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Summary Post‐chemotherapy retroperitoneal lymph node dissection (PC‐RPLND) represents an integral part of multidisciplinary treatment of advanced germ cell cancer; however, it is associated with a high complications rate. The present study aimed to describe sexual disorders in 53 patients with testicular cancer who underwent full bilateral, non‐nerve‐sparing PC‐RPLND in our institution, focusing beyond ejaculatory dysfunction. The International Index for Erectile Function (IIEF) questionnaire was used as diagnostic tool of male sexual functioning pre‐operatively and three months after RPLND, while post‐operatively patients were asked to describe and evaluate changes in selected sexual parameters. Study findings demonstrate mixed pattern of changes in sexual functioning, with no difference in erectile functioning before and after operation. However, orgasmic function and intercourse and overall sexual satisfaction were found significantly impaired post‐operatively. Sexual desire and frequency of attempted sexual intercourses were found significantly increased post‐operatively, in comparison with pre‐operative levels. With regard to patients' subjective perception on sexual functioning alterations after PC‐RPLND, a significant number of patients reported higher levels of sexual desire, no difference in erectile function and worse orgasmic function and satisfaction post‐operatively. Thus, patients subjected to PC‐RPLND should be closely and routinely evaluated due to close relationship of sexual dissatisfaction with secondary psychological disorders.

PurposeTo evaluate the feasibility, safety, and early oncologic outcomes after post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-RARPLND) for metastatic germ cell tumors (mGCT).MethodsWe retrospectively analyzed patients from four tertiary centers who underwent PC-RARPLND for mGCT, from 2011 to 2021. Previous treatment of mGCT, intraoperative and postoperative complications, and early oncologic outcomes were assessed.ResultsOverall, 66 patients were included. The majority of patients had non-seminoma mTGCT (89%). Median size of retroperitoneal lymph node (RLN) before surgery was 26 mm. Templates of PC-RARPLND were left modified, right modified, and full bilateral in 56%, 27%, and 14%, respectively. Median estimated blood loss and length of stay were 50 mL [50–150] and 2 [1–3] days. Four patients (6.1%) had a vascular injury, only one with significant blood loss and conversion to open surgery (OS). Two other patients had a conversion to OS for difficulty of dissection. No patient had transfusion, most frequent complications were ileus (10.6%) and symptomatic lymphorrea (7.6%) and no complications grade IIIb or more occurred. With a median follow-up of 16 months, two patients had a relapse, all outside of the surgical template (one in the retrocrural space with reascending markers, one in lungs).ConclusionPC-RARPLND is a challenging surgery. In expert centers and for selected patients, it seemed safe and feasible, with a low morbidity. Further prospective evaluation of this procedure and long-term oncologic results are needed.

ObjectiveTo evaluate the perioperative and oncological outcomes after post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-RARPLND).Materials and methodsWe retrospectively reported the perioperative and oncological outcomes of all the patients with testicular cancer who underwent PC-RARPLND at three tertiary teaching centers. Descriptive statistical measures were used to report demographic, clinical, intraoperative, postoperative and oncological outcomes.ResultsThere were 43 consecutive patients who underwent PC-RARPLND at the participating institutions. Mean patient age was 29.2 years (± 8.2), BMI was 26.6 kg/m2 (± 6.2). The mean size of retroperitoneal mass was 4.1 cm (± 3.5). Full bilateral template dissection was performed in 38 (88.3%) patients. Nerve sparing was attempted in 19 (44.1%) patients. Mean operative time was 374 min (± 132) and estimated blood loss was 292 ml (± 445.6). The mean postoperative LOS was 2.8 days (± 5.9). There was a total of 12 complications in 10 patients (Clavien grade I = 5, II = 3, III = 3 and IV = 1). Postoperative pathology demonstrated 24 patients (55%) with necrosis/fibrosis, 16 (37%) with teratoma and 3 (7%) with viable tumor. Mean lymph node (LN) yield was 26.5 LNs (SD ± 16.1). Patients were followed for a mean of 30.7 months (± 24.7). No deaths were documented during follow-up and 2 pulmonary recurrences were identified. Antegrade ejaculation was preserved in 70.6% of patient who underwent nerve sparing. Limitations included retrospective nature and limited follow up.ConclusionPC-RAPLND is safe and technically reproducible. It provides improved morbidity and less convalescence.

