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Loss of Ejaculation Following Bilateral Retroperitoneal Lymphadenectomy
Vol. D8. Sept,.
T'HE JOlJRNAL OF UROLOGY
Copyright.© Hl5i by The \Villiarns & Wilkins Co.
Pn:nted 'in U.S.A .
LOSS OF EJACULATION FOLLOWING BILATERAL RETROPERITONEAL LYJVIPHADENECTOJ\fY ELLIOT LEITER
HERBERT BRENDLEH
AND
From the Department of Urology, M aunt Sinai School of M. edicine, N cw York, New Yark
Two 11atients recently unclenYent bilateral retroperitoneal lyn1phadenectomy for teratocareinoma of the testis. Postoperatively, both reported loss of ejaculation. Penile erection was well maintained and orgasm was preserved. A review of the literature revealed brief mention of this complication.1. 2 This is surprising to us since loss of ejaculation is a common complication following sy1npatheGtomy and pre-sacral neurnctomy. Inasmuch as retroperitoneal node dissection probably disrupts the sympathetic innervation of the seminal vesicles, prostate and ampullae, one wonders whether this complication occurs more commonly after complete retrorieritoneal lymphadeuectomy than has been suspected. CASE REPORTS
Case 1. :;\J.S., MSH No. 299083, a 19-year-old white male college student, entered ~\fount Sinai Hospital on November 12, 1965 with a mass in the right testis, first noted 2 weeks prior to admission. General physical examination was negative. A hard, slightly tender 3.5 cm. mass was felt in the lower pole of the right testis, possibly involving the adjacent epicliclymis. The vas def.erens and spermatic rnrcl were normal. Chest x-ray was negative. Urinary chorionic gonadotrophins were negative. Right orchiectomy was performed 011 the day of admission. The histologic diagnosis was malignant teratoma of the testis. On November 19, hilateral retroperitoneal lymphadenectomy was performed through a right transabdominal parameclia11 incision. All uodes, lymphatic channels and fat along the vena cava and aorta were removed. Dissection procee
Accepted for publication October 27, 1966. Nagama.tsu, C. R.: A new extraperitoneal approach for bilateral retroperitoneal lymph node dissection in testis tumor. J. Urnl., 90: 588-590, 1
1903. 2 1Vhitinme, vV. F., Jr.: Some experiences with retroperitoneal lymph node dissection and chemoin the management of testis neoplasms. Urol., 34: 436-447, 1962.
375
valescence was uneventful and the patient was discharged 11 days postoperatively. A mouth later the patient stated that he had had no ejaculation since the operation. Physical examination was negative. Three months later he stated that erections were normal and that he had experienced a normal orgasm; however, there was still no ejaculation. Again, physical examination of the abdomen, external genitalia and prostate revealed no abnorrn.alities. There were no unusual neurological findings. Peripheral pulse,c, were excellenL Chest x-ray showed clear lung fields. A. voided urine specimen following masturbation showed no sperm. However, massage of the seminal vesicles and ampullae yielded a few scant drops of fluid which contained a few non-rnotik sperm. Seven mouths postoperatively, the patient':; condition was essentially unchanged. Physical examination, chest x-ray and excretory urography showed no evidence of tumor recm-rence. His sexual life was active but at no time did he note seminal emission. Erection and orgasm were normal. V\Then last seen, 10 months postoperatively, the patient sti!l had not experienced ejaculation A urine ~pecimeu following masturbation once more failed to reveal evidence of spermatozoa. Prostatic massage yielded a few drops of nonnal prnstatic fluid. No sperm. were seen. Erection and orgasm were normal. Case 2. G.K., MSH ".'\o. 291102, a 27-year-old single v:hite man, was admitted to the )fount Sinai Hospital on November 10, 196.5 with a 6month history of right testicular swelling. An 8 by 4 cm., smooth, hard, non-tender mass, which did not transmit light, was felt in the right scrotum. Chest x-ray and excretory urography were negative. Urine was positive for chorionie gonadotrophins. Right orchiectomy was performed on November 11. The histologie diagnosi, was teratocarcinoma with foci of chorioearcinorna. Transabdominal bilateral retroperitoneal lyrnphaclenectomy was performed on N ovembcr I(-; in the manner previously described. A large, firm
376
LEITER AND BRENDLER
