Critical Evaluation of Modified Templates and Current Trends in Retroperitoneal Lymph Node Dissection

Robotic-assisted retroperitoneal lymph node dissection for stage II testicular cancer

Objective

To evaluate the perioperative as well as early oncological outcomes of patients undergoing robotic retroperitoneal lymph node dissection for treatment of testicular cancer.

Methods

We conducted a prospective consecutive case series of patients undergoing robotic assisted retroperitoneal lymph node dissection for metastatic testicular cancer between May 2018 and July 2021 at our institution. Data were collected on patient and tumour characteristics, intraoperative and postoperative parameters, and functional and oncological outcomes. Descriptive statistics are presented.

Results

Nineteen patients were identified; 18 (94.7%) completed the procedure robotically and one was converted to open surgery; 78.9% of patients had stage ≥IIB and 12 (63.2%) patients had undergone prior chemotherapy. The median operative time was 300 (interquartile range [IQR] 240-315) min. Median blood loss was 100 (IQR 50-175) mL. Median length of stay was 2 (range 1-11) days. All robotically completed patients commenced diet and passed flatus on Day 1 and were discharged by Day 3. The median lymph node yield was 40.5 (IQR 38-51) nodes. All patients undergoing nerve-sparing procedures recovered antegrade ejaculatory function. One patient had a Clavien-Dindo III complication (chylous ascites requiring drainage). At a median follow-up of 22.3 (IQR 16.3-24.9) months, one patient developed retroperitoneal recurrence, which was successfully treated with second-line chemotherapy; no other patients have had recurrences.

Conclusion

Robotic retroperitoneal lymph node dissection is a safe and feasible alternative to open surgery in appropriately selected patients, offering low morbidity. Early oncological outcomes are promising. Larger cohorts and longer follow-ups are required to validate our institution's findings.

Nerve-sparing technique in RPLND for testicular cancer

PURPOSE OF REVIEW

The management of testicular cancer has evolved over time with multimodal therapy. Retroperitoneal lymph node dissection (RPLND), which is a complex and potentially morbid treatment option, remains the mainstay in surgical treatment. This article reviews the surgical template, approach and anatomical considerations with regards to nerve spare in RPLND.

RECENT FINDINGS

The standard full bilateral RPLND template has evolved over time to include the area between the renal hilum, bifurcation of the common iliac vessels, and the ureters. Morbidity with regards to ejaculatory dysfunction has led to further refinements in this procedure. Advancements in anatomical understanding of the retroperitoneal structures and their relationship to the sympathetic chain and hypogastric plexus has allowed for modification of surgical templates. Further refinements in surgical nerve sparing techniques have improved functional outcomes without sacrificing oncological outcomes. Finally, extraperitoneal access to the retroperitoneum and minimally invasive platforms have been implemented to further reduce morbidity.

SUMMARY

RPLND requires strict adherence to oncological surgical principles regardless of template, approach and technique. Contemporary evidence shows that outcomes are best for advanced testis cancer patients when managed at high volume tertiary care facilities with surgical expertise and access to multidisciplinary care.

Surgery in Early Metastatic Seminoma: A Phase II Trial of Retroperitoneal Lymph Node Dissection for Testicular Seminoma With Limited Retroperitoneal Lymphadenopathy

PURPOSE

The long-term toxicities of chemotherapy and radiotherapy can represent a significant burden to testicular cancer survivors. Retroperitoneal lymph node dissection (RPLND) is an established treatment for testicular germ cell tumors with minimal late morbidity although little data exist on its efficacy in early metastatic seminoma. Surgery in early metastatic seminoma is a prospective phase II single-arm, multi-institutional trial of RPLND as first-line treatment for testicular seminoma with clinically low-volume retroperitoneal lymphadenopathy.

PATIENTS AND METHODS

Twelve sites in the United States and Canada prospectively enrolled adult patients with testicular seminoma and isolated retroperitoneal lymphadenopathy (1-3 cm). Open RPLND was performed by certified surgeons with a primary end point of 2-year recurrence-free survival (RFS). Complication rates, pathologic up/downstaging, recurrence patterns, adjuvant therapies, and treatment-free survival were assessed.

