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Sperm parameters and ejaculation before and after operative treatment of patients with germ-cell testicular cancer
Vol. 43, No.3, March 1985 Printed in U.SA.
FERTILITY AND STERILITY Copyright ' 1985 The American Fertility Society
Sperm parameters and ejaculation before and after operative treatment of patients with germ-cell testicular cancer
Klaus Fritz, M,D. * Lothar Weissbach, M.D.t University Clinic, Bonn-Venusberg, West Germany
In testicular tumor patients, the stage of disease is most accurately determined by retroperitoneal lymph node dissection (RLND) and histologic examination of the operative specimen. The resection of possibly metastatic nodes is essential for securing a good prognosis. However, the most frequently encountered loss of ejaculatory function is a major disadvantage of radical RLND. In patients who intraoperatively proved to be free of metastases, we successfully employed a modified technique aiming at the preservation of sympathetic nerve fibers which mediate ejaculation. In 29 of 37 patients (78%), postoperative ejaculation was antegrade. It was retrograde in 5 of 37 patients (13.5%); 3 patients had no emission. These results are retrospectively compared with results of radical RLNDin 87 patients of whom 64% suffered a total loss of ejaculation and only 23% had antegrade ejaculation. RLND did not affect sperm count, motility, and cell morphology. Potentia coeundi was preserved in all cases, although 27% of patients experienced diminished erectility or libido. Fertil Steril 43:451, 1985
Testicular cancer is the fourth most prevalent malignant disease among males in the age group 20 to 34 years. 1 The prognosis of patients has been greatly improved by the introduction of aggressive forms oftreatment.2 They may, however, cause damage to the germinal epithelium (cytostatic agents, irradiation 3 , 4) or impair sexual function (retroperitoneal lymph node dissection [RLND]). Loss of ejaculatory ability (up to 100% of cases) is a particularly grave consequence to young patients wishing to father children. In view of the excellent prognosis in stage I (tumor confined to scrotal content) and the dem-
Received February 15, 1984; revised and accepted November 7, 1984. *Reprint requests: Dr. Klaus Fritz, Department of Dermatology, University Clinic, D-5300 Bonn-Venusberg, West Germany. tPresent address: Department of Urology, Hospital Am Urban, Berlin, West Germany. Vol. 43, No.3, March 1985
onstrated regularity of testicular lymphatic drainage, 5 we perform a modified RLND aimed at the preservation of ejaculatory function. 6 This technique may be employed when, after orchiectomy, tumor markers a-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are normal or normalizing within the biologic half-life period and when there is no other clinical or radiologic evidence (palpation, intravenous urography, lymphography, computerized tomography, sonography) of retroperitoneal metastases. According to Ray et al.,5 first (solitary) metastases of left-sided tumors are found only lateral to the aortic circumference or, in rare cases, along the left testicular vein and the left iliac vessels. The area of dissection as defined by us extends from the upper circumference of the left renal artery to approximately a hand's width distal to the origin of the left common iliac artery, as cranial and caudal boundaries, respectively. The lateral boundaries are toward the left, the testicular
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
451
vein (to be resected), and toward the median, the left aortic circumference (Fig. lA). In the case of right-sided tumors, metastases are to be expected before the aorta (preaortic) and toward the right (interaortocaval, precaval, paracaval). Infrequently, metastases may occur along the right testicular vein or the right iliac vessels. 5 The area of dissection extends from the right renal hilus down to directly be"Iow the bifurcation of the right common iliac artery. Laterally, it is delimited toward the left by the right aortic circumference and by the right testicular vein (to be resected) toward the right (Fig. IB). The inferior mesenteric artery is preserved. Palpable lymph nodes outside these areas must also be dissected. The resected lymph nodes are inspected by the surgeon for macroscopic evidence of metastatic involvement and subject to microscopic examination during surgery. If one or more lymph nodes are positive, RLND has to be radical. All operations have been performed by only a few surgeons, who closely followed the above outlines. A
MATERIALS AND METHODS PATIENTS
The results presented in this article are based on data of 124 patients with germ-cell testicular tumors who had ablatio testis (AT) and radical (n = 87) or modified (n = 37) RLND during the years 1977 to 1982. The mean age of patients at the time of AT was 29 years (18 to 44 years). Fifty-two men (42%) had not yet fathered chil' dren. Semen was available for analysis from 86 patients. During the course of treatment, three samples each were obtained from 36 patients, two each from 26 patients, and one each from 24 patients. They were compared with respect to time of provision (before AT, after AT, after modified or radical RLND). Table 1. Preservation of Ejaculatory Function Depending on Operative Technique Modified RLND Radical RLND Postoperative ejaculation
B Figure 1 (A), Modified RLND. Tumor on left side. (B), Modified RLND. Tumor on right side. 452
Antegrade Retrograde None
(n = 37)
(n = 87)
n
%
n
%
20
23 13
29 5 3
78 13.5 8.5
11 56a
64
aNo urine analysis in 7 cases.
