Retroperitoneal lymph node dissection

There are several reasons to treat the retroper-itoneal lymph node in patients with testicular cancer. First, based on the results of RPLND and surveillance series, the retroperitoneum is the initial and often only site of metastatic spread in up to 90% of patents with GCT [9,13]. Second, accurate clinical staging of the retroperitoneum continues to have an approximately 30% error rate despite improved radiographic imaging [9]. Third, untreated retroperitoneal lymph node metastases are usually fatal [8,13]. In autopsy studies of patients who died of GCT, metastases of brain, bone, and liver were late events and usually associated with bulky retroperitoneal disease [8,14,15]. Furthermore, the retroperitoneum is the most common site for late relapse of both teratoma and viable GCT [6,16,17].

RPLND has been well established in the management of NSGCT since 1948; however, its role and the surgical templates and techniques have undergone considerable change over the past 30 years [8]. Initially, RPLND included all the nodal tissue between both ureters down to the bifurcation of the common iliac arteries and as well as both suprahilar regions. In the pre-cisplatin era very extensive dissection of all lymph nodes was necessary given the absence of effective alternative therapy [8]; however, extensive suprahilar dissection can result in increased renovascular and pancreatic complications as well as increased incidence of chylous ascites [8]. In an effort to reduce surgical morbidity, the original suprahilar dissections were replaced by the bilateral infrahilar RPLND.

Historically, bilateral infrahilar RPLND was associated with the loss of antegrade ejaculation because of damage to the paravertebral sympathetic ganglia, postganglionic sympathetic fibers, and/or the hypogastric plexus [8]. The incidence of retrograde ejaculation is related to the extent of the retroperitoneal dissection [8,18,19].

In an effort to preserve antegrade ejaculation, a number of side-specific modified templates have been proposed, variably limiting contralateral dissection, particularly below the level of the inferior mesenteric artery (IMA) [8,20,21]. The highest rates of antegrade ejaculation are reported with "nerve-sparing" techniques in which the sympathetic fibers, hypogastric plexus, and post-ganglionic sympathetic fibers are prospectively identified, dissected, and preserved [8,18,22].

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