Current controversies on the role of retroperitoneal lymphadenectomy for testicular cancer

Abstract

Retroperitoneal lymph node dissection (RPLND) is an important component of the multimodal treatment which cures most patients diagnosed with testicular germ cell tumors. Considering the high cure rates achieved, research focus in recent years has been directed toward improving quality of life and decreasing long-term treatment related sequelae. Consequently, the role of RPLND has evolved over the past 3 decades in both low-stage and advanced testicular cancer. The use of RPLND in clinically stage I and low volume stage II disease may offer the advantages of treating retroperitoneal teratoma which is present in 15% to 20% of patients, avoiding chemotherapy and reducing the need for frequent imaging during follow-up. Similarly, ongoing studies are evaluating the safety and effectiveness of RPLND for the treatment of early stage seminoma to avoid the long-term effects of chemotherapy and radiotherapy. RPLND is traditionally used for the treatment of residual masses >1 cm after completion of chemotherapy. Its role in subcentimeter residual masses remains somewhat controversial given the fact that 25% to 30% of these patients are found to harbor either teratoma or viable nonteratomatous germ cell tumors. The presence of teratoma increases the probability of teratoma in metastatic sites. Modified unilateral templates were developed based on early mapping studies with the aim of preserving antegrade ejaculation. Recent data suggests initial mapping studies underestimated the risk of contralateral retroperitoneal metastases which may reach 32%. Furthermore, antegrade ejaculation may be preserved in >95% of patients undergoing bilateral nerve sparing primary RPLND and >80% undergoing nerve-sparing PC-RPLND, which, in our view is the more prudent oncologic approach. Recently, multiple series have demonstrated the safety and short-term efficacy of minimally invasive RPLND; however, larger studies with prolonged follow-up are required to validate the long-term oncologic efficacy of newer techniques.

Keywords: Minimally invasive surgery; Postchemotherapy surgery; Retroperitoneal lymph node dissection; Testicular germ cell tumors.

Figure 1

– Boundaries of full-template RPLND. The renal vessels form the superior boundary, the ureters form the lateral boundary, and the bifurcation of the iliac vessels forms the inferior boundary. IMA, inferior mesenteric artery; IVC, inferior vena cava; SMA, superior mesenteric artery. Obtained with permission from Thomas E. Keane, Sam D. Graham and Marc Goldstein, Glenn’s Urologic Surgery 8th edition, Philadelphia: Wolters Kluwer, 2016.

Figure 2

– Right and left modified templates for RPLND. Several side-specific modified templates for patients with low-stage NSGCT have been proposed, with each including ipsilateral lymph nodes inferior to the renal hilum extending to the bifurcation of the iliac arteries. Right-sided templates include the interaortocaval region, and both avoid dissection below the contralateral IMA. Obtained with permission from Thomas E. Keane, Sam D. Graham and Marc Goldstein, Glenn’s Urologic Surgery 8th edition, Philadelphia: Wolters Kluwer, 2016.