Retroperitoneal lymph node dissection: reassessment of modified templates

The retroperitoneum is the initial metastatic site in 90% of patients with nonseminomatous germ cell tumours (NSGCTs) of the testis. A retroperitoneal lymph node dissection (RPLND) provides accurate staging and effective therapy, minimizes the need for adjuvant chemotherapy in patients with low-volume metastases, and optimizes durable cure rates. We review the rationale for and development of RPLND, focusing specifically on the advantages and limitations of the variable surgical templates. Bilateral RPLND has a long-standing record of maximizing cancer control and minimizing secondary therapy. Both modified templates and prospective nerve-sparing techniques were introduced to optimize rates of antegrade ejaculation. Limited resections as advocated by modified templates are appealing in the setting of primary RPLND but can be associated with a 3-23% risk of residual disease. Modified templates have also been advocated for highly selected patients after chemotherapy but, if applied to all patients undergoing surgery after chemotherapy, will lead to an unacceptably high rate of residual disease, even in patients with small masses after chemotherapy. For patients undergoing primary or post-chemotherapy RPLND, a full bilateral template (with nerve-sparing when appropriate) maximizes cure rates while minimizing ejaculatory morbidity and the subsequent need for chemotherapy.