lymph node was encountered at the bifurcation of the right common iliac vein. Microscopic examination of this node revealed undifferentiated carcinoma. All other lymph nodes were grossly and microscopically normal. Following lymphadenectomy the urine was negative for chorionic gonadotrophins. Convalescence was uneventful and the patient was discharged from. the hospital 14 days postoperatively. Coitus was attem.pted 4 weeks postoperatively. The erection was normal but orgasm proved to be less satisfactory than before operation. ~ o ejaculate was noted in the condom. In the next 2 months no ejaculate was observed following coitus despite frequent sexual exposure. Erections were normal but orgasm was described as less intense. Three months postoperatively, the patient noted the gradual return of ejaculatory volume and a simultaneous increase in orgasm. ViThen last seen, 7 months postoperatively, the patient stated that his sexual activity was as good as ever. Physical examination was entirely unremarkable. Ejaculatory volume was 1.2 ml. Coagulation and liquefaction were normal. The semen contained abundant motile sperm. ANATOMY AND PHYSIOLOGY
The sympathetic innervation of the accessory male genitalia arises from the lumbar sympathetic chain via the hypogastric (pre-sacral) plexus. Budge, in 1858, showed that stimulation of the inferior mesenteric ganglion and the hypogastric nerve caused contraction of the vasa deferens and seminal vesicles. 3 Other workers have confirmed the observation that sympathetic stimulation results in the discharge of seminal fluid. 4 • 5 Simeone demonstrated that after sympathetic denervation, transport of spermatozoa through the vas deferens was delayed significantly enough so that animals were probably rendered devoid of fertilizing capacity. 6 In a recent review 3 Budge, J. L.: Ueber das centrurn genitospinale des. nervus sympathicus. Virch. Arch., 15: 115-126,
1858. 4 Langley, J. N. and Anderson, H. K.: The constituents of the hypogastric nerves. J. Physiol.,
17: 177-191, 1894. 5 Langley, J. N. and Anderson, H. K.: On the
innervation of the pelvic and adjoining viscera. Part 1. The lower part of the intestine. J. Physiol., 18: 65-105, 1895. 6 Simeone, F. A.: A neuromuscular mechanism in the ductus epididymidis and its impairment by sympathetic denervation. Amer. J. Physiol., 103:
582-591, 1933.
of the literature Sjostrand concluded that the "vas deferens and the accessory male genital glands received their motor innervation from the lumbar sympathetic outflow and, in the case of the primates, probably also from the last thoracic root" .7 He felt that the weight of the evidence favored the hypogastric nerves as the roots by which the sympathetic fibers reached the pelvis. DISCUSSION
There is general agreement that, in man, resection of the lumbar sympathetic outflow can cause loss of ejaculation. However, the exact level of resection necessary to cause this complication is not clear. Smithwick, in 1951, stated that ejaculation was not usually affected after removal of both first lumbar ganglia. 8 He added that if one second lumbar ganglion was removed about half the patients might not ejaculate, while if both second lumbar ganglia were resected "loss of ejaculation is almost the invariable consequence". He felt that orgasm. was rarely affected and impotence was extremely rare, regardless of the procedure. McGregor felt that ejaculation is not lost if the first lumbar ganglia are preserved. 9 In 1951, Whitelaw stated that if syrn.pathectomy was not extended to the first lumbar ganglion on either side, there would be no interference with sexual function. 10 However, where the first, second and third lumbar ganglia were removed on both sides, 54 per cent of patients suffered permanent loss of ejaculation. These findings were re-stated by White and associates who felt that "from the over-all statistics it becomes evident that in certain individuals the outflow from the first lumbar and possibly the lowest thoracic ganglia is of major importance to the innervation of the seminal vesicles and ducts, while in others, the fibers 7 Sjostrand, N. 0.: The adrenergic innervation of the vas deferens and the accessory male genital glands. An experimental and comparative study of its anatomical and functional organization in some mammals, including the presence of adrenaline and chromaffin cells in these organs. Acta Physiol. Scand., 65: 1-82 (suppl. 257), 1965. 8 Smithwick, R. H.: Surgical Measures in Hypertension. Springfield, Illinois: C. C. Thomas, 1951,
p. 32. 9 McGregor, A. L.: A Synopsis of Surgical Anatomy. Baltimore: The Williams & Wilkins Co., 1950, p. 548. 10 Whitelaw, G. P. and Smithwick, R. H.: Some secondary effects of sympathectomy with particular reference to disturbance of sexual function. New Engl. J. Med., 245: 121-130, 1951.
