Is Routine Primary Retroperitoneal Lymph Node Dissection Still Justified in Patients with Low Stage Non‐seminomatous Testicular Cancer?

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Abstract
Summary— We present 8 years' experience of primary retroperitoneal lymph node dissection (RLND) in 190 patients with low stage non‐seminoma; 154 patients had clinical stage I (CSI) and 36 had clinical stage lla (CSIIa) disease. Of the 154 patients with CSI tumours, 33 had increased serum AFP and/or HCG before RLND (CSIM +)and 121 had normal tumour markers (CSIM‐).Retroperitoneal lymph node metastases (pathological stage II) (PSII) were found in 38 of 121 patients with CSIM ‐, in 19 of 33 patients with CSIIM + and in 26 of 36 patients with CSIIa. In a multivariate analysis, the presence of small vessel infiltration (demonstrated in histological sections of the primary tumour) and a prolonged tumour marker half‐life were predictive factors for PSII. These 2 factors enabled a group of non‐seminoma patients with CSI disease to be identified who had a 15% risk of retroperitoneal tumour growth (low risk group) as compared with a high risk group where 60 to 70% of patients had retroperitoneal lymph node metastases.Relapses occurred in 7 of 107 patients with PSI and in 6 of 83 patients with PSII disease; in the latter group, 5 relapses developed before the start of routine adjuvant chemotherapy; 6% of patients developed major post‐operative complications. In addition, “dry ejaculation” was the principal side effect following RLND (unilateral RLND: 20/132 patients; bilateral RLND: 50/54 patients).The comparative cost to the health service during the first year of follow‐up was estimated for low risk non‐seminoma patients with CSI subjected to RLND and for those in whom a surveillance policy was adopted. The latter approach was preferable.It was concluded that a surveillance policy should be followed in low risk non‐seminoma CSI patients provided that frequent follow‐up is possible. A more active policy is recommended in high risk patients (e.g. adjuvant chemotherapy without RLND). Nerve‐sparing RLND may be considered in patients with CSIIa disease and negative tumour markers.