Although RPLND is both a diagnostic and therapeutic procedure, it must always be performed with therapeutic intent. An uncontrolled retroperitoneum can result in late relapse, reoperative surgery, and compromised clinical outcome.

Incomplete resection of metastatic retroperito-neal disease has been shown to be a significant and independent adverse prognostic variable for patients with NSGCT. A substantial proportion of patients undergoing primary RPLND and PC-RPLND will have unresected extratemplate disease if modified templates are used. Therefore, surgical margins and templates should not be compromised in an attempt to preserve ejaculation. With prospective nerve-sparing techniques preserving antegrade ejaculation in the majority of patients, the argument and need for modified templates is less compelling.

It has become apparent that the anatomic mapping studies, which provided the basis for modified templates, have significant limitations. The left para-aortic region is the most frequent site for surgical failure after RPLND. Teratoma-tous elements are commonly found in the retro-peritoneum of patients undergoing reoperative surgery. Effective cisplatin-based chemotherapy will not reliably compensate for inadequate initial surgery. Reoperative surgery can be performed with acceptable morbidity in tertiary centers with experienced surgeons. The proper integration of reoperative surgery and chemotherapy can salvage almost 70% of patients with retroperitoneal relapse after initial suboptimal RPLND.

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