Laparoscopic Bilateral Nerve-Sparing Retroperitoneal Lymph Node Dissection for Testicular Cancer After Chemotherapy

Nerve-sparing techniques are commonly used in retroperitoneal lymph node dissection (RPLND) for patients with testicular cancer to preserve postoperative ejaculation. Laparoscopic RPLND is applicable to small residual masses; however, nerve-sparing techniques remain challenging. This study aimed to establish a safe, bilateral nerve-sparing laparoscopic RPLND via the transperitoneal approach. The technique was developed through cadaveric surgical training (CST) and applied clinically.

Thiel-fixed human cadavers were used for CST. In patients with testicular cancer after chemotherapy, laparoscopic RPLND was performed based on normalized tumor markers, typically with a residual mass of 5 cm or less. Patients were placed in the lateral position, and four to six ports were used, including the umbilical port; central ports were shared bilaterally. The dissection extent followed a bilateral full-template approach.

In CST, lumbar splanchnic nerves were identified and preserved, supporting the clinical feasibility of laparoscopic RPLND. The bilateral nerve-sparing laparoscopic RPLND was performed in 10 patients: 6 with non-seminoma and 4 with seminoma. The mean pre-chemotherapy tumor diameter was 2.7 cm (range, 1.2-5.6 cm). The mean blood loss was 165 mL (range, 0-540 mL). The bilateral lumbar splanchnic nerves were preserved in all cases, and postoperative ejaculatory function was confirmed to be preserved in 9 cases. Surgical complications included Grade 1 chyle leakage in 5 patients, all of whom improved with conservative management.

A laparoscopic bilateral nerve-sparing RPLND technique was developed to achieve both minimal invasiveness and preservation of ejaculatory function. Long-term follow-up is necessary to confirm oncological outcomes.