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
Fertility and Sterility
Table 2. Semen from Antegrade Ejaculation After Radical and Modified RLND Radical RLND Semen
Viable sperm Azoospermia Not analyzed
modified RLND, 29 of 37 patients (78%) experienced normal ejaculation. It was retrograde in five (13.5%) and absent in three (8.5%) cases (Table 1). The localization of the primary tumor and, consequently, the different areas of dissection in modified RLND did not produce any difference with respect to preserved or lost emission. The results of semen analyses from antegrade ejaculation after radical and modified RLND are given in Table 2. A comparison of preoperative and postoperative semen (pre-AT, post-AT, post-RLND) of a total of 36 patients (21 with radical, 15 with modified RLND) indicates that the surgical intervention(s) did not affect semen quality (Table 3). Twentynine of 37 patients who had given information regarding potentia coeundi continued to lead a normal sex life following treatment, and 8 patients (27%) reported impaired erectile potency.
Modified RLND
(n = 20)
(n = 29)
3 1 16
10
1 18
Data were evaluated with the hope of answering the following questions: (1) Does quality of semen change in the course of treatment, and (2) does technique of RLND employed affect the respective result? Seventy-five patients with loss of ejaculation after RLND were asked to provide postorgasmic urine to be examined for the presence of spermatozoa. Sixty-eight patients, 60 with radical and 8 with modified RLND, obliged. Forty milliliters each of the urine samples was centrifuged at 2000 rpm for 10 minutes. The sediment was searched for spermatozoa under the microscope in 40 fields of vision with 40 x 12.5 magnification. A positive result was taken as evidence of retrograde ejaculation. Within 1 to 3 years postoperatively, 152 patients were asked for information on whether orgasm was normal, or had changed, as compared with preoperative orgasm, or was lost. Forty-five patients were asked about potentia coeundi. One hundred twenty-four and 37 patients, respectively, replied.
DISCUSSION
Postoperative infertility results mainly from loss of ante grade ejaculation. It is clear from our results that the extension of the areas of dissection in RLND is crucial to the preservation of emission. The modified RLND as proposed by Weissbach and Bode 6 thus achieves the protection of ejaculatory ability. This is confirmed by results of a prospective investigation currently under way.7 With this technique it is possible to avoid damage to sympathetic nerve fibers passing in close proximity to retroperitoneal lymph tracts beside, before, and below the aorta. They are the paravertebral ganglia Th 12-L3 and the plexus hypogastricus. 8 Resection of these fibers affects the functions controlled by the sympathetic system, such as emission and competence of the musculus sphincter vesicae internus. 9 This results clinically in loss of ante grade ejaculation. If only
RESULTS
After radical RLND, ejaculatory ability was preserved in 20 of 87 patients (23%). Sixty-seven of 87 patients (78%) had no emission. Of the latter, analysis of postorgasmic urine revealed retrograde ejaculation in 11 cases and none in 49; 7 patients had not provided urine samples. After
Table 3. Preoperative and Postoperative Semen Analysis and Ejaculation (n Patients with radical RLND (n Pre·AT
Post·AT
10 6
8
4 1
5
=
=
21)
Post·RLND
36) Patients with modified RLND
(n =
15)
Pre·AT
Post·AT
Post·RLND
10
millionslml
Sperm count > 40 10-40 0-10 Azoospermia Retrograde ejaculation Loss of ejaculation
Vol. 43, No.3, March 1985
7
1
4
9 5
8
1 1
1
1
1 2
3 16
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
2
2
453
the sphincter function is impaired, a retrograde ejaculation results. REFERENCES 1. Mostofi FK: Epidemiology and pathology of tumors ofhu-
