The evolution, controversies, and potential pitfalls of modified retroperitoneal lymph node dissection templates

Over the past century, retroperitoneal lymph node dissection (RPLND) for patients with non-seminomatous germ cell tumors has evolved to become an indispensable diagnostic and therapeutic procedure. Bilateral RPLND with inclusion of the suprahilar regions initially established therapeutic efficacy but was associated with significant ejaculatory morbidity. Decades later, multiple anatomic mapping studies demonstrated a predilection for low-volume retroperitoneal metastases to be ipsilateral and infrahilar, leading to the introduction and popularity of several modified templates. By minimizing contralateral dissection and avoiding essential neural pathways, coordinated antegrade ejaculation rates improved considerably. Simultaneously, prospective nerve-sparing techniques were developed to preserve sympathetic nerve function, allowed for modified or bilateral templates, and resulted in minimal ejaculatory morbidity. The primary oncologic concern with modified templates remains the potential for unresected 'extra-template' disease leading to retroperitoneal or systemic recurrences requiring additional therapy. While modified templates continue to be widely used, larger scale and longer-term studies are essential to fully elucidate their appropriate application and therapeutic efficacy.