Nerve-sparing Retroperitoneal Node Research Articles

Clinical stage IIA/B seminoma - to do or not to do: the role of retroperitoneal lymphadenectomy

About 10% of patients with seminomatous testicuar germ cell tumors are diagnosed with clinical stage II/B. The current guideline recommended treatment options include systemic chemotherapy with 3 cycles PEB or radiation therapy with 30 Gy for CS IIA and 36 Gy for CS IIB. Despite a high cure rate of 90-94% and 82-90% for CS IIA and CS IIB, respectively, both options are associated with a high rate of treatment-associated long-term toxicities. A significantly increased risk for the development of secondary malignancies, cardiovascular and metabolic disease as well as an increased for treatment-associated mortality has been proven in various studies. Primary nerve sparing retroperitoneal lymph node dissection (nsRPLND) has been evaluated in 5 prospective and retrospective clinical studies and it has emerged as a valid treatment alternative. The relapse-rate after a median follow-up of 25-33 months is in the range of 11-30%, so that 70-90% of patients are cured without being subjected to chemotherapy and potential long-term toxicities. All relapsing patients have been cured with secondary salvage chemotherapy. The frequency of significant surgery-associated complications is low with 3-13%. Therapeutic success depends on the surgical experience of the various surgeons and the chosen template, so that this type of surgical interventions should only be performed in centres of excellence with dedicated surgeons. Preoperative evaluation of the new biomarker miR371 has been shown to predict the presence of metastatic disease with an accuracy of around 100% so that this marker might be used in daily routine prior to active treatment in CS IIA/B seminomas.

VE56 - Bilateral robotic assisted nerve sparing retroperitoneal lymph node dissection in a patient with non-seminomatous germ cell tumour residual after first-line chemotherapy: A video case report

VE56 - Bilateral robotic assisted nerve sparing retroperitoneal lymph node dissection in a patient with non-seminomatous germ cell tumour residual after first-line chemotherapy: A video case report

Retroperitoneal Lymph Node Dissection: Anatomical and Technical Considerations from a Cadaveric Study

Metastatic testis cancer in the retroperitoneum presents a technical challenge to urologists in the primary and post-chemotherapy settings. Where possible, bilateral nerve sparing retroperitoneal lymph node dissection should be performed in an effort to preserve ejaculatory function. However, this is often difficult to achieve, given the complex neurovascular anatomy. We performed what is to our knowledge the first comprehensive examination of the anatomical relationships between the sympathetic nerves of the aortic plexus and the lumbar vessels to facilitate navigation and nerve sparing during bilateral retroperitoneal lymph node dissection. The relative anatomy of the infrarenal vasculature (lumbar vessels, right gonadal vein and inferior mesenteric artery) was investigated in 21 embalmed human cadavers. The complex relationships between these vessels and the sympathetic nerves of the aortic plexus were examined by dissection of an additional 8 fresh human cadavers. Analysis of the infrarenal vasculature from 21 cadavers demonstrated that the position of the right gonadal vein and the inferior mesenteric artery may be useful to locate the right superior lumbar vein and the first pair of infrarenal lumbar arteries as well as the common lumbar trunk (vein) and the second pair of infrarenal lumbar arteries, respectively. Furthermore, the lumbar splanchnic nerves supplying the aortic plexus were most often positioned anteromedial to the respective lumbar vein. The current study describes the complex neurovascular relationships that are crucial to performing successful nerve sparing retroperitoneal lymph node dissection. Surgical techniques are also discussed. Collectively, these results may help surgeons decrease the rate of postoperative retrograde ejaculation and/or anejaculation.