RESULTS

A total of 55 patients were enrolled, with a median (IQR) largest clinical lymph node size of 1.6 cm (1.3-1.9). RPLND pathology demonstrated a median (IQR) largest lymph node size of 2.3 cm (0.9-3.5); nine patients (16%) were pN0, 12 (22%) pN1, 31 (56%) pN2, and 3 (5%) pN3. One patient received adjuvant chemotherapy. With a median (IQR) follow-up of 33 months (12.0-61.6), 12 patients experienced recurrence, with a 2-year RFS of 81% and a recurrence rate of 22%. Of the patients who experienced recurrence, 10 were treated with chemotherapy and two underwent additional surgery. At last follow-up, all patients who experienced a recurrence were disease-free and the 2-year overall survival was 100%. Four patients (7%) experienced short-term complications, and four patients experienced long-term complications including incisional hernia (1) and anejaculation (3).

CONCLUSION

RPLND is a treatment option for testicular seminoma with clinically low-volume retroperitoneal lymphadenopathy and is associated with low long-term morbidity.

What should be done in terms of fertility preservation for patients with cancer? The French 2021 guidelines

AIM

To provide practice guidelines about fertility preservation (FP) in oncology.

METHODS

We selected 400 articles after a PubMed review of the literature (1987-2019).

RECOMMENDATIONS

Any child, adolescent and adult of reproductive age should be informed about the risk of treatment gonadotoxicity. In women, systematically proposed FP counselling between 15 and 38 years of age in case of treatment including bifunctional alkylating agents, above 6 g/m2 cyclophosphamide equivalent dose (CED), and for radiation doses on the ovaries ≥3 Gy. For postmenarchal patients, oocyte cryopreservation after ovarian stimulation is the first-line FP technique. Ovarian tissue cryopreservation should be discussed as a first-line approach in case of treatment with a high gonadotoxic risk, when chemotherapy has already started and in urgent cases. Ovarian transposition is to be discussed prior to pelvic radiotherapy involving a high risk of premature ovarian failure. For prepubertal girls, ovarian tissue cryopreservation should be proposed in the case of treatment with a high gonadotoxic risk. In pubertal males, sperm cryopreservation must be systematically offered to any male who is to undergo cancer treatment, regardless of toxicity. Testicular tissue cryopreservation must be proposed in males unable to cryopreserve sperm who are to undergo a treatment with intermediate or severe risk of gonadotoxicity. In prepubertal boys, testicular tissue preservation is: - recommended for chemotherapy with a CED ≥7500 mg/m2 or radiotherapy ≥3 Gy on both testicles. - proposed for chemotherapy with a CED ≥5.000 mg/m2 or radiotherapy ≥2 Gy. If several possible strategies, the ultimate choice is made by the patient.

Post-chemotherapy modified template retroperitoneal lymph node dissection in patients with nonseminomatous germ cell tumours

INTRODUCTION/BACKGROUND

Although a full bilateral template RPLND is thought to be the standard of care for the management of postchemotherapy retroperitoneal residual masses for nonseminomatous germ cell tumors (NSGCT), in the past decade modified templates have become increasingly popular. In this study, we aimed to present our oncological and perioperative outcomes of consecutive seventeen NSGCT patients who underwent a modified template unilateral PC-RPLND for retroperitoneal residual disease.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 17 consecutive NSGCT patients who underwent modified template unilateral PC-RPLND in our university hospital between 2017 and 2020. All patients had normal serum tumour markers with residual disease in the retroperitoneum. Surgical characteristics including the size of the retroperitoneal residual mass, residual tumor pathology, removed lymph nodes, positive percentage of removed lymph nodes, accompanying operations, complications, mean operation time and hospital stay, and long-term results including survival and antegrade ejaculation were evaluated.

RESULTS

Eleven patients underwent left and six right-sided surgery. Median residual lymph node diameter was 41mm. Median hospitalisation time was 3.5 days. Median follow-up time was 10.5 months. Necrosis/fibrosis was seen in 6 patients, and teratoma in 11 patients. No viable tumour was seen. No patients died in the follow-up period. None of the patients relapsed during follow-up. Ten/seventeen patients had antegrade ejaculation.

