Retroperitoneal Node Research Articles

A case of renal cell carcinoma with tumor thrombus extension into the right atrium

Introduction: Over the last half-century, mortality from renal cell carcinoma (RCC) has seen a dramatic reduction, while 5-year survival rates have reached an all-time high (34% to 75%). Case presentation: A 77-year-old female with Stage 4 RCC (cT3c, cN1, cM1) presented with acute onset chest and back pain. Imaging revealed interval enlargement of a left renal mass with propagation of tumor thrombus (TT) throughout the left renal vein, intrahepatic and suprahepatic inferior vena cava (IVC) with extension into the right atrium (RA). The patient successfully underwent a high-risk open left nephrectomy with caval thrombectomy, retroperitoneal lymph node dissection, and atrial thrombectomy. Discussion: Approximately 1% of RCC cases involve the right atrium, and radical nephrectomy with vena caval thrombectomy remains the most effective treatment for cavoatrial TT, with 5-year survival rates between 30% and 72%. While patients with renal vein involvement have better survival rates than those with IVC involvement, advanced TT cases (Types III and IV) often require extracorporeal circulation. Though the patient understood the prognosis of her RCC, discussing the risks of a complex procedure versus not intervening was challenging. Despite a typical median survival of 12 months for level IV tumor thrombus (TT), she remains stable 28 months post-surgery. Conclusion: Although the five-year survival rate for renal cell carcinoma (RCC) has increased from 34% to 75%, the disease still adversely affects patients’ quality of life. A multidisciplinary approach is essential when managing metastatic RCC, particularly involving the heart. Despite the associated risks, surgical intervention is more effective in prolonging life by preventing sudden cardiac death due to embolic events.

A case of seminal vesicle metastasis from bilateral seminoma

IntroductionPostoperative recurrence of seminoma is often seen in lungs, liver, and retroperitoneal lymph nodes, such as the para‐aortic lymph nodes. Most of these recurrences (>90%) occur in the first 3 years after orchiectomy. We report a case of a single recurrence in the seminal vesicle after bilateral radical orchiectomies for metachronous bilateral testicular seminoma.Case presentationA 52‐year‐old patient with a past history of bilateral testicular seminoma was diagnosed with left seminal vesicle metastasis by magnetic resonance imaging followed by needle biopsy 8 years after the first orchiectomy. After four cycles of bleomycin, etoposide, and cisplatin regimen were administered, FDG‐18 positron emission tomography‐computed tomography showed no abnormal signal in the left seminal vesicle.ConclusionTo the best of our knowledge, this is the first report of seminal vesicle metastasis following radical orchiectomies for bilateral testicular seminoma.

Surgical management of testicular cancer with limited retroperitoneal disease.

Chemotherapy offers excellent long-term survival rates for men with clinical stage II germ cell tumours. However, in this predominantly younger population, chemotherapy is associated with long-term adverse effects. Primary retroperitoneal lymph node dissection (RPLND) may serve as an alternative treatment option, preserving oncological safety while potentially reducing adverse effects in men with limited retroperitoneal disease. The rate of negative surgical specimens (pN0) in primary RPLND series varies between 4% and 16% in seminoma and 12-29% in nonseminoma, respectively. This suggests that early restaging, novel biomarkers, and/or percutaneous biopsies should be considered to minimize overtreatment. In stage II seminoma, three prospective RPLND series with follow-up periods ranging from 22 to 51 months report recurrence rates between 6% and 30%. In contrast, only retrospective data are available for stage II nonseminoma, with follow-up periods and recurrence rates yet to be fully defined. Following primary RPLND with confirmed viable cancer, adjuvant chemotherapy reduces recurrence risk. In cases of recurrence after primary RPLND, first-line chemotherapy remains a highly effective salvage option. Ongoing research is needed to identify risk factors for contralateral retroperitoneal disease to refine surgical templates and to determine predictors of recurrence, allowing for more personalized decisions regarding the use of adjuvant chemotherapy and follow-up strategies. Men with clinical stage II germ cell tumours may benefit from RPLND due to its lower risk of long-term side effects. Chemotherapy is an effective salvage treatment if needed. Although RPLND is a safe and promising option, further studies are required to better understand relapse risks and to tailor treatment plans based on individual patient factors.

