Nerve of the Hypogastric Plexus in Patients with Testicular Cancer Undergoing Retroperitoneal Lymph-Node Dissection for Cure

Genitourinary applications of nerve reconstruction have recently been brought to the forefront with restoration of sympathetic function conveyed by the cavernous nerves via nerve grafting, in order to restore erectile function in patients undergoing radical retropubic prostatectomy with nerve sacrifice. This successful restoration of autonomic function with nerve grafting procedures prompted these authors to apply these principles to a group of younger men undergoing radical retroperitoneal lymphadenectomy (RPLND) for treatment and cure of testicular carcinoma, with nerve grafting of the postganglionic parasympathetic nerves of the hypogastric plexus that confers anterograde ejaculatory function.

Although nerve-sparing RPLND can maintain ejaculatory function, nerve sacrifice may be necessary, depending on the tumor burden. Since 75% of men who have retroperitoneal relapse will still be cured of disease and can have normal fertility, maintenance of anterograde emission can alleviate the need for in vitro fertility strategies in the future for these patients.

Nerve grafting of the hypogastric plexus has been carried out in three men (age range: 28–33 years) undergoing RPLND, using genitofemoral (GF) nerve grafts. Reconstructions were bilateral in two cases and unilateral in one case. Multiple grafts were placed in all cases and the nerve gap was usually 10 cm. Nerve coaptation utilized 8-0 nylon sutures.

Patients have been followed for 4–15 months. There are no complaints related to sensory disturbance in the distribution of the GF nerves. To date, the first patient who underwent bilateral plexus grafts has developed anterograde ejaculatory function. Follow-up is pending on the remaining patients.

These early results demonstrate the feasibility of GF nerve grafting of the hypogastric plexus in young men undergoing RPLND for cure of testicular cancer, in order to successfully restore ejaculatory function for potential fertility after cure.