Anesthetic and critical care challenges in massive chyle leak following robotic surgery: a special case report

A unique case report is hereby presented which entails the multi-modality management of a very rare complication of modern minimally-invasive robotic surgery. Chyle leak can be an extremely challenging problem following certain surgeries, especially in cancer patients. Medical, nutritional and/or surgical management is required to control the leak. Prolonged massive chyle leaks which do not respond to conservative management require surgical intervention. Retroperitoneal lymph node dissection is a complex procedure undertaken for lymph node clearance in germ cell tumors after primary radical surgery. Robotic surgeries have revolutionized the field of minimally invasive operations. A patient who underwent robotic nerve sparing retroperitoneal lymph node dissection for non-seminomatous germ cell tumor of the right testis, post-chemotherapy, developed a continuous large volume chylous ascites, presenting with electrolyte imbalances and hypotension. Exploratory laparotomy in the operation theatre was required for sealing the chyle leak after failure of medical and nutritional management in the intensive care unit. The main take-away message is that refractory chyle leak can occur in retroperitoneal surgeries requiring multidisciplinary management. Careful coordinated action between critical care, oncological, anesthesia and surgical teams is mandatory for a favourable outcome. Familiarity with the nuances of robotic surgery and eternal vigilance are the keys to successful conduction of complex robotic procedures.Journal of Society of Anesthesiologists of Nepal 2015; 2(2): 73-76

Efficacy and safety of nerve sparing laparoscopic retroperitoneal lymph node dissection for early stage testicular cancer

Objective To evaluate of efficacy and safety of nerve sparing laparoscopic retroperitoneal lymph node dissection for early stage testicular cancer. Methods From January 2001 to September 2014, 83 patients with primary testicular nonseminomatous germ cell tumors (NSGCT) received nerve sparing LRPLND at 1-4 week after orchiectomy.Their age ranged from 18 to 44 years old, mean 25 years old.Serum AFP was abnormally elevated in 51 patients, ranged from 15to 1432μg/L (mean 874 μg/L). beta-HCG were abnormally elevated in 46 patients, ranged from 5-70 IU/L(mean 56 IU/L). All of their clinical stage was stage Ⅰ and did not suffer from ejaculatory dysfunction.The operating time, intraoperative blood loss, postoperative intestinal function recovery time, drainage removal time, hospital stay, intra - and post - operative complications were recorded. Results The nerve sparing laparoscopic retroperitoneal lymph was successfully performed in all patients.The mean operating time was 218 min, (range 158-285 min). The mean intraoperative blood loss was 368ml (range 255-587ml). The postoperative intestinal function recovery time ranged from 24 to 48 hours (mean 31 hours). And the hospital stay ranged from 5 to 9 days (mean 7days). The inferior vena cava was injured during operation and was sutured laparoscopically in 1 patient.Mild chylous retroperitoneal drainage was seen in 3 patients, which was cured within 1 week after operation by restriction of high - fat diet.22 cases were noticed ejaculation dysfunction postoperatively, which recovered spontaneously within 8 to 12 weeks.Within the 3 to 76 months follow - up, 73 patients revealed no evidence of recurrence or distant metastasis. Conclusions Nerve sparing LRPLND is technically feasible, mini invasive, the morbidity and complication were significantly lower.It can be performed with satisfactory results in young patients with early stage NSGCT. Key words: Testicle; Nonseminomatous germ cell tumors; Nerve sparing retroperitoneal lymph node dissection; Laparoscopy; Ejaculation

602 Unilateral and nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with non-seminomatous germ cell tumours – indication and recurrence rates

602 Unilateral and nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with non-seminomatous germ cell tumours – indication and recurrence rates

Short-Term Morbidity of Primary Retroperitoneal Lymph Node Dissection in a Contemporary Group of Patients

We defined the blood loss, operative time and short-term morbidity of primary retroperitoneal lymph node dissection in a contemporary series to assess whether laparoscopic retroperitoneal lymph node dissection actually confers the magnitude of benefit claimed. A retrospective chart review was performed of 75 consecutive patients who underwent primary retroperitoneal lymph node dissection during the 18 months ending May 2005. Two patients were excluded, including 1 who underwent right hemicolectomy for cecal adenocarcinoma and 1 with a pure seminomatous intra-abdominal testicle. Of the 73 patients 69 (94%) underwent unilateral dissection and 60 (82.2%) underwent a nerve sparing procedure. Mean operative time was 132 minutes (range 81 to 246) and mean blood loss was 207 cc (range 50 to 500). Nasogastric tubes were placed in 2 patients (2.7%). Mean time to start clear liquids was 1.0 day. Mean hospital stay was 2.8 days (range 2 to 4). The short-term morbidity of open retroperitoneal lymph node dissection, including operative time, blood loss and hospital stay, has significantly improved compared to historical controls. Perioperative management has changed with time. Comparing the morbidity of laparoscopic retroperitoneal lymph node dissection to that of historical controls is inappropriate.

