Minimally invasive retroperitoneal lymph node dissection for stage IIA/B testicular seminomatous germ cell tumors

Cover Page

Cite item

Full Text

Abstract

Background. According to primary orchiectomy data, up to 50–60 % of testicular germ tumors are seminomas. For stage IIA and IIB seminomas, radiotherapy (RT) and polychemotherapy (PCT) are generally accepted treatment standards with excellent 5-year survival up to 99 %. Despite high treatment efficacy, PCT and RT are accompanied by significant toxic effects which can severely decrease patients’ quality of life.

Aim. To evaluate efficacy and safety of retroperitoneal lymph node dissection (RPLND) as a first stage of treatment after orchiectomy as an alternative to PCT and RT.

Materials and methods. In total, 24 patients with stage IIA/B testicular seminomatous germ cell tumors without RT were selected. The patients were divided into groups: in the 1st group, robot-assisted RPLND without PCT after orchiectomy was performed (n = 14); in the 2nd group, PCT per the BEP scheme (bleomycin + etoposide + cisplatin) with subsequent laparoscopic RPLND after orchiectomy was performed (n = 10). In both groups, complications per the Clavien–Dindo classification, operative time, blood loss volume, hospital days, recurrence-free survival, presence of ejaculation after RPLND, histological conclusion, PCT toxicity were assessed.

Results. Mean patient age was 38 years. Patient distribution per disease stage: 18 (75.0 %) patients with stage IIA, 6 (25.0 %) patients with stage IIB. There were no intraoperative vascular complications, no transition to laparotomy. Mean operative time was 267 ± 19.4 min. Mean blood loss volume was 174 ± 25 mL. Mean hospital days were 8 days. No significant postoperative complications (severity grade ≥IV per the Clavien–Dindo classification) were reported. In the late postoperative period, 2 patients required surgical treatment for lymphorrhea in the form of transcutaneous translumbar puncture with embolization of the lymph ducts under the control of flat detector computed tomography. Mean number of resected lymph nodes was 27.1. Viable tumor was verified in 2 (8.3 %) patients of the 1st group. Functional results: retrograde ejaculation in 11 (45.8 %) cases (in group 1: 3 (21.4), in group 2: 8 (80.0); p = 0.01). Recurrence-free survival in the 1st group (2-year observation) was 13.1 ± 1.9 (9.3–16.9) months, in the 2nd group (observation from 2013 to 2025), 57 ± 5.7 (11.0–116.8) months. None of the patients had signs of recurrence per clinical, instrumental or laboratory data.

Conclusion. Prophylactic RPLND decreases the risk of recurrence and progression of germ line testicular tumors and allows to avoid risks of delayed toxicity associated with PCT and RT. In patients with stage IIA/B seminomas and low volume of residual retroperitoneal masses, RPLND provides good prognosis with minimal risks of treatment continuation in the future.

About the authors

Eldar M. Mamizhev

Saint Petersburg City Clinical Oncology Dispensary

Author for correspondence.
Email: mamijev@mail.ru
ORCID iD: 0000-0001-6883-777X
Russian Federation, 56 Prospekt Veteranov, Saint Petersburg 198255

R. V. Orlova

Saint Petersburg City Clinical Oncology Dispensary

Email: mamijev@mail.ru
ORCID iD: 0000-0003-4447-9458
Russian Federation, 56 Prospekt Veteranov, Saint Petersburg 198255

D. I. Rumyantseva

Clinic of High Medical Technologies named after N. I. Pirogov, Saint Petersburg State University

Email: mamijev@mail.ru
ORCID iD: 0000-0002-8067-9150
Russian Federation, 154 Naberezhnaya reki Fontanki, Saint Petersburg 191038

S. A. Antonova

N.N. Petrov National Medical Research Center of Oncology, Ministry of Health of Russia

Email: mamijev@mail.ru
Russian Federation, 68 Leningradskaya St., Pesochnyy, Saint Petersburg 197758

P. M. Gorlin

N.N. Petrov National Medical Research Center of Oncology, Ministry of Health of Russia

Email: mamijev@mail.ru
Russian Federation, 68 Leningradskaya St., Pesochnyy, Saint Petersburg 197758

N. F. Krotov

N.N. Petrov National Medical Research Center of Oncology, Ministry of Health of Russia

Email: mamijev@mail.ru
ORCID iD: 0000-0002-5590-8804
Russian Federation, 68 Leningradskaya St., Pesochnyy, Saint Petersburg 197758

A. K. Nosov

N.N. Petrov National Medical Research Center of Oncology, Ministry of Health of Russia

Email: mamijev@mail.ru
ORCID iD: 0000-0003-3850-7109
Russian Federation, 68 Leningradskaya St., Pesochnyy, Saint Petersburg 197758