CONCLUSIONS

Modified template unilateral PC-RPLND leads to very good oncological outcomes with decreased perioperative morbidity as well as better antegrade ejaculation rates. Low volume retroperitoneal disease seems to fit this procedure best.

A narrative review on the research progress of gonadal function protection in children with cancer

Background and Objective

The global incidence of malignant tumors in children (0-14 years) and adolescents (15-19 years) ranges between 95 per 1 million and 255 per 1 million, which seriously affects the survival of patients. In the past 30 years, with the application of comprehensive treatments (including surgery, chemotherapy, radiotherapy, and bone marrow transplantation), great progress has been made in the treatment of malignant tumors in children and adolescents. The 5-year survival rate now exceeds 80%, and most patients can smoothly enter adolescence or the reproductive period. However, due to the particular age of patients with malignant tumors in children and adolescents, treatment may cause abnormal growth of the patient's height, bones, and some vital organs (such as the pituitary gland and reproductive organs). Treatment may also cause abnormal secretion of growth hormones, thyroid hormones, and sex hormones. These complications seriously affect the quality of life of tumor patients. In the past ten years, countries have established long-term follow-up specifications for children with tumors. These programs have found that, in adulthood, 67% to 75% of children who survived having tumors have at least one treatment-related complication. Among patients receiving chemotherapy, gonadal dysfunction is the most common related endocrine dysfunction.

Methods

This paper reviews the literature on fertility protection services for cancer patients in foreign countries was conducted to provide a reference for developing gonadal protection services for cancer patients and for establishing consensus or guidelines on gonadal protection in China.

Key Content and Findings

In the treatment of childhood cancer, the assistance of reproductive technology can effectively reduce the occurrence of complications from treatment.

Conclusions

Therefore, minimizing the effects of radiotherapy and chemotherapy on the growth and endocrine of children and adolescents while treating tumors is a new challenge for oncologists.

Management of Stage II Germ Cell Tumors

There are several treatment approaches for stage II germ cell tumors (GCTs), and a thorough understanding of the staging classification and histologic differences in tumor biology and therapeutic responsiveness is critical to determine an effective, multimodal management strategy that involves urologists, medical oncologists, and radiation oncologists. This article discusses contemporary management strategies for stage II GCTs, including chemotherapy, radiotherapy, retroperitoneal lymph node dissection (RPLND), and surveillance. Patient selection, histology, and extent of lymphadenopathy drive management, and, as both treatment and detection strategies continue to emerge and be refined, the management of patients with stage II GCT continues to evolve.

Preservation of Fertility in Testis Cancer Management

The presence of cancer in the testis, as well as the therapies used to treat testis cancer, can impair fertility potential for affected men. Fertility preservation is an important aspect of survivorship care and should be offered to all patients before initiating treatment. The only established means of fertility preservation in men is cryopreservation of sperm. Methods for fertility preservation in prepubertal boys are still experimental. Physicians treating men with testicular cancer should be familiar with the available options. This article outlines testicular cancer and its treatment's effects on fertility, fertility preservation options, and barriers to accessing this specialized care.

Psychological Impacts of Male Sexual Dysfunction in Pelvic Cancer Survivorship

INTRODUCTION

A common negative sequela of cancer treatment in men is sexual dysfunction, which can have a significant psychological impact and can contribute to feelings of depression, anxiety, and other mental health issues. Management of cancer survivors' psychological and mental well-being plays an important role in the treatment and recovery process.

AIM

To identify how sexual dysfunction impacts the lives of male cancer survivors and to provide clinicians with treatment recommendations specific to this patient population.

METHODS

A total of 51 peer-reviewed publications related to sexual dysfunction in male cancer survivors were selected for analysis. Sources were chosen based on relevance to current cancer therapies, causes and psychological impacts of sexual dysfunction, and treatment recommendations for clinicians caring for cancer survivors. PubMed search terms included "sexual dysfunction," "cancer survivorship," and "male cancer survivors."

MAIN OUTCOME MEASURES

Measures of sexual dysfunction were based on cancer survivors reporting inadequate erectile capacity for penetrative sexual intercourse, decreased sensitivity of the genitalia, or inability to enjoy sex.

