Complications of surveillance

For patients with clinical stage I disease with favorable histopathologic features, management options include surveillance following primary orchiectomy [108,109]. Surveillance entails an exceptionally motivated and compliant patient willing to undergo a rigorous regimen of physical exam, serum tumor markers, and radiographic studies [110].

While limiting the morbidity of an invasive surgical procedure or radiation therapy, relapse can and does happen with rates that approach 25% to 35% [111-113]. Up to 30% of patients with the diagnosis of clinical stage I disease are found to have pathologic stage II disease following RPLND, indicating a substantial risk of understaging [20-22]. The majority of patients on surveillance relapse in the first 2 years, although recurrences much later have been reported. Additionally, a substantial proportion of patients on surveillance who relapse will be found with high-volume or systemic disease [114].

Poor adherence with the follow-up regimen is common, elucidating the burden of the clinician to use careful patient selection when offering this option for treatment [115]. In addition to disease recurrence, another complication of surveillance is the significant anxiety and possible negative psychological effect on these young, active patients. Finally, surveillance protocols are unlikely to be cost-effective when compared to primary RPLND or radiation therapy [116].

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