References

  1. Costelloe S.J., Spencer J.D., Humphries K. et al. Elevations of α-fetoprotein in patients undergoing chemotherapy for pure testicular seminoma: a retrospective cohort study. BMC Cancer 2025;25(1):241. doi: 10.1186/s12885-025-13559-5
  2. Rajpert-De Meyts E., McGlynn K.A., Okamoto K. et al. Testicular germ cell tumours. Lancet 2016;387(10029):1762–74. doi: 10.1016/S0140-6736(15)00991-5
  3. Passarelli R., Pfail J.L., Jang T.L. Contemporary surgical management of testicular seminoma. Transl Cancer Res 2024;13(11):6463–72. doi: 10.21037/tcr-24-241
  4. Patrikidou A., Cazzaniga W., Berney D. et al. European Association of Urology Guidelines on Testicular Cancer: 2023 Update. Eur Urol 2023;84(3):289–301. doi: 10.1016/j.eururo.2023.04.010
  5. Giannatempo P., Greco T., Mariani L. et al. Radiotherapy or chemotherapy for clinical stage IIA and IIB seminoma: a systematic review and meta-analysis of patient outcomes. Ann Oncol 2015;26(4):657–68. doi: 10.1093/annonc/mdu447
  6. Lubberts S., Groot H.J., de Wit R. et al. Cardiovascular disease in testicular cancer survivors: identification of risk factors and impact on quality of life. J Clin Oncol 2023;41(19):3512–22. doi: 10.1200/JCO.22.01016
  7. Kier M.G., Hansen M.K., Lauritsen J. et al. Second malignant neoplasms and cause of death in patients with germ cell cancer: a Danish Nationwide Cohort Study. JAMA Oncol 2016;2(12):1624–7. doi: 10.1001/jamaoncol.2016.3651
  8. Kailavasan M., Power N., Beech B.B. Is primary retroperitoneal lymph node dissection the way forward for patients with testicular seminoma and limited retroperitoneal metastases? Urol Oncol 2025;43(5):318–23. doi: 10.1016/j.urolonc.2025.01.016
  9. Hellesnes R., Myklebust T.Å., Fosså S.D. et al. Testicular cancer in the cisplatin era: causes of death and mortality rates in a population-based cohort. J Clin Oncol 2021;39(32):3561–73. doi: 10.1200/JCO.21.00637
  10. Heidenreich A., Paffenholz P., Hartmann F. et al. Retroperitoneal lymph node dissection in clinical stage IIA/B metastatic seminoma: results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS). Eur Urol Oncol 2024;7(1):122–7. doi: 10.1016/j.euo.2023.06.004
  11. Hiester A., Che Y., Lusch A. et al. Phase 2 single-arm trial of primary retroperitoneal lymph node dissection in patients with seminomatous testicular germ cell tumors with clinical stage IIA/B (PRIMETEST). Eur Urol 2023;84(1):25–31. doi: 10.1016/j.eururo.2022.10.021
  12. Daneshmand S., Cary C., Masterson T. et al. Surgery in early metastatic seminoma: a phase II trial of retroperitoneal lymph node dissection for testicular seminoma with limited retroperitoneal lymphadenopathy. J Clin Oncol 2023;41(16):3009–18. doi: 10.1200/JCO.22.00624
  13. Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.
  14. Mamizhev E.M., Berkut M.V., Rumyantseva D.I. et al. Enhanced recovery program in surgical treatment of patients with germ cell tumors of the testicle: experience of a specialized hospital. Onkourologiya = Cancer Urology 2022;18(4):81–92. (In Russ.). doi: 10.17650/1726-9776-2022-18-4-81-92
  15. Mamizhev E.M., Balakhnin P.V., Rumiantseva D.I. et al. Clinical case: percutaneous translumbar puncture and embolization of lymphatic ducts under the control of flat-detector computed tomography (FDCT) – an effective method for the treatment of lymphorrhea after retroperitoneal lymphadenectomy. Voprosy onkologii = Problems in Oncology 2024;70(6):1215–22. (In Russ.). doi: 10.37469/0507-3758-2024-70-6-1215-1222
  16. NCCN. Testicular Cancer (Version 1.2025). 2025. Available at: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1468
  17. Paly J.J., Lin C.C., Gray P.J. et al. Management and outcomes of clinical stage IIA/B seminoma: results from the National Cancer Data Base 1998–2012. Pract Radiat Oncol 2016;6(6):e249–58. doi: 10.1016/j.prro.2016.05.002
  18. Ahmed K.A., Wilder R.B. Stage IIA and IIB testicular seminoma treated postorchiectomy with radiation therapy versus other approaches: a population-based analysis of 241 patients. Int Braz J Urol 2015;41(1):78–85. doi: 10.1590/S1677-5538.IBJU.2015.01.11