RESULTS AND CONCLUSIONS

Sexual dysfunction was present in male cancer survivors from diverse ages, cancer diagnoses, and treatments of cancer. Many of the men surveyed presented with psychological distress resulting from their posttreatment sexual dysfunction. This had a significant negative impact on their sexual self-esteem, body image, and mental health. Sexual and social development was delayed in survivors of childhood cancer. Healthcare practitioners should initiate conversations with patients regarding the potential for sexual dysfunction at the time of cancer diagnosis and throughout treatment and follow-up. Physical symptoms of sexual dysfunction should be treated, whenever possible, using phosphodiesterase 5 inhibitors or other interventions, and all cancer survivors presenting with psychological distress related to sexual dysfunction should be offered professional counseling. Twitchell DK, Wittmann DA, Hotaling JM, et al. Psychological Impacts of Male Sexual Dysfunction in Pelvic Cancer Survivorship. Sex Med Rev 2019;7:614-626.

Testicular Cancer Biomarkers: A Role for Precision Medicine in Testicular Cancer

Testicular germ cell tumors (TGCTs) represent the most common solid tumors among men aged 15 to 34 years. Fortunately, recent advances have made testicular cancer a highly curable disease. Despite the high cure rates, there are still several areas in testis cancer care where treatment decisions are controversial and guided only with clinical factors and historic serum tumor markers. Unfortunately, unlike other genitourinary malignancies, modern research techniques have not been widely tested or applied to germ cell tumors, perhaps as a result of excellent prognosis in this cohort of young men. Despite this, there remain numerous challenges and pitfalls in testis cancer care that need to be addressed. A reliable set of biomarkers could be extremely useful in helping risk-stratify patients, detect relapse early, guide surgical decision-making, and tailor follow-up. Current tumor markers (Alpha-fetoprotein, human chorionic gonadotrophin, and lactate dehydrogenase) have low accuracy and low sensitivity when used not only as diagnostic but also as prognostic and predictive markers. In twenty-first century medicine, there is a role for further prognostic stratification and the development of novel biomarkers that offer greater sensitivity and specificity for TGCTs. Despite the initial promising results, the majority of preclinical biomarkers do not, as yet have a proven validated role in clinical practice, and future prospective trials are needed to support and confirm the results of cohort studies. In this narrative review, we aimed to highlight the recent innovations in the development and implementation of novel testicular tumor markers and discuss their clinical applications and limitations in the management of this disease.

Limited post-chemotherapy retroperitoneal resection of residual tumour in non-seminomatous testicular cancer: complications, outcome and quality of life

BACKGROUND

Resection of residual masses after chemotherapy plays a crucial role in management of patients with germ cell tumours (GCTs). The extent of surgery is controversial and we present the experiences from Aarhus University Hospital over a 20-year period. The aim was to evaluate survival, complications, working ability and quality of life (QOL) following a limited surgical procedure performed to resect residual masses in non-seminomatous testicular cancer patients after chemotherapy.

MATERIAL AND METHODS

A consecutive patient cohort of 109 patients having surgery between 1993 and 2013 was investigated. Hospital records were reviewed and complications were graded according to the Clavien-Dindo classification. QOL data were assessed in a cross-sectional analysis using the European Organisation for Research and Treatment of Cancer (EORTC), QLQ-C30 version 3.0. Patients were matched 1:1 with controls to evaluate the influence of surgical resection on the QOL.

RESULTS

With a median follow-up of 10.3 years, 11 relapses in retroperitoneum were recorded in 10 patients (9%), and four patients (5%) died of disease progression. The majority of relapses in patients considered having no evidence of disease (NED) after primary retroperitoneal surgery occurred 10 + years after treatment and was outside the field of the elective lymph node dissection. Twenty-seven (44%) grade I, 15 (24%) grade II, 7 (11%) grade IIIa and 13 (21%) grade IIIb complications were recorded. No grade IV and V complications were observed. Twenty-three patients (20%) reported loss of antegrade ejaculation. We found no significant differences between patients and controls regarding QOL.