man testis. Recent Results Cancer Res 60:176, 1977 2. Einhorn LH, Williams SD, Mandelbaum J, Donohue JP: Surgical resection in disseminated testicular cancer following chemotherapy cytoreduction. Cancer 48:904, 1981 3. Sandemann TF: The effects of x-irradiation on male human fertility. Br J Radiol 39:901, 1967 4. Rowley MJ, Leach DR, Warner GA, Heller GR: Effects of graded doses of ionizing radiation on the human testis. Radiat Res 59:665, 1974
454
5. Ray B, Hajdu SJ, Whitmore WF: Distribution of retroperitoneal lymph node metastases in testicular germinal tumors. Cancer 33:340, 1974 6. Weissbach L, Bode HU:. Die modifizierte Lymphadenektomie zur Protektion der Ejakulation. In Nicht-seminomatose Hodentumoren, Edited by HJ Iiliger, H Sack, S Seeber, L Weissbach. Basel, S. Karger, 1982, p 133 7. Weissbach L, Boedefeld EA, Oberdiirster W: Non-seminomatous testicular tumors: results after 2 years of a prospective clinical trial in stage I. Verh Dtsch Krebsges 5:651, 1984 8. Kedia KR, Markland C, Fraley EE: Sexual function following high retroperitoneal lymphadenectomy: J Urol 114:237, 1975 9. Narayan P, Lange PH, Fraley EE: Ejaculation and fertility after extended retroperitoneal lymph node dissection for testicular cancer. J Urol 127:685, 1982
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
Fertility and Sterility
FERTILITY AND STERILITY Copyright ' 1985 The American Fertility Society
Sperm parameters and ejaculation before and after operative treatment of patients with germ-cell testicular cancer
Klaus Fritz, M,D. * Lothar Weissbach, M.D.t University Clinic, Bonn-Venusberg, West Germany
In testicular tumor patients, the stage of disease is most accurately determined by retroperitoneal lymph node dissection (RLND) and histologic examination of the operative specimen. The resection of possibly metastatic nodes is essential for securing a good prognosis. However, the most frequently encountered loss of ejaculatory function is a major disadvantage of radical RLND. In patients who intraoperatively proved to be free of metastases, we successfully employed a modified technique aiming at the preservation of sympathetic nerve fibers which mediate ejaculation. In 29 of 37 patients (78%), postoperative ejaculation was antegrade. It was retrograde in 5 of 37 patients (13.5%); 3 patients had no emission. These results are retrospectively compared with results of radical RLNDin 87 patients of whom 64% suffered a total loss of ejaculation and only 23% had antegrade ejaculation. RLND did not affect sperm count, motility, and cell morphology. Potentia coeundi was preserved in all cases, although 27% of patients experienced diminished erectility or libido. Fertil Steril 43:451, 1985
Testicular cancer is the fourth most prevalent malignant disease among males in the age group 20 to 34 years. 1 The prognosis of patients has been greatly improved by the introduction of aggressive forms oftreatment.2 They may, however, cause damage to the germinal epithelium (cytostatic agents, irradiation 3 , 4) or impair sexual function (retroperitoneal lymph node dissection [RLND]). Loss of ejaculatory ability (up to 100% of cases) is a particularly grave consequence to young patients wishing to father children. In view of the excellent prognosis in stage I (tumor confined to scrotal content) and the dem-
Received February 15, 1984; revised and accepted November 7, 1984. *Reprint requests: Dr. Klaus Fritz, Department of Dermatology, University Clinic, D-5300 Bonn-Venusberg, West Germany. tPresent address: Department of Urology, Hospital Am Urban, Berlin, West Germany. Vol. 43, No.3, March 1985
