A 25-year-old man underwent a right radical orchiectomy (see radical orchiectomy) for an enlarged, hard right testicle, which showed a heterogeneous tumor on ultrasound. The patient had a markedly elevated beta human chorionic gonadotrophin (ß-HCG). The pathology was mixed germ cell tumor (10% embryonal, 10% teratoma, and 80% yolk sac), with a seminomatous component (65% of germ cell tumors are seminomas, 35% mixed). Workup including the CT scan shown, showed no evidence of metastasis, and no lymphadenopathy. The ß-HCG (primarily from the yolk sac component) level returned to normal several weeks postoperatively. The patient was presented the option of elective retroperitoneal lymph node dissection (RPLND) vs. observation, and chose to have the nodal dissection.
A nerve sparing extraperitoneal approach was chosen, and the pre-peritoneal plane was approached through a midline incision (head to right). The extraperitoneal approach reduces bowel manipulation and ileus inherent in a conventional transperitoneal approach to RPLND, and removes the right colic vessels (see lower GI bleed) out of the field of dissection.
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