Surgery

Virtually all cases of seminoma begin with an orchidectomy, which has an excellent rate of local control, is often curative and also provides staging information. Unlike non-seminomatous germ cell tumours, retroperitoneal lymph node dissection is not widely used as the tumour nearly always curable with radiation and chemotherapy.

Radical Orchidectomy

This is both curative in a number of cases as well as providing important staging information.

Technique

  • An incision is made above the inguinal ligament and the external inguinal ring identified.
  • 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

Scrotal Violation

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. If this has occurred (through biopsy, inappropriate surgery) then radiotherapy fields are classically required to be extended to encompass the ipsilateral iliac and inguinal nodes.


Retroperitoneal Lymph Node Dissection

Retroperitoneal lymph node dissection is rarely needed for seminoma due to its responsiveness to radiation and cytotoxics. The only situation it is considered is when a residual mass is found after chemotherapy. The difficulty arises from the dense fibrotic reaction that occurs following cytotoxic chemotherapy of seminoma; these makes a resection technically difficult it not impossible, with higher morbidity.
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 for non-seminomatous germ cell tumours but is very difficult following radiation and chemotherapy for seminoma.
In general, surgery is reserved for cases where residual masses are larger than 3 cm and have increased uptake of 18F-DHG on PET imaging.

Technique

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, the tissue anterior to and including the lumbar arteries is removed. If nerve preserving surgery is undertaken, the sympathetic nerves are identified and (as much as possible) not divided.


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