onstrated regularity of testicular lymphatic drainage, 5 we perform a modified RLND aimed at the preservation of ejaculatory function. 6 This technique may be employed when, after orchiectomy, tumor markers a-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are normal or normalizing within the biologic half-life period and when there is no other clinical or radiologic evidence (palpation, intravenous urography, lymphography, computerized tomography, sonography) of retroperitoneal metastases. According to Ray et al.,5 first (solitary) metastases of left-sided tumors are found only lateral to the aortic circumference or, in rare cases, along the left testicular vein and the left iliac vessels. The area of dissection as defined by us extends from the upper circumference of the left renal artery to approximately a hand's width distal to the origin of the left common iliac artery, as cranial and caudal boundaries, respectively. The lateral boundaries are toward the left, the testicular
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
451
vein (to be resected), and toward the median, the left aortic circumference (Fig. lA). In the case of right-sided tumors, metastases are to be expected before the aorta (preaortic) and toward the right (interaortocaval, precaval, paracaval). Infrequently, metastases may occur along the right testicular vein or the right iliac vessels. 5 The area of dissection extends from the right renal hilus down to directly be"Iow the bifurcation of the right common iliac artery. Laterally, it is delimited toward the left by the right aortic circumference and by the right testicular vein (to be resected) toward the right (Fig. IB). The inferior mesenteric artery is preserved. Palpable lymph nodes outside these areas must also be dissected. The resected lymph nodes are inspected by the surgeon for macroscopic evidence of metastatic involvement and subject to microscopic examination during surgery. If one or more lymph nodes are positive, RLND has to be radical. All operations have been performed by only a few surgeons, who closely followed the above outlines. A
MATERIALS AND METHODS PATIENTS
The results presented in this article are based on data of 124 patients with germ-cell testicular tumors who had ablatio testis (AT) and radical (n = 87) or modified (n = 37) RLND during the years 1977 to 1982. The mean age of patients at the time of AT was 29 years (18 to 44 years). Fifty-two men (42%) had not yet fathered chil' dren. Semen was available for analysis from 86 patients. During the course of treatment, three samples each were obtained from 36 patients, two each from 26 patients, and one each from 24 patients. They were compared with respect to time of provision (before AT, after AT, after modified or radical RLND). Table 1. Preservation of Ejaculatory Function Depending on Operative Technique Modified RLND Radical RLND Postoperative ejaculation
B Figure 1 (A), Modified RLND. Tumor on left side. (B), Modified RLND. Tumor on right side. 452
Antegrade Retrograde None
(n = 37)
(n = 87)
n
%
n
%
20
23 13
29 5 3
78 13.5 8.5
11 56a
64
aNo urine analysis in 7 cases.
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
Fertility and Sterility
Table 2. Semen from Antegrade Ejaculation After Radical and Modified RLND Radical RLND Semen
Viable sperm Azoospermia Not analyzed
modified RLND, 29 of 37 patients (78%) experienced normal ejaculation. It was retrograde in five (13.5%) and absent in three (8.5%) cases (Table 1). The localization of the primary tumor and, consequently, the different areas of dissection in modified RLND did not produce any difference with respect to preserved or lost emission. The results of semen analyses from antegrade ejaculation after radical and modified RLND are given in Table 2. A comparison of preoperative and postoperative semen (pre-AT, post-AT, post-RLND) of a total of 36 patients (21 with radical, 15 with modified RLND) indicates that the surgical intervention(s) did not affect semen quality (Table 3). Twentynine of 37 patients who had given information regarding potentia coeundi continued to lead a normal sex life following treatment, and 8 patients (27%) reported impaired erectile potency.