Desmoplastic Small Round Cell Tumor: a study of CT, MRI, PET/CT multimodal imaging features and their correlations with pathology

PurposeExploring the computed tomography (CT), magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography (FDG-PET)/CT Multimodal Imaging Characteristics of Desmoplastic Small Round Cell Tumor (DSRCT) to enhance the diagnostic proficiency of this condition.MethodsA retrospective analysis was performed on clinical data and multimodal imaging manifestations (CT, MRI, FDG-PET/CT) of eight cases of DSRCT. These findings were systematically compared with pathological results to succinctly summarize imaging features and elucidate their associations with both clinical and pathological characteristics.ResultsAll eight cases within this cohort exhibited abdominal-pelvic masses, comprising six solitary masses and two instances of multiple nodules, except for one case located in the left kidney, the remaining cases lacked a clear organ source. On plain images, seven cases exhibited patchy areas of low density within the masses, four cases showed calcification within the masses. Post-contrast imaging displayed mild-to-moderate, uneven enhancement. Larger masses displayed patchy areas without significant enhancement at the center. In the four MRI examinations, T1-weighted images exhibited uneven, low signal intensity, while T2-weighted images demonstrated uneven high signal intensity. Imaging unveiled four cases of liver metastasis, four cases of ascites, seven cases of lymph node metastasis, three cases of diffuse peritoneal thickening, and one case involving left ureter invasion with obstruction. In the FDG-PET/CT examinations of seven cases, multiple abnormal FDG accumulations were observed in the abdominal cavity, retroperitoneum, pelvis, and liver. One postoperative case revealed a new metastatic focus near the colonic hepatic region. The range of maximum standardized uptake values (SUVmax) for all lesions are 6.62–11.15.ConclusionsDSRCT is commonly seen in young men, and the imaging results are mostly multiple lesions with no clear organ source. Other common findings include intratumoral calcification, liver metastasis, ascites, peritoneal metastasis, and retroperitoneal lymph node enlargement. The combined use of CT, MRI and FDG-PET/CT can improve the diagnostic accuracy and treatment evaluation of DSRCT. However, it is imperative to underscore that the definitive diagnosis remains contingent upon pathological examination.

Primary retroperitoneal lymph node dissection in clinical stage 2a/b non-seminomatous germ cell tumour.

To reassess the role of primary retroperitoneal lymph node dissection (RPLND) in patients with marker-negative non-seminomatous germ cell tumour (NSGCT) clinical stage (CS) 2a, to explore results in patients with CS 2b and to evaluate surgical methods, recurrence, and adjuvant chemotherapy indications. Data from 17 institutions were collected, comprising 305 men who underwent primary RPLND for CS 2 NSGCT. Regression analyses were conducted to predict histology in the RPLND specimen and disease-free survival (DFS). A larger retroperitoneal lymph node diameter was associated with pure teratoma in the RPLND specimen (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.07; P = 0.03), but no association was observed with DFS. The 5-year DFS rates in marker negative CS 2a and 2b were 79% and 76%. In men with non-teratomatous viable cancer in the RPLND specimen, the 5-year DFS rates for CS 2a and 2b were 95% and 87% with adjuvant chemotherapy, and 67% and 74% without adjuvant chemotherapy. We did not identify an association between the number of adjuvant chemotherapy cycles and DFS. Our study suggests considering primary RPLND not only in marker-negative CS 2a but also in CS 2b. Further research should determine the efficacy of primary RPLND in men with CS 2c and marker-positive CS 2, as well as which patients may benefit from adjuvant chemotherapy and the optimal cycle number.

A predictive system comprising serum microRNAs and radiomics for residual retroperitoneal masses in metastatic nonseminomatous germ cell tumors.

Predicting the histopathology of residual retroperitoneal masses (RMMs) before post-chemotherapy retroperitoneal lymph node dissection in metastatic nonseminomatous germ cell tumors (NSGCTs) can guide individualized treatment and minimize complications. Previous single approach-based models perform poorly in validation. Herein, we introduce a machine learning model that evolves from a single-dimensional tumor diameter to incorporate high-dimensional radiomic features, with its effectiveness assessed using the macro-average area under the receiver operating characteristic curves (AUCs). In addition, we utilize more precise and specific microRNAs (miRNAs), not common clinical indicators, to construct an integrated radiomics-miRNA predictive system, achieving an AUC of 0.91 (0.80-0.99) in the prospective test set. We further develop a web-based dynamic nomogram for swift and precise calculation of the histopathological probabilities of RMMs based on radiomic scores and serum miRNA levels. The radiomics-miRNA integrated system offers a promising tool to select personalized treatments for patients with metastatic NSGCT.

