Primary nerve-sparing RPL

Early results from prospective nerve-sparing RPL data were promising in terms of both ejaculation and recurrence rates. We demonstrated that bilateral nerve identification and sparing RPL resulted in return of normal ejaculation in 90% to 97% of patients and that the number of nerves spared did not necessarily correlate with positive results [11,26]. This encouraging decrease in morbidity was not associated with retroperitoneal recurrences at 18-month follow-up. Before this report, most patients became infertile as a result of nerve damage and loss of antegrade ejaculation. Subsequently, DeBruin and colleagues [27] reported 86% and 95% 12-month antegrade ejaculation rates in clinical Stage I NSGCT patients who underwent bilateral and unilateral nerve-sparing RPL, respectively. Finally, the largest cohort reported is from the Indiana group, whose data span the evolution of RPL template modification and the adoption of prospective nerve-sparing techniques [16]. Of 2200 cases, 483 had primary nerve-sparing RPLs for clinical Stage I disease. All patients surveyed in this sample report normal ejaculation and 84% of those who have attempted pregnancy have been successful. Twenty-six percent of cases were upgraded to pathologic Stage II and the reported survival rate was 99.6%.

The German Testicular Cancer Study Group reported complications of primary nerve-sparing RPL for clinical Stage I NSGCT in 239 patients operated in a relatively large number of centers. Modified unilateral templates were used in 88.2% of cases and full bilateral RPLs in 11.8%. There was no statistically significant difference in complication rate between unilateral and bilateral procedures. Overall, minor complications such as wound infection, ileus, and lymphocele occurred in 19.7% and major complications such as chylous ascites, pulmonary embolism, and hydro-nephrosis occurred in 5.4% of cases. There was a 93.3% antegrade ejaculation rate but a 5.8% disease recurrence rate including three in the retroperitoneum.

Overall, the results of primary nerve-sparing RPL for low-stage NSGCT demonstrate a high rate of ejaculatory preservation and acceptable fertility with relatively few significant complications and recurrences. Results are similar for unilateral and bilateral procedures.

Postchemotherapy nerve-sparing RPL

The more challenging nature of postchemo-therapy surgery prevents nerve sparing in some cases and may be associated with a slightly higher morbidity when nerve sparing is performed. Wahle and colleagues [28] reported an antegrade ejaculation rate of 89.5% and no retroperitoneal recurrences in their series of 38 postchemotherapy cases after 12-month follow-up. Full bilateral dissections were performed in 31 patients and 6 had masses greater than 6 cm in maximum diameter. In a larger cohort, Donohue and colleagues [8] report on 93 postchemotherapy RPLs in which prospective nerve-sparing techniques were used. After 2 patients died from extraperitoneal metastatic disease and 10 were lost to follow-up, the Indiana group demonstrates no retroperitoneal recurrences and 77% self-reported normal ejaculation in 81 patients with adequate follow-up. Furthermore, 11 patients have achieved pregnancy and 8 had uneventful full-term delivery. In another large series, Coogan and colleagues [29] reported results for 81 postchemotherapy nerve-sparing RPLs with a mean residual tumor size of 6.3 cm by CT scan. Antegrade ejaculation rates were 74%, 85%, and 100% for full bilateral (n = 64), left-modified template (n = 13), and right-modified template (n = 3) dissections, respectively. There were no retroperitoneal recurrences documented in this series. It appears that left-sided dissection, particularly below the level of the inferior mesenteric artery (IMA), bears the highest risk of sympathetic injury and possibly greater risk of resultant complications. Both studies underscore the importance of careful patient selection in postche-motherapy nerve-sparing RPL where low-volume unilateral disease in patients and clear desire for future fertility are favorable features. When evaluating the results of postchemotherapy RPL, one should also appreciate the potential for chemotherapy-induced azoospermia and potential subfertility that occurs in roughly 25% of these patients irrespective of surgical risk [30].

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