Modified RLND
(n = 20)
(n = 29)
3 1 16
10
1 18
Data were evaluated with the hope of answering the following questions: (1) Does quality of semen change in the course of treatment, and (2) does technique of RLND employed affect the respective result? Seventy-five patients with loss of ejaculation after RLND were asked to provide postorgasmic urine to be examined for the presence of spermatozoa. Sixty-eight patients, 60 with radical and 8 with modified RLND, obliged. Forty milliliters each of the urine samples was centrifuged at 2000 rpm for 10 minutes. The sediment was searched for spermatozoa under the microscope in 40 fields of vision with 40 x 12.5 magnification. A positive result was taken as evidence of retrograde ejaculation. Within 1 to 3 years postoperatively, 152 patients were asked for information on whether orgasm was normal, or had changed, as compared with preoperative orgasm, or was lost. Forty-five patients were asked about potentia coeundi. One hundred twenty-four and 37 patients, respectively, replied.
DISCUSSION
Postoperative infertility results mainly from loss of ante grade ejaculation. It is clear from our results that the extension of the areas of dissection in RLND is crucial to the preservation of emission. The modified RLND as proposed by Weissbach and Bode 6 thus achieves the protection of ejaculatory ability. This is confirmed by results of a prospective investigation currently under way.7 With this technique it is possible to avoid damage to sympathetic nerve fibers passing in close proximity to retroperitoneal lymph tracts beside, before, and below the aorta. They are the paravertebral ganglia Th 12-L3 and the plexus hypogastricus. 8 Resection of these fibers affects the functions controlled by the sympathetic system, such as emission and competence of the musculus sphincter vesicae internus. 9 This results clinically in loss of ante grade ejaculation. If only
RESULTS
After radical RLND, ejaculatory ability was preserved in 20 of 87 patients (23%). Sixty-seven of 87 patients (78%) had no emission. Of the latter, analysis of postorgasmic urine revealed retrograde ejaculation in 11 cases and none in 49; 7 patients had not provided urine samples. After
Table 3. Preoperative and Postoperative Semen Analysis and Ejaculation (n Patients with radical RLND (n Pre·AT
Post·AT
10 6
8
4 1
5
=
=
21)
Post·RLND
36) Patients with modified RLND
(n =
15)
Pre·AT
Post·AT
Post·RLND
10
millionslml
Sperm count > 40 10-40 0-10 Azoospermia Retrograde ejaculation Loss of ejaculation
Vol. 43, No.3, March 1985
7
1
4
9 5
8
1 1
1
1
1 2
3 16
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
2
2
453
the sphincter function is impaired, a retrograde ejaculation results. REFERENCES 1. Mostofi FK: Epidemiology and pathology of tumors ofhu-
man testis. Recent Results Cancer Res 60:176, 1977 2. Einhorn LH, Williams SD, Mandelbaum J, Donohue JP: Surgical resection in disseminated testicular cancer following chemotherapy cytoreduction. Cancer 48:904, 1981 3. Sandemann TF: The effects of x-irradiation on male human fertility. Br J Radiol 39:901, 1967 4. Rowley MJ, Leach DR, Warner GA, Heller GR: Effects of graded doses of ionizing radiation on the human testis. Radiat Res 59:665, 1974
454
5. Ray B, Hajdu SJ, Whitmore WF: Distribution of retroperitoneal lymph node metastases in testicular germinal tumors. Cancer 33:340, 1974 6. Weissbach L, Bode HU:. Die modifizierte Lymphadenektomie zur Protektion der Ejakulation. In Nicht-seminomatose Hodentumoren, Edited by HJ Iiliger, H Sack, S Seeber, L Weissbach. Basel, S. Karger, 1982, p 133 7. Weissbach L, Boedefeld EA, Oberdiirster W: Non-seminomatous testicular tumors: results after 2 years of a prospective clinical trial in stage I. Verh Dtsch Krebsges 5:651, 1984 8. Kedia KR, Markland C, Fraley EE: Sexual function following high retroperitoneal lymphadenectomy: J Urol 114:237, 1975 9. Narayan P, Lange PH, Fraley EE: Ejaculation and fertility after extended retroperitoneal lymph node dissection for testicular cancer. J Urol 127:685, 1982
Fritz and Weissbach Fertility after retroperitoneal lymphadenectomy
Fertility and Sterility