Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Germ Cell Tumors of the Testis

Abstract

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumors (TGCT). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumors >3 cm in diameter is only indicated if a PET scan is performed 6–8 weeks after chemotherapy demonstrates a positive lesion. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic lesions >1 cm in diameter and with negative or plateauing serum tumor marker concentrations following systemic chemotherapy. Based on the location and the size of the primary and the residual lesion, it has to be decided if a modified or bilateral template resection needs to be performed. Loss of antegrade ejaculation represents the most common long-term complication which can be prevented by a nerve-sparing or modified template resection. Patients with residual masses <1 cm and an initially good prognosis can undergo active surveillance. PC-RPLND is only indicated in men with intermediate/poor prognosis or a testicular lesions containing teratoma predominantly. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemo-refractory 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 centers only.