Retroperitoneal Lymph Node Dissection for the Primary Treatment Recommendation in Clinical Stage I Nonseminomatous Germ Cell Tumors of the Testis: Contrary to European Guidelines

Context: The optimal management strategy for clinical stage I (CS1) non-seminomatous germ cell tumors (NSGCTs) of the testis is controversial. Objective: Evidence is presented to suggest that retroperitoneal lymph node dissection (RPLND) is among the primary treatment options in the management of CS1 NSGCTs. Evidence acquisition: A nonsystematic search performed in January 2011 was used to identify relevant literature regarding advantages of RPLND as the primary adjuvant therapy for CS1 NSGCT after orchiectomy. Evidence synthesis: European guidelines follow a risk-adapted strategy for the primary management of CS1 NSGCTs based on the presence of vascular invasion. Surveillance is recommended as the primary treatment option for the low-risk group, whereas two cycles of platin-based chemotherapy is suggested for high-risk patients. Aside from the benefits of this strategy, there are some drawbacks that surgery may ameliorate. The absence of accurate prognostic markers compels risk adaptation. The difficulties in radiologic staging of retroperitoneum, the high relapse rates in surveillance, the long-term toxicity of chemotherapy, and a teratoma component in retroperitoneal relapses are the main problems that nerve-sparing RPLND (ns-RPLND) can resolve with minimal morbidity. The ns-RPLND provides similar oncologic outcomes with better retroperitoneal staging and facilitation of follow-up for abdominal recurrences. Conclusions: Surveillance, adjuvant chemotherapy, and ns-RPLND are all accepted treatments for long-term survival. The ns-RPLND has similar merits to surveillance and adjuvant chemotherapy and should be presented to patients as an equal option. (C) 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.