Retroperitoneal lymphadenectomy and resection for testicular cancer: an update on best practice

Abstract

Clinical stage I testicular nonseminomatous germ cell tumours (NSGCTs) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines. Clinical stage I is defined as negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low-risk and in high-risk NSGCTs with an anticipated relapse rate of about 15% and 50%. The majority of patients will relapse with good and intermediate prognosis tumours which have to be treated with three to four cycles chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for residual masses. Primary chemotherapy with one or two cycles of cisplatin (Platinol), etoposide and bleomycin (PEB) is a therapeutic option for high-risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. nsRPLND, if performed properly, will cure about 85% of all high-risk patients with clinical stage I NSGCT without the need for chemotherapy. PC-RPLND forms an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCTs). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography (PET) scan performed 6-8 weeks after chemotherapy is positive. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%, however it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemorefractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

Keywords: germ cell tumour; postchemotherapy RPLND; retroperitoneal lymph node dissection; retroperitoneal lymphadenectomy; testicular cancer.

Figure 1.

(a) Retroperitoneal situs after abdominal midline incision demonstrating a large interaortacaval and paraaortal mass. Prior to the resection of the mass all major vessels have been secured. (b) The same situs demonstrating complete resection of the mass. The inferior vena cava had been opened to resect a large intracaval tumour thrombus. (c) Resected intracaval tumour thrombus demonstrating mature teratoma on pathohistological examination.

Figure 2.

(a) Intraoperative situs of a patient with a right-sided retrocrural mass after a thoracoabdominal incision: the diaphragm has been incised, the right liver lobe has been completely mobilized via a Langenbeck’s manoeuvre, the suprahilar and infrahilar aspect of the inferior vena cava is exposed. (b) The right-sided retrocrural mass is exposed and completely excised; histology revealed mature teratoma.

Figure 3.

(a, b) MRI of the retroperitoneum demonstrating a large paracaval mass with compression and potential infiltration of the lateral wall of the inferior vena cava. (c) Intraoperative situs of the same patient demonstrating the extension of the mass with infiltration of the wall of the IVC.

Figure 4.

Intraoperative situs of a patient with a large paraaortic residual mass; the sympathetic nerve fibres initially running ventrally to the mass have been isolated (yellow vessel loops) and preserved, the mass was excised completely.