LOSS OF' EJACULATION
nnrning through the tbfrd lumbar ganglion are of equal importance. There i,o no set rule for this distribution, a fact which corresponds with the well-kuown irregularities in the arrangement of the lumbar ganglia." 11 All of these investigators c1,re in complete agreement that pre-sacral neureC'tomy invariably results in loss of ejaculation. Therefore, there are 2 reasons for tbe loss of ejaculation in patients wlio have undergone retroperitoneal lyrn phaclenectomy. Both arr based on injury to the 0ympa.thetic innervation of the accessory sexual appa.ratus. lnterruption of the sympathetic outflow may be either at the level of the lumbar sympathetic ganglia or at the level o[ the hypogastric: plexm. The operative procedure consists of stripping all tissue from the aorta and the vena cava, a~ 1,ell as from the sulc.us between these vesseb. 12 - 14 On the left, the chain o[ lumbar ganglia lies jnst beneath the edge of the aorta, in t.he gutter between the psoas muscle and the ,-e1tebrae. It is usually surrnunded by the mass of lymphatic trunks and nodes that the surgeon is trying to rescct. On the right, the same relationR hold true except that the sympathetic trunk lies adjacent to the vena cava (fig. 1). With resection of the secondary chain of lymph node~ aloug the iliac; vessels and in the aortic bifurcation, removal of the superior hypogastric plexus (pre-sacral ncurectomy) can be expectrcL This plexus lies intern1iugled ,vith pelvic lymphatics and lom,e comwc:tive tissue in the hollow of the sacrum between Lhe 2 common iliac arteries (fig. 2). In one of our patients lm;s of ejaculation has persisted since lymphadeuectomy 10 months previously; in the other, ejacnlation began to return slowly after 3 months and appears to be nonual at present. Although it has been staled that, loss of ejaculaLio11 occurs oHly irregularly, and is temporary u Wbite, J. C., Smithwick, R.H. and Simeone, F. A.: The Autonomic Nervous . Anatomy, Physiology and Surgical New York: MacMillan Co., 1952, p. 12 Culp, D. A., Graf, R. A. and Haschek, H.: Trn,ticular tumor. J. Urn!., 89: 843-850, 1963. 13 Tobenkin, ]VI. I., Binkley, F. M. and Smith, D. R.: :Expo,sll!'e of the rel,roperi toneL1m for radical dissection of lymph nodes,;, J. UroL, 86: 596--601, 1961. 14 Tave!, F. R, Osius, T. G., Parker, ,J, W., Coodfriend, R. B., McGoniglc, D ..J., .Tassie, M. J-'., Simmons, :E. L., Tobe11kin, M. I. and Schulte, .J. W.: Retroperitoneal lymph node dissection. J. Urol., 89: 241-2,15, 1963.
AbdonunaL aortic plexus
FiG. 1. Lnmbar sympathel:ic trnnk a.nd 1\s reh,.ti01,s to aorta and renal arteries. (Iteprodnced f'rnm--Strong, 0. S. and Elwyn, A.: Human Ana1omy. Baltimore: The Williams & Wilkins Co., 1953, third edition, fig. 1(16, p. 166.)
Fm. 2. Superior hypogastric and its relations Lo aortic duced from-Adson, A. W. and Masson, ,J, C .J.A.M.A., 102: 986-\JDO. 19:14.)
after operative excision of the rerroperitoneal lymph nocles,2 anatomic studies of nerve fiber regeneration suggest that this complication ma.y be more serious. Tower and Richter oh~e1Yed regeneration of pre-ganglionic nelll'ons as early a~ 18 clays a.Her nerve section in the cat_i., L!ow, ever, eYiclencc of post-ganglionic regcll(•.rn.Lion was not observed during the <-mtire ,study period 15 Tower, S.S. and Richter, C. P,. Injury and repair within the sympathetic nervous system. 1 The preganglionic neurons, Arch. Nenrol. & Psychiat., 26: 485 4\J5, 1931.
