The gold standard for treatment of all primary tumors is unilateral radical inguinal orchiectomy
* Corresponding author. E-mail address: [email protected] (S.S. Chang).
with high ligation of the spermatic cord . Inguinal orchiectomy provides not only histopatho-logic and staging information but also local control of the neoplasm and, potentially, a complete cure for patients with testis-confined disease.
Although morbidity is limited, the most frequent complication from inguinal orchiectomy is bleeding from the spermatic vessels into the scrotum or retroperitoneum. Misinterpretation of retroperitoneal hematomas as metastatic disease may result in unnecessary treatments . Inappropriate scrotal violation, reported in up to 17% of cases, can alter lymphatic drainage and/ or contaminate the scrotum with neoplastic cells resulting in a risk of local recurrence between 2.9% and 11% [12-14]. Wide excision of the scrotal scar should be performed in such cases. Additional treatment for seminoma should include extension of the radiation field to include the ipsi-lateral groin and scrotum, although systemic cyto-toxic therapies do not demonstrate a survival advantage.
Orchiectomy can have a damaging psychosocial consequence resulting in impairments in body image and self-perception . Fortunately, most men treated for testicular cancer eventually regain normal body image . Insertion of a testicular prosthesis is a viable option to improve scrotal cosmesis following orchiectomy, although the implant itself is not without possible associated complications such as pain, infection, and lymph-adenopathy [17-19]
Retroperitoneal lymph node dissection
Germ-cell tumors can have a propensity for lymphatic metastasis with retroperitoneal metastases
Short term Bleeding from spermatic vessels
Surgical site infection Body image impairment Vascular injury Bowel injury
Long term Ventral hernia
Hematologic toxicity Mucositis
Pulmonary toxicity Hemorrhagic cystitis Central nervous system toxicity
Infertility discovered in the lymph nodes of 27% of patients preoperatively deemed to have stage I disease [20-22]. The pattern of lymphatic drainage has been recognized for more than a century and modern analysis has allowed development of strategies for surgical resection of appropriate lymphatic beds via retroperitoneal lymph node dissection (RPLND) [23-27]. Historically, RPLND included a bilateral suprahilar node dissection with associated pancreatic and renovascular complications . RPLND has since evolved to the present standard of modified infrahilar unilateral templates to maximize staging and cancer control while minimizing morbidity [29-31]. However, RPLND is a major surgical procedure and continues to be associated with a variety of potential complications, both short and long term [32,33].
Vascular injury is a rarely reported complication, but can be devastating if unrecognized [32,33]. Vascular injuries are more common in the postchemotherapy RPLND and in those patients with bulky suprahilar disease [7,34]. Injuries to the renal vein are more common on the left because of less spacious anatomy. Careful mobilization of the entire vein and prompt closure of any bleeding are crucial. Complete vascular dissection using the ''split and roll'' technique can assist in avoiding vascular injury . Renal vein anomalies have been noted in 3.2% of men undergoing RPLND . Preoperative imaging can help in recognizing these vascular anomalies and planning for the appropriate surgical approach.
Direct injury of the bowel during RPLND is rare during primary surgery, and most commonly occurs in the duodenum when resection of large or reactionary masses is attempted . Full-thickness injuries require primary two-layer closure with interposition of omentum to decrease incidence of abscess and fistula. Small bowel fistulas can often be managed conservatively with low-residue diets and intravenous (IV) hyperalimentation. Small bowel obstruction is observed in 0.2% of primary RPLNDs , with a higher frequency in the population undergoing bilateral node dissection. Postoperative paralytic ileus is reported in approximately 2% of patients after RPLND and is often responsive to conservative management [32,37].
Although rare, lymphoceles that manifest symptoms can occur following transabdominal lymphadenectomy . These are frequently treated with percutaneous surgical drainage with sclerotherapy reserved for persistent drainage
, and may occasionally require open drainage and marsupialization.