  19. Garcia-del-Muro X., Maroto P., Gumà J. et al. Chemotherapy as an alternative to radiotherapy in the treatment of stage IIA and IIB testicular seminoma: a Spanish Germ Cell Cancer Group Study. J Clin Oncol 2008;26(33):5416–21. doi: 10.1200/JCO.2007.15.9103
  20. Haugnes H.S., Wethal T., Aass N. et al. Cardiovascular risk factors and morbidity in long-term survivors of testicular cancer: a 20-year follow-up study. J Clin Oncol 2010;28(30):4649–57. doi: 10.1200/JCO.2010.29.9362
  21. Hellesnes R., Kvammen Ø., Myklebust T.Å. et al. Continuing increased risk of second cancer in long-term testicular cancer survivors after treatment in the cisplatin era. Int J Cancer 2020;147(1):21–32. doi: 10.1002/ijc.32704
  22. Leitner S.P., Bosl G.J., Bajorunas D. Gonadal dysfunction in patients treated for metastatic germ-cell tumors. J Clin Oncol 1986;4(10):1500–5. doi: 10.1200/JCO.1986.4.10.1500
  23. Bokemeyer C., Berger C.C., Kuczyk M.A., Schmoll H.J. Evaluation of long-term toxicity after chemotherapy for testicular cancer. J Clin Oncol 1996;14(11):2923–32. doi: 10.1200/JCO.1996.14.11.2923
  24. Lavrinovich O.E., Nosov A.K., Mamizhev E.M. et al. Preservation of fertility in cancer patients. Saint Petersburg: NMITs onkologii im. N.N. Petrova, 2022. 78 p. (In Russ.).
  25. Rumyantsev A.A., Volkova M.I., Gladkov O.A. et al. Practical recommendations for the treatment of germ cell tumors in men. RUSSCO Practical Guidelines, Part 1. Zlokachestvennyye opukholi = Malignant Tumors 2023;13(3s2):661–94. (In Russ.).
  26. Kollmannsberger C., Beyer J., Droz J.P. et al. Secondary leukemia following high cumulative doses of etoposide in patients treated for advanced germ cell tumors. J Clin Oncol 1998;16(10):3386–91. doi: 10.1200/JCO.1998.16.10.3386
  27. Subramanian V.S., Nguyen C.T., Stephenson A.J. et al. Complications of open primary and post-chemotherapy retroperitoneal lymph node dissection for testicular cancer. Urol Oncol 2010;28(5):504–9. doi: 10.1016/j.urolonc.2008.10.026
  28. Beck S.D., Bey A.L., Bihrle R. et al. Ejaculatory status and fertility rates after primary retroperitoneal lymph node dissection. J Urol 2010;184(5):2078–80. doi: 10.1016/j.juro.2010.06.146
  29. Donohue J.P., Thornhill J.A., Foster R.S. et al. Clinical stage B non-seminomatous germ cell testis cancer: the Indiana University experience (1965–1989) using routine primary retroperitoneal lymph node dissection. Eur J Cancer 1995;31A(10):1599–604. doi: 10.1016/0959-8049(95)00330-l
  30. Nonomura N., Nishimura K., Takaha N. et al. Nerve-sparing retroperitoneal lymph node dissection for advanced testicular cancer after chemotherapy. Int J Urol 2002;9(10):539–44. doi: 10.1046/j.1442-2042.2002.00520.x
  31. Tabakin A.L., Shinder B.M., Kim S. et al. Retroperitoneal lymph node dissection as primary treatment for men with testicular seminoma: utilization and survival analysis using the national cancer data base, 2004–2014. Clin Genitourin Cancer 2020;18(2):e194–201. doi: 10.1016/j.clgc.2019.10.018
  32. Nicolai N., Nazzani S., Tesone A. et al. Retroperitoneal lymph-node dissection (RPLND) as upfront management in stage II germ-cell tumours: evaluation of safety and efficacy. Tumori 2023;109(4):379–86. doi: 10.1177/03008916221112697
  33. Tachibana I., Alabd A., Tong Y. et al. Primary retroperitoneal lymph node dissection for stage II seminoma: is surgery the new path forward? J Clin Oncol 2023;41(23):3930–8. doi: 10.1200/JCO.22.01822

Supplementary files

Supplementary Files
Action
1. JATS XML
Download

Copyright (c) 2026 Mamizhev E.M., Orlova R.V., Rumyantseva D.I., Antonova S.A., Gorlin P.M., Krotov N.F., Nosov A.K.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.
СМИ зарегистрировано Федеральной службой по надзору в сфере связи, информационных технологий и массовых коммуникаций (Роскомнадзор).
Регистрационный номер и дата принятия решения о регистрации СМИ: серия ПИ № ФС 77-36986 от  21.07.2009.