Introduction: Retroperitoneal lymphadenectomy (RPLND) is indicated in patients with testicular cancer of all stages for staging, prognostic, and therapeutic purposes. Modification of the classic RPLND to incorporate nerve sparing has reduced the morbidity associated with this procedure with respect to ejaculation and fertility.
Technical considerations: Performance of nerve-sparing RPLND requires an understanding of the anatomy of the sympathetic chains, their branches, and their relationship to the major structures of the retroperitoneum. The key element of this procedure is the prospective identification of the postganglionic nerves, which arise from the lumbar sympathetic chains and form an anastomosing network anterior to the aorta and surrounding the origin of the inferior mesenteric artery. Precise dissection of these nerves allows complete skeletonization of the great vessels and removal of all lymphatic tissue, without compromising cancer control.
Conclusions: Nerve-sparing RPLND is the procedure of choice for patients with testicular cancer in whom surgical therapy of the retroperitoneum is indicated. The procedure is associated with minimal morbidity and results in preservation of ejaculation in virtually all patients with low-stage disease and in selected patients with advanced disease or after chemotherapy.