PurposeTo evaluate the outcome of robot-assisted residual mass resection (RA-RMR) in nonseminomatous germ cell tumor (NSGCT) patients with residual tumor following chemotherapy.Patients and methodsRetrospective medical chart analysis of all patients with NSGCT undergoing RA-RMR at two tertiary referral centers between January 2007 and April 2019. Patients were considered for RA-RMR in case of a residual tumor between 10 and 50 mm at cross-sectional computed tomography (CT) imaging located ventrally or laterally from the aorta or vena cava, with normalized tumor markers following completion of chemotherapy, and no history of retroperitoneal surgery.ResultsA total of 45 patients were included in the analysis. The Royal Marsden stage before chemotherapy was IIA in 13 (28.9%), IIB in 16 (35.6%), IIC in 3 (6.7%) and IV in 13 patients (28.9%). The median residual tumor size was 1.9 cm (interquartile range [IQR] 1.4–2.8; range 1.0–5.0). Five procedures (11.1%) were converted to an open procedure due to a vascular injury (n = 2), technical difficulty (n = 2) or tumor debris leakage (n = 1). A postoperative adverse event occurred in two patients (4.4%). Histopathology showed teratoma, necrosis and viable cancer in 29 (64.4%), 14 (31.1%), and two patients (4.4%), respectively. After a median follow-up of 41 months (IQR 22–70), one patient (2.2%) relapsed in the retroperitoneum. The one- and 2-year recurrence-free survival rate was 98%.ConclusionRA-RMR is an appropriate treatment option in selected patients, potentially providing excellent cure rates with minimal morbidity. Long-term outcome data are needed to further support this strategy and determine inclusion and exclusion criteria.

We aimed to report sexual and reproductive outcomes following post-chemotherapy robot-assisted retroperitoneal unilateral lymph node dissection (PC-rRPLND) for non-seminomatous germ cell tumors (NSGCTs) at a high-volume cancer center. We collected records regarding sexual and reproductive outcomes of patients undergoing unilateral PC-rRPLND for stage II NSGCTs from January 2018 to November 2021. Preoperative and postoperative (at 12 months) ejaculatory function as well as erectile function, based on the International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS), were assessed. Only patients with a pre-operative IIEF-5 of ≥22 and EHS of ≥3 were included in this analysis. Overall, 22 patients undergoing unilateral PC-rRPLND met the inclusion criteria. Of these, seven (31.8%) patients presented an andrological disorder of any type after PC-rRPLND. Specifically, retrograde ejaculation was present in three (13.6%) patients and hypospermia was present in one (4.5%) patient. Moreover, three (13.6%) patients yielded erectile dysfunction (IIEF-5 < 22 and/or EHS < 3). Lastly, two (9.1%) succeeded in naturally conceiving a child after PC-rRPLND. Retrograde ejaculation is confirmed to be one of the most common complications of PC-rRPLND. Moreover, a non-negligible number of patients experience erectile dysfunction.

Objectives We aim to determine if robot‐assisted retroperitoneal lymph node dissection (R‐RPLND) can be performed as a safe option to open RPLND in selected patients with metastatic germ cell cancer. Patients and methods This population‐based prospective study was performed at a one of two national referral centres for RPLND in Sweden. All patients referred during January 2017–March 2021 were screened for possible inclusion. R‐RPLND was performed using the Da Vinci Xi surgical system. Perioperative parameters, postoperative complications (Clavien–Dindo), final pathology, preservation of antegrade ejaculation and relapse rates were evaluated. Classifiers for selecting patients to open versus robotic RPLND were analysed by logistic regression modelling. The median follow‐up was 23 months. Results Of 87 patients referred, 29 were selected for R‐RPLND, 19 in a post‐chemotherapy setting. In median, retroperitoneal tumour diameter was 18 mm, BMI 24 kg/m2, operative time 433 min, estimated blood loss 50 ml and length of stay 3 days. One patient underwent open conversion due to failure to progress. Four patients had Clavien–Dindo grade 3 complications, of which three were chylous‐related. No in‐field recurrences occurred during follow‐up. Conclusion This population‐based study suggests that R‐RPLND can be safely performed in at least one third of patients referred for an RPLND. A relatively high rate of lymph‐leakage may represent a potential drawback. Tumour size may be the most important discriminator when deciding on robotic versus open RPLND. Further studies with longer follow‐up are needed to validate the results.

Testicular cancer (TC) is the most common solid cancer in men between the third and fourth decade of life. Due to successful treatment approaches, TC survivors (TCSs) have long life expectancy, but with numerous potential long-term sequelae, including sexual dysfunction. We investigated predictors of long-term normal sexual function (SF) recovery in TCSs. Sociodemographic, medical, and psychometric data were analyzed in 143 Caucasian-European TCSs, who underwent orchiectomy at a single institution. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients completed the International Index of Erectile Function (IIEF). Statistical models tested the association between predictors (including age at surgery, body mass index, CCI, and adjuvant therapy: radiotherapy [RT], chemotherapy [CT], CT followed by retroperitoneal lymph node dissection [RPLND] and RPLND alone) and the long-term recovery of normal SF (defined as IIEF-erectile function [EF] ≥26, and sexual desire [SD], intercourse satisfaction [IS] orgasmic function [OF], and overall satisfaction [OS] domain scores in the upper tertiles). At a mean follow-up of 86 months, 35 (25.5%) TCSs had erectile dysfunction (ED), with 16 (11.2%) experiencing severe ED. Median time of EF recovery was 60, 60, and 70 months after CT, RT, and RPLND, respectively. Only adjuvant RT emerged as an independent predictor of nonrecovery of normal EF (HR: 0.55, P= 0.01). Neither adjuvant CT nor CT plus RPLND or RPLND alone significantly impaired the recovery of normal erections. Adjuvant therapy was not associated with impaired recovery of normal sexuality as a whole, considering the IIEF-SD, -OF, -IS, and OS domains.