Ejaculatory function in stage T1 nonseminomatous germ cell tumors: retroperitoneal lymph node dissection versus surveillance--a decision analysis.

Ejaculatory function remains a major concern for patients with low stage nonseminomatous germ cell tumors of the testis. Whereas, it has been extensively studied in patients undergoing retroperitoneal lymph node dissection, preservation of ejaculatory function on surveillance protocols has not been studied. To compare ejaculatory function for surveillance protocols to primary retroperitoneal lymph node dissection appropriately, we constructed a decision analysis model mimicking the standard treatment algorithm for stage 1 nonseminomatous germ cell tumor of the testis. The primary clinical payoff for this study is ejaculatory function. Based on this model, we established that a primary nerve sparing retroperitoneal dissection must be performed with a 96.8% ejaculatory function rate to be recommended as the appropriate therapy. However, if a highly skilled surgeon routinely performs post-chemotherapy dissection with an ejaculatory function rate of 69.2% or greater, surveillance should be offered as the primary treatment modality. This result simply demonstrates a high skill level to allow the surgeon to salvage ejaculatory function in post-chemotherapy retroperitoneal lymph node dissection settings. If this level cannot be achieved, primary retroperitoneal lymph node dissection is the best choice. If we account for a 10% loss of ejaculatory function from primary chemotherapy, the minimum ejaculatory function rate for primary retroperitoneal dissection decreases to 95.7%. In the post-chemotherapy setting an 85.7% ejaculatory function rate must be achieved for surveillance to be considered the optimal choice. Clearly, less surgical rigor is needed with a primary retroperitoneal lymph node dissection when correcting for the effects of chemotherapy on ejaculatory function. Despite this fact, 1-way sensitivity analysis revealed that our model is insensitive to the ejaculatory function effects of chemotherapy. Furthermore, if the likelihood of recurrence on surveillance is greater than 16%, primary nerve sparing retroperitoneal lymph node dissection should again be recommended. Thus, to maximize ejaculatory function for patients with stage 1 nonseminomatous germ cell tumor a nerve sparing primary retroperitoneal lymph node dissection should always be performed, unless the likelihood of recurrence on surveillance is low or the surgical skill level allows for a highly successful post chemotherapy nerve sparing dissection.

V1153: Laparoscopic Nerve Sparing Retroperitoneal Lymph Node Dissection

You have accessJournal of UrologyVideo Session, Tuesday, May 24, 2005, 10:00 am - 12:00 pm1 Apr 2005V1153: Laparoscopic Nerve Sparing Retroperitoneal Lymph Node Dissection James R. Porter, Brian C. Fong, Can Obek, and Paul H. Lange James R. PorterJames R. Porter More articles by this author , Brian C. FongBrian C. Fong More articles by this author , Can ObekCan Obek More articles by this author , and Paul H. LangePaul H. Lange More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)35886-5AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "V1153: Laparoscopic Nerve Sparing Retroperitoneal Lymph Node Dissection." The Journal of Urology, 173(4S), p. 313 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 173Issue 4SApril 2005Page: 313 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information James R. Porter More articles by this author Brian C. Fong More articles by this author Can Obek More articles by this author Paul H. Lange More articles by this author Expand All Advertisement Loading ...

Complications of primary nerve sparing retroperitoneal lymph node dissection for clincal stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group: Heidenreich A, Albers P, Hartmann M, Kleisch S, KU Kohrmann K, Krege S, Lossin P, Weissbach L, German Testicular Cancer Study Group, Department of Urology and Pediatric Urology, Philipps University, Marburg, Germany.

