Evolution of retroperitoneal lymphadenectomy (RPLND) in the management of non-seminomatous testicular cancer (NSGCT).

The metastatic lymphatic drainage of testis cancer to the retroperitoneum was noted clinically about a century ago. Beginning with extraperitoneal approaches, RPLND was attempted. The first cure after RPLND of node positive disease was in 1905 by Cuneo in Paris. Transperitoneal approaches failed due to infection until post World War II experience at Walter Reed Army Hospital. Thoracoabdominal approaches became popular several decades later. But Improved exposure and vascular management strategies led to increased usage of the transabdominal approach once again. The advent of platinum based combination chemotherapy has had a major impact on both the timing of and the technical requirements of RPLND. Owing to our early involvement in this area, we have accumulated the largest database available on this disease. Our experience with over 2500 RPLNDs in the last 3 decades is divided between low stage (I and II) and high stage (III, postchemotherapy) disease. The former has been "down-regulated" to modified templates and prospective nerve sparing techniques to preserve ejaculation. The latter has been "up-regulated" to include a spectrum of surgical needs including hepatic, vascular, gut and mediastinal resections. Despite these extended requirements, outcomes are good (> 80% survival) postchemotherapy. The evolutionary change of RPLND reflects an optimal paradigm of surgical-medical oncologic interaction.