Andrological complications following retroperitoneal lymph node dissection for testicular cancer

Retroperitoneal lymph node dissection (RPLND) is a fundamental surgical step in the treatment of testicular cancer. Nowadays, primary RPLND has partially lost its role in favour of active surveillance (for low risk stage I disease) and short cycle chemotherapy in non-seminomatous germ cell tumor (NSGCT). Conversely, post-chemotherapy RPLND (PC-RPLND) remains the standard treatment for residual masses after chemotherapy. In consideration of curability rate of testicular cancer and the life expectancy of testicular cancer survivors the identification and the prevention of andrological complications became fundamental. Erectile dysfunction (ED) is generally transitory and interests about 25% of patients, conversely retrograde ejaculation (RE) is definitive. Antegrade ejaculation is guaranteed by the sparing of at least one paravertebral sympathetic trunks and the postganglionic sympathetic fibers, which travel dorsal to the inferior vena cava and cross ventrally to the aorta. The maintenance of antegrade ejaculation can be obtained by a bilateral sparing of these fibers or by the modification of templates. In primary RPLND setting RE ranged between 2-6.7% and 1.2-61% in the major open and laparoscopic series respectively. In PC-RPLND series it ranged between 21-36% and 4-7.1% for open and laparoscopic approach respectively with the limitation of the restrictive indications of laparoscopic approach. The setting of this surgery and the importance of the oncological and functional outcomes that are pursued reinforced following the evidence that RPLND is a highly technical demanding procedure, whose best performances are achieved only when delivered in referral, high-volume centers.