CONCLUSION

The survival outcome and complication rate are favourable and are comparable to studies involving full and modified template lymph node dissection. We find that limited resection constitutes an applicable and safe procedure. Limited surgical resection did not influence the patients' long-term QOL. Longer follow-up might be considered.

Improving Male Reproductive Health After Childhood, Adolescent, and Young Adult Cancer: Progress and Future Directions for Survivorship Research

Reproductive health is a common concern and often a source of distress for male childhood, adolescent, and young adult cancer survivors. Clinical and epidemiologic research in survivor populations has identified alkylating agent chemotherapy, testicular radiation, and surgery or radiation to the genitourinary organs, lower spine, or the hypothalamic-pituitary region as risk factors for adverse reproductive outcomes, including impaired spermatogenesis, testosterone insufficiency, and sexual dysfunction. Much of the research on male survivors has focused on the outcome of fertility, using spermatogenesis, serum gonadotropins, and paternity as the measures. However, these studies often fail to account for the clinically relevant but difficult-to-quantify aspects of fertility such as sexual function, cancer-related delayed psychosocial development, medical comorbidities, and socioeconomic concerns. Clinical and basic science research has made significant contributions to improving reproductive outcomes for survivors, with recent advancements in the areas of fertility preservation, clinical assessment of reproductive function, and treatment of adverse reproductive outcomes. Furthermore, there is an emerging qualitative literature addressing the psychosexual aspects of male reproductive health, the clinical application of which will improve quality of life for survivors. This review summarizes the current survivorship literature on reproductive health outcomes for male survivors, including the epidemiology of impaired spermatogenesis, testosterone insufficiency, and sexual dysfunction; clinical and laboratory assessment of reproductive function; and established and investigational interventions to preserve reproductive function for patients newly diagnosed and survivors. Although survivorship research has made significant contributions to improving reproductive outcomes, additional scientific progress is needed in the areas of fertility preservation, risk assessment, and psychosexual support with the aim of optimizing reproductive health for current and future survivors.

Testicular damage in children and adolescents treated for malignancy: a short review

Significant advances have been made over recent decades in the treatment of childhood malignancies. These advances had an incredible cost, as an increasing number of young survivors suffer subfertility or infertility, because of the high sensitivity of testicular cells, especially the rapidly dividing germ cells, to cytotoxic drugs and irradiation. Therefore, the impact of treatment on future fertility is of significant concern, both to parents and patients. Assessment of fertility damage in childhood remains problematic. For post-pubertal males, semen analysis represents a good indicator of spermatogenesis and testicular function, and allows for sperm cryopreservation. The available method for prepubertal children is only gonadal tissue cryopreservation. This method is still experimental and raises ethical concerns. Ideally, a multidisciplinary team approach needs to be used in addressing the needs of fertility preservation for this population. Precise knowledge of these issues would help pediatric oncologists and endocrinologists to counsel their patients and inform them for factors and resources that may protect or preserve parenthood options in the future. (www.actabiomedica.it)

Sexual dysfunction and male infertility

Infertility affects up to 12% of all men, and sexual dysfunction occurs frequently in men of reproductive age, causing infertility in some instances. In infertile men, hypoactive sexual desire and lack of sexual satisfaction are the most prevalent types of sexual dysfunction, ranging from 8.9% to 68.7%. Erectile dysfunction and/or premature ejaculation, evaluated with validated tools, have a prevalence of one in six infertile men, and orgasmic dysfunction has a prevalence of one in ten infertile men. In addition, infertile men can experience a heavy psychological burden. Infertility and its associated psychological concerns can underlie sexual dysfunction. Furthermore, general health perturbations can lead to male infertility and/or sexual dysfunction. Erectile dysfunction and male infertility are considered proxies for general health, the former underlying cardiovascular disorders and the latter cancerous and noncancerous conditions. The concept that erectile dysfunction in infertile men might be an early marker of poor general health is emerging. Finally, medications used for general health problems can cause sperm abnormalities and sexual dysfunction. The treatment of some causes of male infertility might improve semen quality and reverse infertility-related sexual dysfunction. In infertile men, an investigation of sexual, general, and psychological health status is advisable to improve reproductive problems and general health.