Laparoscopic Retroperitoneal Lymph Node Dissection After Chemotherapy for Nonseminomatous Testicular Germ-Cell Tumor at a Single Center.

This study investigated the perioperative and oncological outcomes of laparoscopic retroperitoneal lymph node dissection (RPLND) procedures for post-chemotherapy patients with nonseminomatous testicular germ-cell tumor at a single center. This study included patients with nonseminomatous testicular cancer who underwent RPLND after chemotherapy at the Kyushu University Hospital between 2016 and 2024. The preoperative clinicopathological characteristics, perioperative outcomes, and oncological outcomes were investigated. A total of 13 patients underwent laparoscopic RPLND. Median maximum retroperitoneal tumor size at post-chemotherapy before RPLND was 11 mm (range, 2-30 mm). RPLND template was one side and both sides in nine and four patients. Median operative time was 272 min (range, 129-490 min), and median estimated blood loss was 27 mL (range, 0-100 mL). Median time from operation to discharge was 8 days (range, 5-15 days). There was no severe perioperative and postoperative complication. Residual cancer and teratoma were detected in one and seven patients. During median follow-up of 18.6 months (range, 1.0-95.7 months), no case presented recurrence. Laparoscopic RPLND presented safety in perioperative outcomes and favorable oncological outcomes. Thus, it was confirmed that laparoscopic RPLND is a feasible minimally invasive procedure for selected cases.

NCMP-18. A CASE OF METASTATIC GLIOBLASTOMA MULTIFORME

Abstract Glioblastoma multiforme (GBM) is the most common primary brain tumor and rarely causes metastasis. We present a case of a 43-year-old female who developed tingling and heaviness in her right lower extremity in March 2023. This sensation progressed to involve her entire right hemi-body over the next two months. She presented to the emergency department where an MRI show a large left frontal parietal mass measuring 5.2x3.7x3.7cm with significant mass effect. She underwent surgical resection and surgical pathology showed IDH1-mutant R132H, retained ATRX, MGMT promoter mutation, and ki-67 of 80%. She received 6 weeks chemoradiation and then started maintenance temozolomide at 150mg/m2. Temozolomide was increased to 200mg/m2 for cycle 3 maintenance. In March 2024, she presented to the hospital with pain radiating down her legs and saddle anesthesia. MRI lumbar spine showed infiltrating osseous mass at S1 and S2 and bilateral sacral ala with anterior and posterior extraosseous invasion, invading the spinal canal resulting in moderate to severe spinal canal narrowing and compression of the sacral nerve roots. She underwent biopsy of the lesion which showed IDH wildtype metastatic GBM. She also underwent lumbar puncture and cerebrospinal fluid cytology was negative. She experienced pancytopenia limiting chemotherapy options. In April 2024, she underwent PET scan which showed hypermetabolic epidural soft tissue in spinal canal at L5-S1 level, widespread hypermetabolic skeletal lesions, tiny left cervical level 4 lymph node, small hypermetabolic right hilar, aortocaval, left retroperitoneal nodes and a tiny left common iliac node. The incidence of extracranial metastasis is 0.4-2.0% with less than 25 reported cases of bone marrow spread. This is thought to be rare due to the absence of lymphatics within the brain and the limited survival associated with GBM. This metastasis may occur through vascular invasion, perineural spread, lymphatics, direct invasion, or iatrogenic spread into soft tissues.

Adult supratentorial peripheral primitive neuroectodermal tumor with multiple metastases: a case report and literature review

BackgroundIntracranial primitive neuroectodermal tumors (PNETs) are characterized by poorly differentiated, highly malignant, aggressive small round tumor cells originating from the central and peripheral nervous systems.Case presentationA 25-year-old Chinese woman experienced sudden onset headache, vomiting, and severe anemia. Imaging examinations revealed a mass in the left parietal occipital lobe. Following microsurgery, histological confirmation revealed the tumor to be pPNET. Postoperative computed tomography (CT) showed multiple metastases in the lung, liver, and retroperitoneal lymph node. Unfortunately, she died of tumor cachexia 1 month after chemotherapy.ConclusionsDue to the rare presentation of pPNET, pPNET would be misdiagnosed without the histological diagnosis. Here, we aimed to provide clinicians with information about the treatment and relevant literature of pPNET.