378
LEITER AND BRENDLER
of 18 months. 16 Inasmuch as the post-ganglionic fibers are the ones apt to be injured during the dissection, loss of ejaculation may be more frequent and more permanent than hitherto recognized.17 Although retroperitoneal node dissection can be regarded as a, relatively straight-forward procedure, 18 the complication of loss of ejaculation can be a serious matter to a healthy young man: Because of the distinct possibility that, in certain individuals, the damage may be per-manent, we feel that it is advisable that all patients be informed of this possibility prior to the operation. 1s Tower, S. S. and Richter, C. P.: Injury and repair within the sympathetic nervous system. II. The postganglionic neurons. Arch. Neurol. & Psychiat., 28: 1139-1148, 1232. . . . 17 Smithwick, R. H.: Evaluat10n of surgical treatment of hypertension. Bull. New York Acad. Med., 25: 698-716, 1949. 1a Patton, J. F., Seitzman, D. N .. and Zone, R. A.: Diagnosis and treatment of testicular tumors. Amer. J. Surg., 99: 525-532, 1960.
SUMMARY AND CONCLUSIONS
Two cases have been presented in which loss 0f ejaculation occurred following retroperitoneal lymphadenectomy for testis tumor. In 1 patient, loss of ejaculation has persisted; in the other, it has gradually retmned to normal. In both patients, penile erection and orgasm have remained undisturbed. The explanation for this complication seems to be related to disruption of the sympathetic innervation of the prostate, seminal vesicles and ampullae dming dissection of the retroperitoneal lymphatics and nodes. Because loss of ejaculation may occur more frequently than has previously been suspected, it seems advisable to inform patients of this possible complication preoperatively. ADDENDUM
M. S. (case 1) has been followed for 18 months. He still has no ejaculation. Erections are normal and orgasm is characterized as adequate.
T'HE JOlJRNAL OF UROLOGY
Copyright.© Hl5i by The \Villiarns & Wilkins Co.
Pn:nted 'in U.S.A .
LOSS OF EJACULATION FOLLOWING BILATERAL RETROPERITONEAL LYJVIPHADENECTOJ\fY ELLIOT LEITER
HERBERT BRENDLEH
AND
From the Department of Urology, M aunt Sinai School of M. edicine, N cw York, New Yark
Two 11atients recently unclenYent bilateral retroperitoneal lyn1phadenectomy for teratocareinoma of the testis. Postoperatively, both reported loss of ejaculation. Penile erection was well maintained and orgasm was preserved. A review of the literature revealed brief mention of this complication.1. 2 This is surprising to us since loss of ejaculation is a common complication following sy1npatheGtomy and pre-sacral neurnctomy. Inasmuch as retroperitoneal node dissection probably disrupts the sympathetic innervation of the seminal vesicles, prostate and ampullae, one wonders whether this complication occurs more commonly after complete retrorieritoneal lymphadeuectomy than has been suspected. CASE REPORTS
Case 1. :;\J.S., MSH No. 299083, a 19-year-old white male college student, entered ~\fount Sinai Hospital on November 12, 1965 with a mass in the right testis, first noted 2 weeks prior to admission. General physical examination was negative. A hard, slightly tender 3.5 cm. mass was felt in the lower pole of the right testis, possibly involving the adjacent epicliclymis. The vas def.erens and spermatic rnrcl were normal. Chest x-ray was negative. Urinary chorionic gonadotrophins were negative. Right orchiectomy was performed 011 the day of admission. The histologic diagnosis was malignant teratoma of the testis. On November 19, hilateral retroperitoneal lymphadenectomy was performed through a right transabdominal parameclia11 incision. All uodes, lymphatic channels and fat along the vena cava and aorta were removed. Dissection procee
Accepted for publication October 27, 1966. Nagama.tsu, C. R.: A new extraperitoneal approach for bilateral retroperitoneal lymph node dissection in testis tumor. J. Urnl., 90: 588-590, 1
1903. 2 1Vhitinme, vV. F., Jr.: Some experiences with retroperitoneal lymph node dissection and chemoin the management of testis neoplasms. Urol., 34: 436-447, 1962.