J Urol 2003;169:1710–4 Purpose Nerve sparing retroperitoneal lymph node dissection has been the standard diagnostic and therapeutic approach to clinical stage I nonseminoma. However, the application of prognostic risk factors and introduction of laparoscopy have recently called into question the clinical usefulness of nerve sparing retroperitoneal lymph node dissection. We assessed the therapeutic efficacy and associated complications of this procedure in patients with clinical stage I nonseminomatous germ cell tumor treated at 7 tertiary referral centers to evaluate its role in the modern management of low stage testis cancer. Materials and methods Between January 1995 and September 2000, 239 patients with clinical stage I nonseminomatous germ cell tumor underwent nerve sparing retroperitoneal lymph node dissection in standardized fields of dissection. For retrospective analysis patient charts were reviewed. A minor complication did not prolong hospital stay and a major complication prolonged hospitalization for at least 2 days. Early complications developed within the first 30 days after retroperitoneal lymph node dissection and late complications occurred from postoperative day 31 and thereafter. Results Nerve sparing retroperitoneal lymph node dissection was performed unilaterally in 209 patients (88.2%) and bilaterally in 30 (11.8%). Median operative time was 214 minutes (range 90 to 395), mean hospital stay was 8 days (range 4 to 39) and mean blood loss was less than 150 ml. A mean of 18.5 lymph nodes (range 9 to 57) were dissected with metastases detected in 67 patients (28%). An average of 2.9 lymph nodes (range 1 to 14) with a mean diameter of 2.6 cm. (range 0.3 to 6.0) showed metastasis. Disease was pathological stage I in 172 patients (71.7%), 52 (17.6%) had 3 or fewer metastatic lymph nodes, and 15 (6.3%) had 4 to 5 and 10 (4.2%) had greater than 5 positive lymph nodes. Minor complications occurred in 14.2% of the cases and major complications were observed in 5.4%. Antegrade ejaculation was preserved in 93.3% of the patients, recurrence developed in 14 (5.8%) and retroperitoneal recurrence was observed in 3 (1.2%), including 1 in field and 2 out field. Conclusions Primary diagnostic and therapeutic nerve sparing retroperitoneal lymph node dissection still has a role in the primary management of clinical stage I nonseminomatous germ cell tumor. Surgery is associated with low morbidity and patient followup is easy and cost-effective due to the concentration on extraretroperitoneal locations. Primary nerve sparing retroperitoneal lymph node dissection is curative in about 70% of clinical stage I nonseminoma cases with a maximum of 3 positive lymph nodes.

The management of nonseminomatous testicular cancer.

Despite the fact that testis cancer accounts for only 1% of all male malignancies, it is the most common solid malignancy affecting males between the ages of 15 to 35 years. The management of germ cell tumors (GCT) of the testis has proved to be a model of success among solid tumors. This is due to tremendous advances during the past 2 decades, which have changed the once dismal prognosis for patients with advanced disease. Testicular cancer has, in fact, become one of the most curable of all solid neoplasms. Thirty years ago testicular cancer accounted for 11.4% of all cancer deaths in the 25 to 34 year age group, with an overall 5 year survival rate of 64%. The most recent five-year survival rate for GCT of the testis in the United States was recently reported as being in excess of 90%. Improved prospects for cure and long-term disease free survival rate, are related to a better understanding of the natural history of testicular tumors, improved staging methods and surgical techniques, as well as to the introduction of effective platinum based combination chemotherapy. Modifications to the surgical management of testis cancer have significantly reduced morbidity associated with the classical full bilateral retroperitoneal lymph node dissection. Template and nerve sparing retroperitoneal node dissections are now routinely employed in low stage nonseminomatous germ cell tumors (NSGCT), providing the patient with the benefit of accurate pathological staging combined with reduced morbidity. In addition, nerve sparing techniques have also been used in dissections for residual disease following chemotherapy. Chemotherapy for advanced GCT has undergone a number of important breakthroughs during the past three decades. In the 1960's the first major chemotherapeutic advance in metastatic NSGCT was described; a combination of chlorambucil, methotrexate and dactinomycin produced a response rate of 30%. By the 1970's combination therapies such as vinblastine and bleomycin had been shown to produce objective responses; 57% complete response rates and 45% long-term disease-free survival rates were reported. The discovery of cisplatin as a highly effective anti-neoplastic agent in 1965, and its later use in germ cell tumors of the testis (GCT), was another important breakthrough. In 1974 the combination of cisplatin, vinblastine and bleomycin was investigated by the Indiana group. Of the 47 patients in the initial phase II study, 100% achieved a response rate. Thirty five (74%) patients achieved complete remission, the remaining patients achieved a partial remission.

