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Introduction: Retroperitoneal lymph node dissection (RPLND) for the treatment of testicular germ cell tumor is technically difficult and associated with significant morbidity. We postulated that a novel midline extraperitoneal (EP) approach might minimize the morbidity. Technical Considerations: We describe a midline extraperitoneal approach in detail. The operative time, estimated blood loss, lymph node yield, return of bowel function, length of stay, and postoperative complications were retrospectively reviewed. From April 2010 to May 2011, 12 consecutive patients underwent EP-RPLND at 2 tertiary centers by a single surgeon, including 5 primary and 7 postchemotherapy RPLNDs. The clinical characteristics and outcomes were compared with those from a matched cohort of transperitoneal-RPLND patients. Results: The median follow-up was 173 and 201 days in the EP and transperitoneal groups, respectively. The EP group had a shorter mean operative time of 292 versus 337 minutes (P = .02) and lower estimated blood loss of 305 versus 575 mL (P = .05). More lymph nodes were retrieved in the EP group (44 vs 27 nodes, P = .0006). Finally, an earlier return of bowel function (1.7 vs 2.9 days, P = .0001) and a shorter median length of stay (3.3 vs 5.3 days, P = .0001) was seen in the EP group. Conclusion: EP-RPLND can be performed safely without prolonged operative times or compromised lymph node retrieval, even in the postchemotherapy setting, and is associated with a faster return of bowel function and shortened length of stay. [ABSTRACT FROM AUTHOR]

Introduction and Objective: Perioperative blood transfusion (PBT) is commonplace in radical cystectomy (RC) and has been linked to poorer oncologic outcomes. Limiting PBT in this largely elderly and comorbid population has not been studied. Herein, we first investigate the safety of a restrictive transfusion protocol (RTP) in patients undergoing RC for urothelial carcinoma and then compare oncologic outcomes between patients who did and did not receive PBT.Methods: Outcomes for 173 consecutive patients meeting inclusion criteria undergoing RC for urothelial carcinoma from April 2010 to June 2014 by a single surgeon employing RTP were analyzed from an institutional review board-approved, prospectively collected database. Pairwise matching to a cohort undergoing RC during an earlier era of more liberal PBT was performed, and 90-day outcomes were compared.Results: Median follow-up for the RTP cohort was 3.1 years (range: 0-5.1y). Median age was 70 years (range: 38-93y). Forty-six patients (26.6%) received PBT. Eighty-seven matched pairs were generated from RTP cohort and liberal era where PBT rate was 94%. There were no differences in 90-day complication rates, mortality, or readmission rates (P>0.05). In the RTP cohort, patients who underwent PBT had higher estimated blood loss (500 vs. 350, P = 0.001), lower baseline hematocrit (28.9 vs. 33.3, P = 0.005), and similar operative time (5.8 vs. 5.3h, P = 0.01) and length of stay (5.5 vs. 5, P = 0.07). At discharge and 3-week follow-up, there was no difference in hematocrit (P>0.05). In the no-PBT group, 90-day (65.6% vs. 86.7%, P = 0.007) and high-grade (15.6% vs. 34.8%, P = 0.003) complication rates were lower. On multivariable analysis, predictors of PBT were age (odds ratio [OR] = 1.06, 95% CI [1.01-1.11]), Charlson comorbidity index≥2 (OR = 2.68, CI [1.09-7.04]), neoadjuvant chemotherapy (OR = 3.74, CI [1.46-10.19]),≥pT3 (OR = 5.5, CI [2.33-13.73]), baseline hematocrit (OR = 0.95, CI [0.87-1.00]), and estimated blood loss (OR = 1.001, CI [1-1.003]). PBT was associated with lower recurrence-free survival (hazard ratio = 2.16; CI [1.13-41.12]; P = 0.02) and overall survival (hazard ratio =2.25; CI [1.25-4.88]; P = 0.01).Conclusions: The use of RTP in RC is safe. PBT was associated with poorer recurrence-free survival and overall survival independent of clinicopathologic characteristics. [ABSTRACT FROM AUTHOR]