O09 Correlation between Fibroblast Activation Protein inhibitor (99mTc-FAPi/SPECT) and histology in patients submitted to Retroperitoneal Lymph Node Dissection (RPLND) with residual post-chemotherapy disease in Non-Seminomatous Germ Cell Tumors (NSGCT)

O09 Correlation between Fibroblast Activation Protein inhibitor (99mTc-FAPi/SPECT) and histology in patients submitted to Retroperitoneal Lymph Node Dissection (RPLND) with residual post-chemotherapy disease in Non-Seminomatous Germ Cell Tumors (NSGCT)

P209 Ureteric involvement and obstructive uropathy caused by retroperitoneal lymph nodes in patients with testicular germ cell tumor as seen on post-chemotherapy computed tomography scan – no-brainer or enigma

P209 Ureteric involvement and obstructive uropathy caused by retroperitoneal lymph nodes in patients with testicular germ cell tumor as seen on post-chemotherapy computed tomography scan – no-brainer or enigma

Cytological diagnosis of follicular dendritic cell sarcoma with a unique pattern of D2-40 immunoexpression.

Fine needle aspiration procedure is routinely used for cytological diagnosis of nodal or extra nodal lesions. Follicular dendritic cell sarcoma (FDCS) is a rare mesenchymal neoplasm arising from follicular dendritic cells of lymphoid follicles at nodal and extranodal sites. Multimodal therapies have emerged for FDCS, necessitating its accurate pathologic diagnosis with additional ancillary testing for directing clinical management. By immunohistochemical analysis, FDCS is positive for the complement receptors CD21, CD23, and CD35. In addition, D2-40 is reported to be highly sensitive for FDCS with a strong membranous pattern of expression. In this study, we present the cytological diagnosis of a case of FDCS in retroperitoneal lymph nodes with an emphasis on a unique staining pattern of D2-40 which showed a strong nuclear pattern in tumor cells comparable to the membranous pattern of D2-40 on the control tissue and other surgical cases of FDCS in our comparative study.

Oncological Outcomes Following Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer: A Worldwide Multicenter Study

Background and objectiveThe feasibility and safety of a robotic approach for postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in testicular cancer have been demonstrated, but data on long-term oncological outcomes of this procedure are limited. Our aim was to evaluate oncological outcomes following robotic PC-RPLND in this setting. MethodsThis retrospective cohort study included consecutive patients with testicular cancer treated with robotic PC-RPLND at 11 academic centers worldwide between 2011 and 2023. Patient characteristics, clinicopathological findings, and oncological outcomes were recorded. Recurrence-free survival (RFS) was estimated via the Kaplan-Meier method. Key findings and limitationsA total of 173 patients were included, of whom 159 underwent pure robotic PC-RPLND; 14 cases were converted to open surgery. Among the pure robotic cases, 152 (96%) had nonseminoma, 122 (77%) had International Germ Cell Cancer Collaborative Group good risk, and 120 (76%) had a postchemotherapy mass size ≤5 cm. Salvage chemotherapy was received by ten patients (6%). Median estimated blood loss, operative time, and length of hospital stay were 100 ml, 300 min, and 2 d, respectively. Final pathology revealed necrosis/fibrosis in 64 cases (40%), teratoma in 78 (49%), and viable germ-cell tumor in 17 (11%). At median follow-up of 22 mo (interquartile range 7–50), eight patients had disease recurrence, which was in-field in three cases. One port-site recurrence was identified. The median time to recurrence was 7 mo. The 4-yr RFS rate was 93%. Two cancer-related deaths were recorded. Subgroup analysis revealed that patients with conversion to open surgery were more likely to have a larger preoperative mass and received salvage chemotherapy before RPLND. In addition, conversion to open surgery was associated with a higher rate of perioperative complications; however, oncological outcomes were statistically similar to those for pure robotic PC-RPLND. The main limitation of the study is its retrospective nature. Conclusions and clinical implicationsRobotic PC-RPLND in testicular cancer is associated with acceptable intermediate-term oncological outcomes in appropriately selected patients. Patient summaryIn this large multicenter study, we investigated the outcomes of robotic surgery after chemotherapy for advanced testicular cancer. We found that robotic surgery yields acceptable cancer control results.