Complications of Primary Nerve Sparing Retroperitoneal Lymph Node Dissection for Clinical Stage I Nonseminomatous Germ Cell Tumors of the Testis: Experience of the German Testicular Cancer Study Group

Nerve sparing retroperitoneal lymph node dissection has been the standard diagnostic and therapeutic approach to clinical stage I nonseminoma. However, the application of prognostic risk factors and introduction of laparoscopy have recently called into question the clinical usefulness of nerve sparing retroperitoneal lymph node dissection. We assessed the therapeutic efficacy and associated complications of this procedure in patients with clinical stage I nonseminomatous germ cell tumor treated at 7 tertiary referral centers to evaluate its role in the modern management of low stage testis cancer. Between January 1995 and September 2000, 239 patients with clinical stage I nonseminomatous germ cell tumor underwent nerve sparing retroperitoneal lymph node dissection in standardized fields of dissection. For retrospective analysis patient charts were reviewed. A minor complication did not prolong hospital stay and a major complication prolonged hospitalization for at least 2 days. Early complications developed within the first 30 days after retroperitoneal lymph node dissection and late complications occurred from postoperative day 31 and thereafter. Nerve sparing retroperitoneal lymph node dissection was performed unilaterally in 209 patients (88.2%) and bilaterally in 30 (11.8%). Median operative time was 214 minutes (range 90 to 395), mean hospital stay was 8 days (range 4 to 39) and mean blood loss was less than 150 ml. A mean of 18.5 lymph nodes (range 9 to 57) were dissected with metastases detected in 67 patients (28%). An average of 2.9 lymph nodes (range 1 to 14) with a mean diameter of 2.6 cm. (range 0.3 to 6.0) showed metastasis. Disease was pathological stage I in 172 patients (71.7%), 52 (17.6%) had 3 or fewer metastatic lymph nodes, and 15 (6.3%) had 4 to 5 and 10 (4.2%) had greater than 5 positive lymph nodes. Minor complications occurred in 14.2% of the cases and major complications were observed in 5.4%. Antegrade ejaculation was preserved in 93.3% of the patients, recurrence developed in 14 (5.8%) and retroperitoneal recurrence was observed in 3 (1.2%), including 1 in field and 2 out field. Primary diagnostic and therapeutic nerve sparing retroperitoneal lymph node dissection still has a role in the primary management of clinical stage I nonseminomatous germ cell tumor. Surgery is associated with low morbidity and patient followup is easy and cost-effective due to the concentration on extraretroperitoneal locations. Primary nerve sparing retroperitoneal lymph node dissection is curative in about 70% of clinical stage I nonseminoma cases with a maximum of 3 positive lymph nodes.

Ejaculatory Function in Stage T1 Nonseminomatous Germ Cell Tumors: Retroperitoneal Lymph Node Dissection Versus Surveillance—A Decision Analysis