Transection of major lymphatics, particularly those that drain directly into the cisterna chyli, may result in formation of chylous ascites in around 2% of patients undergoing RPLND . This lymphatic fluid can cause abdominal distention, diaphragmatic irritation, and dyspnea within weeks of surgery. The diagnosis of chylous ascites is confirmed with paracentesis. Treatment strategies include low-fat diets supplemented with medium-chain triglycerides that circumvent small bowel absorption. If these conservative dietary changes are ineffective, IV hyperalimentation is used with or without the somatostatin analogue octreotide . Finally, surgical exploration and ligation or the creation of peritoneovenous shunts may become necessary for recalcitrant cases .
Risk of ureteral injury correlates with post-chemotherapy status, where the incidence is 0.9% . Careful dissection to preserve the adventitial blood supply allows isolation and retraction of the ureter. It is often easiest to locate the ureter at its crossing of the iliac vessels. Immediately recognized injuries should be primarily repaired, but the majority of injuries are often delayed in their presentation and thus close follow-up, particularly in patients with large mass resections, should be helpful in detecting these ureteral complications. In cases with significant retroperitoneal or ure-teral involvement, preoperative ureteral stent placement can facilitate dissection and may obviate need for nephrectomy.
Although risk of thromboembolic events is not as pronounced as in pelvic lymph node surgery, prophylaxis for deep vein thrombosis (DVT) should be considered for this major urologic surgery . Routine use of sequential pneumatic compression and early ambulation are commonly used strategies to prevent DVT and associated complications such as pulmonary embolus.
Mobilization and retraction of the duodenum may result in a transient pancreatitis manifested as nausea and emesis in conjunction with elevated serum pancreatic enzymes . Conservative treatment with dietary restriction and/or modification is often sufficient to resolve this temporary pancreatic inflammation.
As in all surgical procedures, wound-healing issues may arise. Superficial infection occurs in approximately 4.8% of patients who have undergone RPLND and is often successfully managed with short-term antibiotic therapy . A recognized late complication is the development of a ventral hernia in 0.8% to 1.6% of patients undergoing RPLND via a midline incision [7,44].
Ejaculatory dysfunction and infertility following RPLND
One of the most troubling long-term morbidities following RPLND is the loss of antegrade ejaculation secondary to intraoperative damage to crucial autonomic nerve fibers. Sympathetic fibers from the thoracolumbar outflow tract decussating around the aortic bifurcation are responsible for seminal emission into the posterior urethra. Ejaculation depends on both autonomic and somatic sacral and lumbar nerves that tighten the bladder neck, relax the external sphincter, and contract the bulbourethral and perineal muscles. Damage to these structures may result in loss of seminal emission or retrograde ejaculation. This loss of antegrade ejaculation is particularly morbid for this young patient population with its associated potential infertility and patients are counseled to consider sperm banking before RPLND. As our understanding of the neuroanatomy associated with ejaculatory dysfunction has evolved, modifications in the techniques used for RPLND have likewise advanced. Current techniques designated as "nerve-sparing" that minimize contralateral dissection and preserve the crucial sympathetic fibers of the hypogastric plexus have resulted in successful return of ejaculation in almost 100% of patients [10,45-47].
Patients with metastatic germ-cell tumor may undergo cytoreductive chemotherapy before RPLND. Modern imaging has allowed us to identify patients with visible recurrence in the retroperitoneum after primary chemotherapy. RPLND in this patient population may have a higher incidence of complications, up to 35% in some series [32,34,48]. This increased rate reflects a multitude of changes in postchemotherapy patients and likely involves tumor location, size, desmoplastic reaction, and compromised performance status. In addition to the previously mentioned increased incidence of vascular and ureteral injuries in postchemotherapy RPLND
patients, neurologic complications also plague this population. Neurologic sequelae range from transient peripheral neuropathies to paraplegia secondary to ischemic spinal cord injury [34,49]. Perioperative management of these RPLND patients must also account for the potential residual toxicities associated with chemotherapy as will be discussed in detail in the following section .
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