P217 Primary retroperitoneal lymph node dissection for clinical stage II seminoma: a systematic review and meta-analysis of safety and oncological effectiveness

P217 Primary retroperitoneal lymph node dissection for clinical stage II seminoma: a systematic review and meta-analysis of safety and oncological effectiveness

Usefulness of pelvic lymphadenectomy in staging of ovarian dysgerminoma.

To determine the usefulness of pelvic lymphadenectomy in the staging of ovarian dysgerminoma. Patients with a histopathological diagnosis of ovarian dysgerminoma who were staged between January 1995 and December 2013 were retrospectively studied. We found 39 cases, the mean age was 23.5 years. Histologically, 34 were pure dysgerminomas and 5 were mixed associated with endodermal sinus tumors. According to FIGO, we found stage IA in 15 patients, stage IB in 1 patient, stage IC in 8 patients, stage IIB in 1 patient, stage IIIA in 1 patient, and stage IIIC in 13 patients. Pelvic nodes with metastases were not documented in any of the patients studied. The lymphatic spread pattern in ovarian dysgerminomas is always towards the retroperitoneal nodes, both paracaval and paraaortic, but there is no spread towards the pelvic lymph nodes. Therefore, we recommend not performing pelvic lymphadenectomy in surgical staging in these patients.

Results of complete cytoreductive strategy in patients with peritoneal metastases of colorectal origin with or without extraperitoneal metastases: A bicentric analysis

BackgroundIncreased survival can be achieved in patients with colorectal cancer peritoneal metastases (CRPM) treated with cytoreductive surgery. The benefit of this strategy remains uncertain when CRPM are associated with extraperitoneal metastases (EPM). The aim of this study was to compare short- and long-term outcomes of patients treated with CRS for CRPM, with or without EPM. MethodsThis study included 413 consecutive patients who underwent CRS for CRPM: 120 with EPM (EPM+) and 293 without (EPM-). Patients with isolated ovarian metastases were included in EPM-group (n = 83). ResultsEPM were mainly located to the liver (66 %,n = 79), retroperitoneal lymph nodes (33 %,n = 40); less frequently to the spleen (9 %,n = 12), lung (9 %,n = 10) or pleura (1 %,n = 1). Ovarian metastases were present in 126 patients (83 in EMP-, 43 in EPM+). Peritoneal carcinomatosis index (PCI) was similar in EPM- (8 [4–14]) and EPM+ (8 [3–13],p = 0.335) groups, as postoperative mortality (3 % vs 3 %,p = 1) and major morbidity rates (28 % vs 35 %,p = 0.223). Median overall survival (mOS) and disease-free survival were significantly higher in the EPM-group (58m vs 39m, and 16m vs 10m,p = 0.003). We highlighted 3 prognostic groups 1) EPM-with PCI<10 (mOS 93m), 2) EPM+ with PCI<10 (mOS 57m), 3) EPM-with 10<PCI<15 (mOS 35m) or EPM+ with 10<PCI<15 (mOS 31m) or PCI>15 regardless EPM (mOS 26m, p < 0.001). ConclusionComplete cytoreductive surgery seems to be feasible in patients with EPM, without increase in postoperative morbidity and mortality compared to patients without EPM. This strategy provides prolonged survival in selected patients with limited peritoneal metastases from colorectal cancer.

Incidence of Lymphedema and Other Complications in Patients Operated on for Gynecological Cancer Including Utilization of Two Lymph Node Dissection Techniques.

Background: To assess the impact of the lymph node dissection (LND) technique on short- and long-term complications. This retrospective review included patients who underwent hysterectomy, oophorectomy, and pelvic ± para-aortic LND for gynecological malignancies (cervical, endometrial, and ovarian) from 2020 to 2022 in our Gynecological Oncology Surgery clinic. Methods and Results: Among 147 patients who underwent pelvic LND for gynecological malignancy, 48 had procedures involving scissors and 99 had procedures involving unipolar cautery. There was no significant difference in the numbers of extracted pelvic and para-aortic lymph nodes between groups. The extents of LND were comparable between the scissors and unipolar cautery groups (p = 0.945). The scissors group exhibited less fluid drainage between days 2 and 5 postoperatively (1300 [600-3100] vs 1800 [600-3400]; p = 0.038). In terms of primary early and late clinical outcomes, there were no significant differences in lymphocele (16.7% vs 15.2%; p = 0.494) and lymphedema (18.8% vs 17.2%; p = 0.491) rates between groups. Conclusions: After retroperitoneal LND for gynecological malignancy, early complications such as lymphocele and late complications such as lower extremity lymphedema did not significantly differ between procedures using cold scissors and procedures using unipolar cautery.