Ejaculatory function remains a major concern for patients with low stage nonseminomatous germ cell tumors of the testis. Whereas, it has been extensively studied in patients undergoing retroperitoneal lymph node dissection, preservation of ejaculatory function on surveillance protocols has not been studied. To compare ejaculatory function for surveillance protocols to primary retroperitoneal lymph node dissection appropriately, we constructed a decision analysis model mimicking the standard treatment algorithm for stage 1 nonseminomatous germ cell tumor of the testis. The primary clinical payoff for this study is ejaculatory function. Based on this model, we established that a primary nerve sparing retroperitoneal dissection must be performed with a 96.8% ejaculatory function rate to be recommended as the appropriate therapy. However, if a highly skilled surgeon routinely performs post-chemotherapy dissection with an ejaculatory function rate of 69.2% or greater, surveillance should be offered as the primary treatment modality. This result simply demonstrates a high skill level to allow the surgeon to salvage ejaculatory function in post-chemotherapy retroperitoneal lymph node dissection settings. If this level cannot be achieved, primary retroperitoneal lymph node dissection is the best choice. If we account for a 10% loss of ejaculatory function from primary chemotherapy, the minimum ejaculatory function rate for primary retroperitoneal dissection decreases to 95.7%. In the post-chemotherapy setting an 85.7% ejaculatory function rate must be achieved for surveillance to be considered the optimal choice. Clearly, less surgical rigor is needed with a primary retroperitoneal lymph node dissection when correcting for the effects of chemotherapy on ejaculatory function. Despite this fact, 1-way sensitivity analysis revealed that our model is insensitive to the ejaculatory function effects of chemotherapy. Furthermore, if the likelihood of recurrence on surveillance is greater than 16%, primary nerve sparing retroperitoneal lymph node dissection should again be recommended. Thus, to maximize ejaculatory function for patients with stage 1 nonseminomatous germ cell tumor a nerve sparing primary retroperitoneal lymph node dissection should always be performed, unless the likelihood of recurrence on surveillance is low or the surgical skill level allows for a highly successful post chemotherapy nerve sparing dissection.

PARATESTICULAR SPINDLE CELL RHABDOMYOSARCOMA IN AN ADULT

A 20-year-old white man presented with a 14-month history of painless enlargement of the left hemiscrotum. Physical examination revealed a normal left testis and a 3 3 6 cm. firm, irregularly shaped nontender mass at the tail of the epididymis. Serum markers for b-human chorionic gonadotropin, a-fetoprotein and lactate dehydrogenase were normal. Scrotal ultrasound showed a 2.5 3 6 cm. vascular, solid mass with no intratesticular component. Computerized tomography of the chest, abdomen and pelvis was normal. Frozen section at inguinal exploration demonstrated adenomatoid tumor and the mass was excised, sparing the epididymis and testicle. Histological examination revealed bundles of spindle cells with eosinophilic and clear cytoplasm, and rhabdomyoblasts with plump eosinophilic cytoplasm (see [fgc]figure). Desmin, myoglobin and myo-D1 immunostains confirmed skeletal muscle differentiation. Permanent sections disputed the frozen section diagnosis and subsequent hisopathological evaluation confirmed spindle cell rhabdomyosarcoma. After consultation with the most current Intergroup Rhabdomyosarcoma Study protocol and extensive discussion with the patient, he elected to undergo left modified nerve sparing retroperitoneal lymph node dissection and inguinal orchiectomy. Pathological evaluation revealed no evidence of tumor metastasis. The patient experienced antegrade ejaculation 2 months postoperatively and there were no complications from surgery. Chemotherapy was initiated. DISCUSSION

RISK ADAPTED MANAGEMENT WITH ADJUVANT CHEMOTHERAPY IN PATIENTS WITH HIGH RISK CLINICAL STAGE I NONSEMINOMATOUS GERM CELL TUMOR

We propose that patients with high risk, clinical stage I nonseminomatous germ cell tumors receive 2 cycles of chemotherapy initially, instead of undergoing surgery or observation. A total of 59 patients with high risk, clinical stage I nonseminomatous germ cell tumor received risk adapted adjuvant chemotherapy. Until June 1987, 20 patients were treated with 2 courses of adjuvant cisplatin, vinblastine and bleomycin at 3-week intervals. After June 1987 another 39 patients were treated with 2 cycles of bleomycin, etoposide and cisplatin. Long-term results with this treatment strategy have been excellent with limited morbidity. Adjuvant chemotherapy may be of particular value in patients with compromised followup.

