Retroperitoneal lymph node dissection in post-chemotherapy residual mass with 360-degree involvement of the aorta

Post-chemotherapy retroperitoneal lymph node dissection in cases with encasement of major vessels is a formidable surgery. A 25-year-old man presented to us after a right high inguinal orchidectomy that showed a mixed germ cell tumor with predominant embryonal cell carcinoma elements. Following four cycles of bleomycin, etoposide and cisplatin (BEP), the serum markers had normalized but a large retroperitoneal mass predominantly on the left side encasing the large vessels including the left renal hilum persisted. A thoraco-abdominal approach was taken and the supraceliac aorta was defined, and the large mass encasing the left renal hilum was excised along with a left nephrectomy. The preaortic mass was divided applying the “split and roll” technique and subsequently removed. The interaortocaval and the precaval regions were also subsequently cleared. The aorta and the IVC were preserved and cleared completely of the tumor mass. Post-chemotherapy large residual lymph nodes present a difficult challenge in managing testicular malignancies especially if they encase major vessels that need to be preserved. Careful approach to tumor resection and standard surgical principles for lymph node dissection need to be followed to ensure a successful outcome.