375
valescence was uneventful and the patient was discharged 11 days postoperatively. A mouth later the patient stated that he had had no ejaculation since the operation. Physical examination was negative. Three months later he stated that erections were normal and that he had experienced a normal orgasm; however, there was still no ejaculation. Again, physical examination of the abdomen, external genitalia and prostate revealed no abnorrn.alities. There were no unusual neurological findings. Peripheral pulse,c, were excellenL Chest x-ray showed clear lung fields. A. voided urine specimen following masturbation showed no sperm. However, massage of the seminal vesicles and ampullae yielded a few scant drops of fluid which contained a few non-rnotik sperm. Seven mouths postoperatively, the patient':; condition was essentially unchanged. Physical examination, chest x-ray and excretory urography showed no evidence of tumor recm-rence. His sexual life was active but at no time did he note seminal emission. Erection and orgasm were normal. V\Then last seen, 10 months postoperatively, the patient sti!l had not experienced ejaculation A urine ~pecimeu following masturbation once more failed to reveal evidence of spermatozoa. Prostatic massage yielded a few drops of nonnal prnstatic fluid. No sperm. were seen. Erection and orgasm were normal. Case 2. G.K., MSH ".'\o. 291102, a 27-year-old single v:hite man, was admitted to the )fount Sinai Hospital on November 10, 196.5 with a 6month history of right testicular swelling. An 8 by 4 cm., smooth, hard, non-tender mass, which did not transmit light, was felt in the right scrotum. Chest x-ray and excretory urography were negative. Urine was positive for chorionie gonadotrophins. Right orchiectomy was performed on November 11. The histologie diagnosi, was teratocarcinoma with foci of chorioearcinorna. Transabdominal bilateral retroperitoneal lyrnphaclenectomy was performed on N ovembcr I(-; in the manner previously described. A large, firm
376
LEITER AND BRENDLER
lymph node was encountered at the bifurcation of the right common iliac vein. Microscopic examination of this node revealed undifferentiated carcinoma. All other lymph nodes were grossly and microscopically normal. Following lymphadenectomy the urine was negative for chorionic gonadotrophins. Convalescence was uneventful and the patient was discharged from. the hospital 14 days postoperatively. Coitus was attem.pted 4 weeks postoperatively. The erection was normal but orgasm proved to be less satisfactory than before operation. ~ o ejaculate was noted in the condom. In the next 2 months no ejaculate was observed following coitus despite frequent sexual exposure. Erections were normal but orgasm was described as less intense. Three months postoperatively, the patient noted the gradual return of ejaculatory volume and a simultaneous increase in orgasm. ViThen last seen, 7 months postoperatively, the patient stated that his sexual activity was as good as ever. Physical examination was entirely unremarkable. Ejaculatory volume was 1.2 ml. Coagulation and liquefaction were normal. The semen contained abundant motile sperm. ANATOMY AND PHYSIOLOGY
The sympathetic innervation of the accessory male genitalia arises from the lumbar sympathetic chain via the hypogastric (pre-sacral) plexus. Budge, in 1858, showed that stimulation of the inferior mesenteric ganglion and the hypogastric nerve caused contraction of the vasa deferens and seminal vesicles. 3 Other workers have confirmed the observation that sympathetic stimulation results in the discharge of seminal fluid. 4 • 5 Simeone demonstrated that after sympathetic denervation, transport of spermatozoa through the vas deferens was delayed significantly enough so that animals were probably rendered devoid of fertilizing capacity. 6 In a recent review 3 Budge, J. L.: Ueber das centrurn genitospinale des. nervus sympathicus. Virch. Arch., 15: 115-126,
1858. 4 Langley, J. N. and Anderson, H. K.: The constituents of the hypogastric nerves. J. Physiol.,
17: 177-191, 1894. 5 Langley, J. N. and Anderson, H. K.: On the
innervation of the pelvic and adjoining viscera. Part 1. The lower part of the intestine. J. Physiol., 18: 65-105, 1895. 6 Simeone, F. A.: A neuromuscular mechanism in the ductus epididymidis and its impairment by sympathetic denervation. Amer. J. Physiol., 103:
582-591, 1933.
