Nerve Sparing Retroperitoneal Lymphadenectomy

Michael A.S. Jewett, MDa *, Ryan J. Groll, MDb aDivision of Urology, Department of Surgical Oncology, Princess Margaret Hospital and the University Health Network, 610 University Avenue, 3-124, Toronto, ON, Canada M5G 2C4 bDivision of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Retroperitoneal lymphadenectomy (RPL) for testicular cancer has been performed since the late 1940s [1], well before any chemotherapy was available. It was clear that patients with regional metastases could be cured. With the introduction of cisplatinum-based chemotherapy in the 1970s, the procedure was increasingly used for staging and adjuvant chemotherapy was used when the nodes removed contained metastatic tumor. More recently, patients with minimal nodal disease have been followed with salvage therapy for relapse. The trend has been to minimize morbidity while maintaining efficacy.

Historically, the major long-term morbidity of RPL was ejaculatory dysfunction and potential infertility resulting from damage to the sympathetic nerves during dissection. Specifically, injuring the lumbar sympathetic trunks, postganglionic sympathetic fibers, and/or nerves of the hypogastric plexus risked loss of seminal emission and consequently dry ejaculation. The traditional bilateral lymphadenectomy results demonstrated a 70% to 100% risk of this complication [2]. The movement to include suprahilar dissection was short lived and this approach was abandoned when no added benefit was realized [3]. The original procedures have since been further modified such that the minimal dissection is performed to spare relevant sympathetic nerves without risking an incomplete cancer resection. The initial strategy for minimizing postoperative ejaculatory dysfunction attributable to sympathetic nerve injury was the downscaling

* Corresponding author. E-mail address: [email protected] (M.A.S. Jewett).

of dissection boundaries and development of unilateral resection templates so as to avoid contralateral dissection mainly in the area of the hypogastric plexus [4]. The basis for modified templates was a greater confidence in salvage results with the emergence of effective chemotherapeutic agents coupled with an improved understanding of the metastatic pattern and distribution of germ-cell tumors from surgical mapping studies [5-7]. While template surgery improved ejaculation rates in the order of 51% to 88% [8-10], success rates were increased significantly by the development of nervesparing techniques, referring specifically to the prospective identification, careful dissection, and preservation of relevant sympathetic nerves [11]. Nerve-sparing approaches have been adopted in other oncological surgical procedures (such as radical retropubic prostatectomy [12], radical cystectomy [13], radical hysterectomy [14], and total mesorectal excision [15], as well as retroperitoneal lymphadenectomy [11,16]) where complications related to intraoperative injury to nervous structures occur.

Currently, nerve-sparing techniques, applied to either bilateral lymphadenectomy or in conjunction with unilateral template dissections, offer carefully selected patients excellent antegrade ejaculation rates without an apparent higher risk of disease relapse.

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