A medical 3D illustration of testicular cancer.

Sia Daneshmand, MD, a Keck Medicine of USC urologic oncologist, explains how a surgery-only approach is improving quality-of-life outcomes for patients with early-stage testicular cancer.

Testicular cancer is highly curable and predominantly a young man’s disease. Long-term quality of life is a key factor in therapy decisions, especially for patients concerned about potential side effects of chemotherapy and radiation, including increased risk of secondary cancers decades after successful treatment.

Sia Daneshmand, MD, director of urologic oncology for USC Urology, part of Keck Medicine of USC, has developed a cutting-edge treatment for early metastatic seminoma with an advanced surgical approach.

Here, he answers frequently asked questions.

Why is a surgery-only approach beneficial for patients with early metastatic seminoma?

The cure rate for stage 1 is virtually 99%. For stage 2, it’s 95%-98%. We know we can cure this disease. Now it’s about how we treat it and how we cure it.

One has to think about the long-term effects of chemotherapy and radiation because patients can go on to live normal lives for the next several decades.

You developed the “midline extraperitoneal” approach to retroperitoneal lymph node dissection (RPLND) here at Keck Medicine. What are the steps of the operation?

The midline extraperitoneal technique involves a vertical incision in the middle of the abdomen measuring 8-10 centimeters. We keep the peritoneal sac (which contains the intestines) intact and sweep it to the side to gain access to the back of the abdomen (retroperitoneum).

We get the same exposure as we would through the traditional transperitoneal approach, which goes through the peritoneum and requires mobilization of the bowels to get to the retroperitoneum. We then proceed to remove the tumor and the surrounding lymph nodes. Surgery for a stage 2 cancer takes about three hours.

What’s unique about this approach and how has it affected the patient’s recovery?

It sticks to the principles of open surgery but with the advantages of a minimally invasive approach. Our incisions are far smaller than they used to be, putting it on par with robotic surgery. This is a very transferable method and something we can teach trainees, whereas robotic techniques take a number of years to gain mastery of given the rarity of the disease.

It’s also lowered the morbidity of RPLND. Since we’re not in the peritoneal cavity, patients don’t get the nausea and there’s no risk of ileus (bowels slowing down after surgery). Instead of a five-day hospital day, the vast majority of patients are going home after an overnight stay, which is a remarkable advance in postoperative recovery.

It’s shifted how we counsel patients about surgery versus chemotherapy for stage 2. A single low morbidity surgery that can be curative is more attractive than nine weeks of chemotherapy with potential for long-term sequela.

How do you determine whether a patient is a good candidate for a surgery-only approach?

We are advocates of this approach for most patients who present with stage 2a or 2b, and for very select stage 2c cases. For these patients, their personal preferences may further contribute to their decision.

In one case, I treated a 31-year-old man with stage 2 metastatic seminoma who worried about the risks of infertility if he went through chemotherapy and radiation. He opted for the surgery-only approach so that he and his wife could start a family, which they did successfully post-treatment.

However, the bigger the lymph node, and the more lymph nodes that are involved, the less chance that surgery alone, without chemotherapy, will be curative.

We look at whether the disease is clustered in one area rather than multiple areas, because disseminated disease may be better suited for chemotherapy.

How is RPLND affecting clinical outcomes for patients with early metastatic seminoma?

We’re seeing 80%-90% of patients cured with surgery only. The remaining patients were then treated with chemotherapy and also cured. These are now reflected in national guidelines from the National Comprehensive Cancer Network and American Urological Association.

What are common misconceptions about the RPLND approach?

RPLND used to have a months-long recovery process, but that is not the case anymore. Modern RPLND is far less morbid of an operation than it used to be, and patients are doing much better, especially when treated by expert surgeons.

The other misconception is that RPLND is associated with retrograde ejaculation (dry orgasm). At comprehensive cancer centers, the occurrence is less than 5%. In our experience for stage 2, the vast majority of patients maintain normal ejaculation.

What are the next steps?

We now have five years of follow-up for patients who’ve had the surgery. We’re preparing a manuscript on the longer outcomes, and it looks good. We see very few recurrences after two years.

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Can Early Metastatic Testicular Cancer Be Cured with Surgery Alone?