of the literature Sjostrand concluded that the "vas deferens and the accessory male genital glands received their motor innervation from the lumbar sympathetic outflow and, in the case of the primates, probably also from the last thoracic root" .7 He felt that the weight of the evidence favored the hypogastric nerves as the roots by which the sympathetic fibers reached the pelvis. DISCUSSION
There is general agreement that, in man, resection of the lumbar sympathetic outflow can cause loss of ejaculation. However, the exact level of resection necessary to cause this complication is not clear. Smithwick, in 1951, stated that ejaculation was not usually affected after removal of both first lumbar ganglia. 8 He added that if one second lumbar ganglion was removed about half the patients might not ejaculate, while if both second lumbar ganglia were resected "loss of ejaculation is almost the invariable consequence". He felt that orgasm. was rarely affected and impotence was extremely rare, regardless of the procedure. McGregor felt that ejaculation is not lost if the first lumbar ganglia are preserved. 9 In 1951, Whitelaw stated that if syrn.pathectomy was not extended to the first lumbar ganglion on either side, there would be no interference with sexual function. 10 However, where the first, second and third lumbar ganglia were removed on both sides, 54 per cent of patients suffered permanent loss of ejaculation. These findings were re-stated by White and associates who felt that "from the over-all statistics it becomes evident that in certain individuals the outflow from the first lumbar and possibly the lowest thoracic ganglia is of major importance to the innervation of the seminal vesicles and ducts, while in others, the fibers 7 Sjostrand, N. 0.: The adrenergic innervation of the vas deferens and the accessory male genital glands. An experimental and comparative study of its anatomical and functional organization in some mammals, including the presence of adrenaline and chromaffin cells in these organs. Acta Physiol. Scand., 65: 1-82 (suppl. 257), 1965. 8 Smithwick, R. H.: Surgical Measures in Hypertension. Springfield, Illinois: C. C. Thomas, 1951,
p. 32. 9 McGregor, A. L.: A Synopsis of Surgical Anatomy. Baltimore: The Williams & Wilkins Co., 1950, p. 548. 10 Whitelaw, G. P. and Smithwick, R. H.: Some secondary effects of sympathectomy with particular reference to disturbance of sexual function. New Engl. J. Med., 245: 121-130, 1951.
LOSS OF' EJACULATION
nnrning through the tbfrd lumbar ganglion are of equal importance. There i,o no set rule for this distribution, a fact which corresponds with the well-kuown irregularities in the arrangement of the lumbar ganglia." 11 All of these investigators c1,re in complete agreement that pre-sacral neureC'tomy invariably results in loss of ejaculation. Therefore, there are 2 reasons for tbe loss of ejaculation in patients wlio have undergone retroperitoneal lyrn phaclenectomy. Both arr based on injury to the 0ympa.thetic innervation of the accessory sexual appa.ratus. lnterruption of the sympathetic outflow may be either at the level of the lumbar sympathetic ganglia or at the level o[ the hypogastric: plexm. The operative procedure consists of stripping all tissue from the aorta and the vena cava, a~ 1,ell as from the sulc.us between these vesseb. 12 - 14 On the left, the chain o[ lumbar ganglia lies jnst beneath the edge of the aorta, in t.he gutter between the psoas muscle and the ,-e1tebrae. It is usually surrnunded by the mass of lymphatic trunks and nodes that the surgeon is trying to rescct. On the right, the same relationR hold true except that the sympathetic trunk lies adjacent to the vena cava (fig. 1). With resection of the secondary chain of lymph node~ aloug the iliac; vessels and in the aortic bifurcation, removal of the superior hypogastric plexus (pre-sacral ncurectomy) can be expectrcL This plexus lies intern1iugled ,vith pelvic lymphatics and lom,e comwc:tive tissue in the hollow of the sacrum between Lhe 2 common iliac arteries (fig. 2). In one of our patients lm;s of ejaculation has persisted since lymphadeuectomy 10 months previously; in the other, ejacnlation began to return slowly after 3 months and appears to be nonual at present. Although it has been staled that, loss of ejaculaLio11 occurs oHly irregularly, and is temporary u Wbite, J. C., Smithwick, R.H. and Simeone, F. A.: The Autonomic Nervous . Anatomy, Physiology and Surgical New York: MacMillan Co., 1952, p. 12 Culp, D. A., Graf, R. A. and Haschek, H.: Trn,ticular tumor. J. Urn!., 89: 843-850, 1963. 13 Tobenkin, ]VI. I., Binkley, F. M. and Smith, D. R.: :Expo,sll!'e of the rel,roperi toneL1m for radical dissection of lymph nodes,;, J. UroL, 86: 596--601, 1961. 14 Tave!, F. R, Osius, T. G., Parker, ,J, W., Coodfriend, R. B., McGoniglc, D ..J., .Tassie, M. J-'., Simmons, :E. L., Tobe11kin, M. I. and Schulte, .J. W.: Retroperitoneal lymph node dissection. J. Urol., 89: 241-2,15, 1963.