Association of hemoglobin, albumin, lymphocyte and platelet (HALP) score with testicular tumor aggressiveness and prognosis.

The hemoglobin, albumin, lymphocyte and platelet (HALP) score integrates readily available blood markers that reflect systemic inflammation, nutritional status, and immune response, all of which can influence cancer progression. This study investigated the association between the HALP score and clinicopathological characteristics in patients with testicular tumor. Data of patients who underwent radical orchiectomy for testicular tumors between January 2020 and January 2024 were reviewed. Preoperative serum tumor markers, hemogram parameters and albumin levels were recorded. Tumor stages were recorded from postoperative radiological imaging and serum tumor markers. The association between postoperative results and HALP score was analyzed. A total of 74 male patients were included in the study. The mean age of the patients was 30.27 ± 6.42 years. The mean HALP score in the patient group with metastasis and retroperitoneal lypmh node invasion (RPLNI) was statistically significantly lower than the patients without metastasis and RPLNI. HALP score decreased statistically significantly with increasing tumor T stage, N stage and M stage. In addition, the mean HALP score values of patients who received chemotherapy, developed progression and mortality were statistically significantly lower than those of patients who did not. Lower HALP scores are significantly associated with advanced disease and poorer prognosis in patients with testicular tumor. The HALP score, composed of routinely measured blood markers, may serve as a convenient and cost-effective prognostic tool to identify patients at higher risk and guide personalized management strategies.

Primary retroperitoneal lymph node dissection in stage II testicular seminoma: a systematic review.

To conduct a systematic review of the current literature to determine the current role of primary retroperitoneal lymph node dissection (RPLND) in stage II testicular seminoma and its associated oncological, functional and peri-operative outcomes. A comprehensive literature search was conducted in Medline, Embase, and Scopus for publications from inception until November 2023. The systematic review was registered on PROSPERO (ID CRD42023449781), was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and utilised the Methodological Index for Non-Randomised Studies (MINORS) tool. Six studies involving 385 patients were analysed, with 48.5% clinical stage IIA and 51.5% stage IIB seminomas. The patients' mean (range) age was 37 (20-64) years. The median operation time was 187 min, median estimated blood loss was 150 mL and median length of hospital stay was 4 days. In all, 6.1% of patients developed complications that were greater or equal to Clavien-Dindo grade 3. Only four studies reported on anejaculation rate (median: 4.9%). Only one study had long-term data, demonstrating a 92% 5-year overall survival for stage IIA/B disease treated with RPLND. The remaining five studies had a median follow-up of between 18.5 and 37 months and reported a mean recurrence rate of 15.6%. Most recurrences (78%) were not within the field of RPLND. Recurrence was associated with higher clinical and pathological lymph node stage, and metachronous or delayed development of retroperitoneal lymphadenopathy (initially stage I disease, as opposed to de novo stage IIA/B disease). Primary RPLND, performed by experienced surgeons, has good peri-operative outcomes. Recurrence is more common than with standard treatment, but long-term survival and functional data are limited, although promising.

Stage-dependent treatment of seminomas

Germ cell neoplasms of the testis are rare solid tumors predominantly in young men. Seminomas are slightly more frequent than nonseminomatous germ cell tumors. A special feature of seminomas is that they are sensitive to radiation, so that this represents an option in tumor stages with few metastases; however, the guideline recommendation is cautious due to the increased risk of secondary malignancies. In nonmetastasized tumor stages active surveillance is the primary approach to avoid overtreatment of patients. This is also the reason for primary nerve-sparing retroperitoneal lymph node dissection in cases of a low metastasis load. This concept has already been implemented in the American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) guidelines, whereas in the European Association of Urology (EAU) guidelines it is still considered to be an individual approach.