Extraperitoneal robot-assisted laparoscopic retroperitoneal lymph node dissection for early-stage testicular nonseminomatous germ cell tumors: A case report and literature review

RATIONALE

Typically robot-assisted laparoscopic retroperitoneal lymph node dissection (R-RPLND) has been performed via a transperitoneal approach. Herein we report the first case of a novel R-RPLND using an extraperitoneal approach.

PATIENT CONCERNS

A 38-year-old man presented with an enlarging right scrotal mass.

DIAGNOSES

Scrotal ultrasonography demonstrated a 5.5-cm solid mass of the right testis. The patient underwent right radical inguinal orchiectomy. Pathologic examination demonstrated a mixed germ cell tumor, predominately embryonal carcinoma with yolk sac tumor.

INTERVENTIONS

Extraperitoneal R-PRLND was performed 3 weeks after the radical orchiectomy.

OUTCOME

The final pathologic examination showed a count of 19 lymph nodes, all of them negative. Normal antegrade ejaculation returned within 4 weeks postoperatively. No retroperitoneal recurrence or elevation of tumor marker levels were seen via surveillance imaging.

LESSONS

Our study shows that extraperitoneal R-RPLND is a safe and feasible procedure using an extraperitoneal approach that provides minimal invasion and rapid recovery of patients.

Fertility preservation for boys and adolescents facing sterilizing medical therapy

Improvements in childhood cancer survival have allowed boys and their families to increasingly focus on quality of life after therapy, particularly their future ability to father children. Treatments should maintain comprehensive cancer care goals and consider the long-term quality of life of these children. While semen cryopreservation is a well-established method of fertility preservation for post-pubertal children, the use of cryopreserved pre-treatment testicular tissue represents a promising, yet experimental method of fertility preservation for prepubertal males facing sterilizing therapy. Healthcare providers should counsel families about the fertility risks of therapy, discuss or refer patients for standard fertility preservation options, and consider experimental approaches to fertility preservation while being mindful of the ethical questions these treatments raise.

A step-wise approach to sperm retrieval in men with neurogenic anejaculation

Normal fertility is dependent on intravaginal delivery of semen through ejaculation. This process is highly dependent on an intact ejaculatory reflex arc, which can be disrupted through any type of trauma or disease causing damage to the CNS and/or peripheral nerves. Neurogenic anejaculation is most commonly associated with spinal cord injury. This aetiology is especially relevant because most men with spinal cord injuries are injured at reproductive age. Assisted ejaculation in the form of penile vibratory stimulation is the first choice for sperm retrieval in such patients because it is noninvasive and inexpensive. In patients in whom vibratory stimulation fails, electroejaculation is almost always successful. When both methods of assisted ejaculation are unsuccessful, sperm retrieval by aspiration from either the vas deferens or the epididymis, or by testicular biopsy or surgery are reasonable options. In such cases the most inexpensive and least invasive methods should be considered first. The obtained semen can be used for intravaginal or intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection.

Lymphadenectomy for testicular, penile, upper tract urothelial and urethral cancers

PURPOSE OF REVIEW

The lymph node dissection (LND) is an integral component of many oncologic surgeries. Better understanding of each cancer's behaviour and improvements in surgical techniques necessitate a critical analysis of lymph node disease and the optimal LND template. This review will focus on updates in managing lymph node disease in testicular, penile, upper tract urothelial and urethral cancer.

RECENT FINDINGS

For testicular and penile cancer, advances have focused on reducing the morbidity associated with the standard templates of dissection while maintaining oncologic efficacy. For upper tract urothelial carcinoma, data continue to be mixed regarding the need for a LND, though it does seem to benefit patients with advanced tumours. Little is known regarding the optimal LND template for urethral cancer.

SUMMARY

A thorough LND has an established diagnostic and therapeutic role in testicular and penile cancer. For upper tract urothelial carcinoma, the role of an LND remains controversial, though emerging evidence points to an association with improved outcomes. Due to the rarity of urethral cancer, there are no standard LND templates, though excising clinically positive nodes is recommended. For all these cancers, more sophisticated risk stratification based upon clinical and pathologic factors has helped determine which patients require an LND and how to best manage these patients after surgery.