AbdonunaL aortic plexus
FiG. 1. Lnmbar sympathel:ic trnnk a.nd 1\s reh,.ti01,s to aorta and renal arteries. (Iteprodnced f'rnm--Strong, 0. S. and Elwyn, A.: Human Ana1omy. Baltimore: The Williams & Wilkins Co., 1953, third edition, fig. 1(16, p. 166.)
Fm. 2. Superior hypogastric and its relations Lo aortic duced from-Adson, A. W. and Masson, ,J, C .J.A.M.A., 102: 986-\JDO. 19:14.)
after operative excision of the rerroperitoneal lymph nocles,2 anatomic studies of nerve fiber regeneration suggest that this complication ma.y be more serious. Tower and Richter oh~e1Yed regeneration of pre-ganglionic nelll'ons as early a~ 18 clays a.Her nerve section in the cat_i., L!ow, ever, eYiclencc of post-ganglionic regcll(•.rn.Lion was not observed during the <-mtire ,study period 15 Tower, S.S. and Richter, C. P,. Injury and repair within the sympathetic nervous system. 1 The preganglionic neurons, Arch. Nenrol. & Psychiat., 26: 485 4\J5, 1931.
378
LEITER AND BRENDLER
of 18 months. 16 Inasmuch as the post-ganglionic fibers are the ones apt to be injured during the dissection, loss of ejaculation may be more frequent and more permanent than hitherto recognized.17 Although retroperitoneal node dissection can be regarded as a, relatively straight-forward procedure, 18 the complication of loss of ejaculation can be a serious matter to a healthy young man: Because of the distinct possibility that, in certain individuals, the damage may be per-manent, we feel that it is advisable that all patients be informed of this possibility prior to the operation. 1s Tower, S. S. and Richter, C. P.: Injury and repair within the sympathetic nervous system. II. The postganglionic neurons. Arch. Neurol. & Psychiat., 28: 1139-1148, 1232. . . . 17 Smithwick, R. H.: Evaluat10n of surgical treatment of hypertension. Bull. New York Acad. Med., 25: 698-716, 1949. 1a Patton, J. F., Seitzman, D. N .. and Zone, R. A.: Diagnosis and treatment of testicular tumors. Amer. J. Surg., 99: 525-532, 1960.
SUMMARY AND CONCLUSIONS
Two cases have been presented in which loss 0f ejaculation occurred following retroperitoneal lymphadenectomy for testis tumor. In 1 patient, loss of ejaculation has persisted; in the other, it has gradually retmned to normal. In both patients, penile erection and orgasm have remained undisturbed. The explanation for this complication seems to be related to disruption of the sympathetic innervation of the prostate, seminal vesicles and ampullae dming dissection of the retroperitoneal lymphatics and nodes. Because loss of ejaculation may occur more frequently than has previously been suspected, it seems advisable to inform patients of this possible complication preoperatively. ADDENDUM
M. S. (case 1) has been followed for 18 months. He still has no ejaculation. Erections are normal and orgasm is characterized as adequate.