Simultaneous radical orchiectomy and primary RPLND in a case of cancer developed on a secondary intra-abdominal testis

Introduction and objectives: Testicular cancer represents approximately 1-1.5% of all forms of male cancer and 5% of urogenital neoplasia. The relative risk of developing testicular cancer on an intraabdominal testis is 2.75 – 8 times higher. The aim of this paper is to present the therapeutic strategy in a rare case of a testicular tumor developed on a secondary intraabdominally located testis after a surgical intervention. Materials and methods: A 38 year old patient was diagnosed, during the investigations for male infertility, with absence of the left testicle and an abdominal tumor. The anamnesis described a hypermobile left testicle, that became stuck in the abdomen after an intervention for left inguinal hernia which had been performed two years prior. Blood tests including the tumor markers were within the normal ranges. A chest, abdomen and pelvis contrast enhanced CT scan revealed a left pelvic tumor of about 15 cm (the abdominal malignant testis), and microadenopathy on the left side of the aorta.. A hockey stick incision with left pararectal extension was performed, and the left tumor testicle was identified. After the left orchiectomy the frozen section biopsy revealed a pure seminoma. Considering the incidence rate of retroperitoneal micro metastases in stage I high risk seminomas of up to 32%, and taking into account the length of the incision needed to excise the main tumor, we decided to perform a primary left RPLND. The dissection limits were represented superior by the left renal vein, lateral by the ureter, medial by interaorticocaval space above the origin of the inferior mesenteric artery, below this level the limit being set by the common iliac artery, in order to preserve the hypogastric plexus of the anterior side of the aortic bifurcation, with an important role in ejaculation. Results: No immediate or late postoperative complications were registered. The histopathological exam confirmed the diagnosis of a large classical testicular seminoma, with a maximum diameter of 15 cm, that invaded the albugineea, epididimis and fat tissues from the proximal part of spermatic cord (pT3). The analysis of fat and lymphatic tissues from lateroaortic space showed sinusal histiocytosis in a group of 11 lymph nodes (N0). The tumor markers remained negative throughout the follow-up period, and no adjuvant therapy was necessary. At the 1 year mark, a toraco-abdomino-pelvic CT scan showed no signs of local relapse or secondary metastases. Conclusions: This rare case confirms the high incidence of testicular cancer developed on an intraabdominal testis, not only undescended but also secondary after a surgical intervention for an inguinal hernia. Although the standard treatment for testicular high risk seminoma consists of orchiectomy and chemotherapy, in selected cases a primary RPLND ca provide an efficient therapeutic alternative.