Surgery plays an important role in staging and treatment of non-seminomatous germ cell tumours. Operations include orchidectomy (in nearly all patients), retroperitoneal lymph node dissection (in selected patients) and excision of tumours in other sites for patients with residual disease after chemotherapy.
This is both curative in a number of cases as well as providing important staging information.
- An incision is made above the inguinal ligament and the external inguinal ring identified
- The inguinal canal is opened to expose the structures traversing it
- The spermatic cord is identified, the ilioinguinal nerve identified and spared, before being clamped 1 - 2 cm from the internal inguinal ring
- The testis is removed from the scrotum with care not to contaminate the field
- The spermatic cord structures are divided individually
- The muscle and skin layers are closed
Issues with Orchidectomy
Performing an incision through the scrotum itself can alter the lymphatic spread of disease, with an increased risk of inguinal and external iliac nodal involvement. This can cause unexpected spread of malignancy to those nodal groups.
Retroperitoneal Lymph Node Dissection
CONTROVERSY - In the USA retroperitoneal lymph node dissection is performed for all stage I and a number of stage II patients. In Europe, it is only indicated in stage IIA disease with no elevation of markers; or as an option for patients who refuse chemotherapy or surveillance
Australia follows the European approach to the management of stage I and II disease
Retroperitoneal lymph node dissection can be performed for Stage I and IIA/B disease. In stage I disease, chemotherapy is usually preferable as the surgery has significant morbidity. It may be selected due to patient wishes or unavailability/unsuitability of chemotherapy or surveillance. For stage IIA disease with no elevation of tumour markers, retroperitoneal lymph node dissection provides a high cure rate (98%), comparable with chemotherapy. It is also used when residual disease remains after chemotherapy for stage IIA/B disease.
Aside from usual surgical risks, the primary complication of retroperitoneal lymph node dissection is infertility due to loss of antegrade ejaculation. This is caused by damage to the autonomic nerve plexuses of the retroperitoneum, which carry sympathetic nerve fibres from T10 - L1 to the bladder. Nerve sparing surgery is a possibility, but requires experienced surgical skills. Laparoscopic retroperitoneal lymph node dissection is also a possibility.
Retroperitoneal lymph node dissection can be accomplished in three ways:
- Anterior approach
- Thoracoabdominal approach
- Laparoscopic approach
Regardless of technique, the retroperitoneum is exposed followed by ligation of the testicular veins. The lymphatic tissue is identified and removed from the renal arteries superiorly to the crossing of the ureter over the bifurcation of the iliac arteries inferiorly. Posteriorly, excision continues to the vertebral bodies. The aorta and inferior vena cava are 'skeletonised', the only exception being the inferior mesenteric artery which can occasionally be preserved. If nerve preserving surgery is undertaken, the sympathetic nerves are identified and (as much as possible) not divided.
Resection of Residual Disease
Following chemotherapy for advanced disease, surgery has a role in the resection of residual masses. PET scanning is usually not performed (unlike seminoma). Surgery is withheld if:
- There are rising tumour markers
- If there are multiple residual lesions (although biopsy may be attempted)
- If the lesion is not operable
Surgeons who specialise in oncology and/or the region where the residual mass is located (often the lungs) are required for surgical excision. Risks are dependent on the tumour site.