AUTHOR=Hiester Andreas , Nini Alessandro , Fingerhut Anna , große Siemer Robert , Winter Christian , Albers Peter , Lusch Achim 

TITLE=Preservation of Ejaculatory Function After Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND) in Patients With Testicular Cancer: Template vs. Bilateral Resection

JOURNAL=Frontiers in Surgery

VOLUME=5

YEAR=2019

URL=https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2018.00080

DOI=10.3389/fsurg.2018.00080

ISSN=2296-875X

ABSTRACT=<p><bold>Background:</bold> Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays a crucial role in treatment of metastatic non-seminomatous germ cell cancer.</p><p><bold>Objective:</bold> To evaluate the functional outcome regarding the preservation of ejaculatory function comparing a bilateral vs. unilateral template resection in PC-RPLND patients. In addition, oncological safety and perioperative complications of the unilateral template resection was compared to the full bilateral one.</p><p><bold>Design/Setting/Participants:</bold> Between 2003 and 2018, 504 RPLNDs have been performed in 434 patients. The database of consecutive patients was queried to identify 171 patients with PC-RPLND after 1st line chemotherapy for a non-seminoma with or without bilateral template resection. Re-Do's, late relapse, salvage patients, and thoraco-abdominal approaches were excluded. Indication for a template resection was a unilateral residual mass mainly &lt;5 cm as published (<xref ref-type="bibr" rid="B1">1</xref>).</p><p><bold>Outcome, Measurement, and Statistical Analysis:</bold> Descriptive statistics were used to report preoperative features, postoperative outcomes and patterns of recurrence, on the overall population and after stratification for the type of resection (bilateral vs. unilateral). Kaplan-Meier analyses were used to describe recurrence- and cancer-specific mortality-free survival rates at different time points.</p><p><bold>Results and Limitations:</bold> Overall, 90 and 81 patients underwent unilateral and bilateral radical resection, respectively. Median size of residual mass was 7 cm for bilateral and 4 cm for unilateral template resection. Clinical stage II and III were present in 31 and 69% of patients, respectively. Median follow-up was 14.5 months (IQR 3.3–37.6). The 1- and 2-year recurrence-free survival rates were 91 and 91%, and 77 and 72% for patients treated with unilateral template and bilateral resection, respectively (<italic>p</italic> = 0.0078). Median time to recurrence was 9.5 and 9 months in template and bilateral resection group, respectively.</p><p>Adjunctive procedures were performed in 56 patients (33%) and were significantly more frequent in the bilateral resection group (43 vs. 23%, <italic>p</italic> = 0.006). The overall high-grade complication rate (Clavien-Dindo ≥ III) was 6, 3, and 9% in unilateral template and bilateral resection group, respectively (<italic>p</italic> = 0.6). The rate of preservation of antegrade ejaculation was significantly higher in the unilateral group.</p><p><bold>Conclusions:</bold> Antegrade ejaculation in patients undergoing unilateral template resection with a residual mass &lt;5 cm can be preserved at a much higher rate. Moreover, this surgical procedure is oncologically safe in terms of mid-term recurrence and CSM-free survival rates. This data undermines the growing evidence of limited PC-RPLND being justifiable in strictly unilateral residual mass &lt;5 cm. This data has to be confirmed with a longer follow-up regarding in-field and retroperitoneal recurrences.</p>