RETROPERITONEAL LYMPH NODE DISSECTION FOR THE MANAGEMENT OF CLINICAL STAGE I NONSEMINOMA

We review the rationale for the use of retroperitoneal lymph node dissection for clinical stage I nonseminomatous testis cancer. The published literature regarding the alternative treatments for clinical stage I nonseminoma was reviewed as well as the personal experience of the authors to define the role of retroperitoneal lymph node dissection. Retroperitoneal lymph node dissection alone is curative in 50% to 75% of patients with pathological stage II disease. The only significant long-term morbidity is a 1% chance of small bowel obstruction. If recurrence develops after retroperitoneal lymph node dissection, it is virtually always curable with cisplatin based chemotherapy. Retroperitoneal lymph node dissection retains a therapeutic and staging capability in these patients. The probability for cure, short and long-term morbidity, and minimal need for long-term followup in these patients indicates that retroperitoneal lymph node dissection continues to be standard therapy for clinical stage I nonseminoma.

SEXUAL FUNCTIONING AFTER MULTIMODALITY TREATMENT FOR DISSEMINATED NONSEMINOMATOUS TESTICULAR GERM CELL TUMOR

SEXUAL FUNCTIONING AFTER MULTIMODALITY TREATMENT FOR DISSEMINATED NONSEMINOMATOUS TESTICULAR GERM CELL TUMOR

The Fertility of Patients with Clinical Stage I Testis Cancer Managed by Nerve Sparing Retroperitoneal Lymph Node Dissection

Nerve sparing retroperitoneal lymph node dissection reliably preserves emission and ejaculation in patients with clinical stage I nonseminoma. The fertility of 51 patients who underwent nerve sparing retroperitoneal lymph node dissection was assessed by 3 different methods: standard semen analysis, analysis of chromatin content by deoxyribonucleic acid histogram and assessment of ultimate fertility status by a questionnaire. Approximately 75% of these patients have semen analyses generally considered to be in the normal range. Virtually all patients who underwent deoxyribonucleic acid histogram analysis had histograms similar to controls. A retrospective analysis of fertility was performed in 201 patients who had previously undergone nerve sparing retroperitoneal lymph node dissection. Of these patients who attempted pregnancy after nerve sparing retroperitoneal lymph node dissection 76% have been successful. Approximately 75% of patients who present with clinical stage I nonseminoma are potentially fertile. Nerve sparing retroperitoneal lymph node dissection is capable of preserving this potential in allowing these patients to father children.

Nerve Sparing Retroperitoneal Lymphadenectomy After Primary Chemotherapy for Metastatic Testicular Carcinoma

Initial success with nerve sparing retroperitoneal lymph node dissections in patients with low stage nonseminomatous germ cell tumors of the testis has led to the application of these techniques to a select group of 40 patients treated after chemotherapy at our institution between March 1988 and November 1991. A minimum 1-year followup was available for 38 patients. There have been no abdominal relapses, and 34 of the 38 patients report normal ejaculation postoperatively. Nerve sparing techniques are applicable to select patients undergoing retroperitoneal lymph node dissection after primary chemotherapy for metastatic disease without increasing the chance of local recurrence. Emission and ejaculation are preserved in the majority of patients.

Monitoring of Emission as Direct Intraoperative Control for Nerve Sparing Retroperitoneal Lymphadenectomy

An intraoperative test to identify emission relevant lumbar postganglionic nerves during nerve sparing retroperitoneal lymph node dissection is presented. The neurophysiological course of the ejaculation into the posterior urethra, the emission, is described. A retroperitoneal nerve sparing procedure was done for nonseminomatous testicular tumors bilaterally in 7 patients with pathological stage I disease and unilaterally in 4 with pathological stage Ha disease. While the isolated lumbar nerves were electrostimulated, the seminal vesicles and bladder neck were monitored by suprapubic transvesical sonography. Simultaneously, endoscopy of the posterior urethra was performed and time code was registered. Emission began with bladder neck closure, propulsive contraction of the seminal vesicles in the periphery and opening of the paracollicular region. Then, complete contraction of the seminal vesicles was associated with closure of the prostatic urethra and ended in the separate secretion from the ductuli prostatici and ejaculatorii. Descending from nerve LI to L3, their importance for emission usually increased. For intraoperative monitoring of emission transvesical sonography alone is sufficient. In 2 patients this method allowed us to identify the relevant nerves within the retroperitoneal re: