas muscle (PM), and inferiorly by the lower pole of the left kidney (K) and ureter (U). The pulsatility of the aorta (A) can be observed at the medial extent of the working space. (ii) Blunt dissection has exposed the aorta (A). Continuing the dissection inferiorly has revealed the aortic bifurcation (AB). (iii) Dissection of an enlarged para-aortic lymph node (LN), before placement in the cut finger of a surgical glove for safe extraction.

Retroperitoneoscopic para-aortic lymph node sampling Our case demonstrates that retroperitoneoscopic para-aortic lymph node sampling allows rapid recovery and early commencement of chemotherapy.

Conflicts of interest None of the authors have any conflicts of interest to declare. We have no sources of funding to declare.

Ethical approval Ehtical approval was not required for this work.

Appendix Supplementary data Supplementary data associated with this article can be found in the online version, at doi:10.1016/j.jpurol.2009. 07.008

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References [1] Gaur DD. Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol 1992;148:1137e9. [2] European Paediatric Soft Tissue Sarcoma Study Group. RMS 2005: a protocol for non-metastatic rhabdomyosarcoma. European Paediatric Soft Tissue Sarcoma Group; January 2005. [3] Hermans BP, Foster RS, Bhirle R, Little S, Sandler A, Einhorn LH, et al. Is retroperitoneal lymph node dissection necessary for adult paratesticular rhabdomyosarcoma? J Urol 1998;160:2074e7. [4] NHS, National Institute for Health and Clinical Excellence. Laparoscopic retroperitoneal lymph node dissection for testicular cancer. Interventional Procedural Guidance 158, http://www. nice.org.uk/nicemedia/pdf/IPG158guidance.pdf; March 2006. [5] Occelli B, Narducci F, Lanvin D, Querleu D, Coste E, Castelain B, et al. De novo adhesions with extraperitoneal endosurgical para-aortic lymphadenectomy versus transperitoneal laparoscopic para-aortic lymphadenectomy: a randomized experimental study. Am J Obstet Gynecol 2000;183:529e33. [6] Fine BA, Hempling RE, Piver MS, Baker TR, McAuley M, Driscoll D. Severe radiation morbidity in carcinoma of the cervix: impact of pre-therapy surgical staging and previous surgery. Int J Radiat Oncol Biol Phys 1995;31:717e23.

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