Abstract Objective: To report our initial experience and short-term results in post-chemotherapy robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for advanced testicular cancer. Material and methods: We analyzed prospectively collected data of 5 patients who underwent post-chemotherapy RA-RPLND between August 2017 and May 2018. All patients had a diagnosis of non-seminomatous germ cell tumor (NSGCT) of testis and received three or four cycles of BEP chemotherapy for their clinical stage IIC disease before the surgery. Perioperative parameters (operation time, estimated blood loss and intraoperative complications) and postoperative findings (change in hematocrit, duration of hospitalization and postoperative complications) were noted. Pathological outcomes and postoperative radiological imaging in the 3rd month were investigated. Results: RA-RPLND was completed successfully in all patients, and none of them required conversion to open surgery or early intervention. The median operation time was 309 minutes (range, 275-360), and median estimated blood loss was 180 mL (range, 150-210). One patient required postoperative transfusion of 1U red blood cells. The histologic examination of the specimens revealed necrosis in 3, and mature teratoma in 2 patients. The median hospitalization time after surgery was 2 days. During a median follow-up of 10 months (range 7-12), there were no retroperitoneal recurrences or distant metastasis in radiological imaging. No major complication (Clavien ≥3) or death occurred. The only minor complication was transfusion of red blood cells in one patient (Clavien 2) and the overall complication rate was 20 percent. Conclusion: Post-chemotherapy RA-RPLND appears to be a feasible and oncologically safe procedure with acceptable operative morbidity. However, this technique should be applied in centers highly experienced in robotic surgery, considering that RPLND is a surgery with fatal complications. Cite this article as: İslamoğlu E, Özsoy Ç, Anıl H, Aktaş Y, Ateş M, Savaş M. Post-chemotherapy robot-assisted retroperitoneal lymph node dissection in non-seminomatous germ cell tumor of testis: Feasibility and outcomes of initial cases. Turk J Urol 2019; 45(2): 113-7.

Purpose To evaluate the role of two different approaches to perform laparoscopic RPLND: transperitoneal laparoscopic retroperitoneal lymph node dissection (TL-RPLND) and extraperitoneal laparoscopic retroperitoneal lymph node dissection (EL-RPLND). Materials and methods Between February 2003 and April 2013, 39 patients with nonseminomatous germ cell testicular tumors were treated by RPLND in our center. Twenty-one patients had TL-RPLND, and 18 patients had EL-RPLND. We performed a comprehensive retrospective study comparing TL-RPLND and EL-RPLND. Certain parameters, including operative time, estimated blood loss, perioperative complications, resected lymph nodes, postoperative intestinal function recovery time, ejaculation, and postoperative tumor markers, were abstracted and compared. Results In the EL-RPLND and TL-RPLND groups, the operation times were 178 ± 31 and 207 ± 25 min; the amounts of estimated blood loss were 87 ± 26 and 111 ± 21 ml; the postoperative intestinal function recovery times were 1.2 ± 0.7 and 2.4 ± 0.6 days; the postoperative hospital stays were 5.8 ± 1.1 and 5.5 ± 1.4 days; and the numbers of resected lymph nodes were 16.2 ± 1.5 and 15.8 ± 1.6, respectively. No conversion from laparoscopic to open surgery occurred. No patient in either group received an intraoperative blood transfusion. Overall, two patients developed postoperative fever, and one developed abdominal distension. After a median follow-up of 45 months, no regional relapse or metastases occurred, but 4 patients at clinical stage II were treated successfully by three cycles of platinum-based postoperative chemotherapy. Currently, all patients show no evidence of disease. Conclusion Our results demonstrate that EL-RPLND was superior to the transperitoneal approach in terms of the operation time, estimated blood loss, and postoperative intestinal function recovery time, whereas no differences were observed in the number of lymph nodes resected. EL-RPLND was demonstrated to be safe and feasible, with satisfactory clinical outcomes when performed by experienced laparoscopic surgeons. Larger cohorts of patients with longer term follow-up are needed for further studies to determine the role of different approaches to L-RPLND.

Purpose of ReviewThis narrative review provides a comprehensive overview of the evolving role of retroperitoneal lymph node dissection (RPLND) in the management of testicular cancer (TC). It explores the significance of RPLND as both a diagnostic and therapeutic tool, highlighting its contribution to accurate staging, its impact on oncological outcomes, and its influence on subsequent treatment decisions.Recent FindingsRPLND serves as an essential diagnostic procedure, aiding in the precise assessment of lymph node involvement and guiding personalized treatment strategies. It has demonstrated therapeutic value, particularly in patients with specific risk factors and disease stages, contributing to improved oncological outcomes and survival rates. Recent studies have emphasized the importance of meticulous patient selection and nerve-sparing techniques to mitigate complications while optimizing outcomes. Additionally, modern imaging and surgical approaches have expanded the potential applications of RPLND.SummaryIn the context of TC management, RPLND remains a valuable and evolving tool. Its dual role in staging and therapy underscores its relevance in contemporary urological practice. This review highlights the critical role of RPLND in enhancing patient care and shaping treatment strategies, emphasizing the need for further research to refine patient selection and surgical techniques.