We reviewed our experience with retroperitoneal lymphadenectomy (RPLA) after multiple cisplatin-based chemotherapy regimens in nonseminomatous testicular tumors (NSTT) patients and specifically evaluated clinicopathologic and treatment trend in addition to potential predictors of survival. Fort-one patients with NSTT underwent their RPLA between 1982 and 2005 after ≥ 2 regimens of chemotherapy. Thirteen patients (32%) necessitate redo-RPLA, combined with nephrectomy in 6 patients. 13 extra-RP (ERP) resections were performed in 11 patients (27%), including pulmonary (7), neck (4) and liver (2) sites. Thirty patients (73%) are rendered free of disease and 26 (63%) obtained serologic remission. Nine patients who relapse, necessitated new salvage chemotherapy+surgery (3 teratoma, 6 vital carcinoma [VC]). Four of 9 relapsing patients (44%) are currently free of disease with redoRPLA. Alive, free of disease are 19 pts (46%) at median follow-up of 131 months. Study of RP pathology demonstrated the presence of fibrosis in 15%, teratoma in 39% and VC in 46%, with survival in 67%, 56% and 32%, respectively. Different histology occurred in 38% at redo-RPLA and in 64% at ERP resection in comparison to previous RP pathology. Univariate analysis of clinicopathologic parameters associated with VC at RPLA included RP masses ≥ 5 cm (p<0.05), elevated AFP (p<0.001) or HCG (p<0.05) and ERP resection (p<0.04). On univariate analysis survival was worse in patients with RP masses ≥ 5 cm (p<0.04), elevated AFP (p<0.05) or HCG (p<0.007), ERP resection (p<0.01) and VC (p<0.004). On multivariable analysis, a RP masses ≥ 5 cm (p<0.03) and VC (p<0.005) predicted a worse prognosis. Our data support the continued use of salvage RPLA in three separated groups of patients: 1. Patients who achieved a complete response (CR) to 2nd -line chemotherapy and have no radiologic evidence of disease should undergo RPLA; 2. Patients who achieved a partial response (PR) to chemotherapy should undergo RPLA with ERP surgery, as indicated; 3. Highly selected group of patients with residual masses and elevated serum tumor markers (STM), particularly AFP, after chemotherapy may be candidate for surgery.

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