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Testicular cancer survivorship

chemotherapy setting due to either the desmoplastic reaction mass, in addition to depressive symptoms, impaired cognitive
that occurs after chemotherapy or the specific location of function, abdominal obesity, and anemia. 92,93 TD has also been
any residual masses. 80 associated with metabolic syndrome and CVD. 91,92,94
Rates of antegrade ejaculation with a nerve-sparing
approach are as high as 99% in the primary RPLND setting Management recommendations
and 76% in the post-chemotherapy RPLND setting; 79,81-83 • For TCS, the presence of one or more signs or symptoms
however, these rates can be highly variable and dependent of TD should prompt evaluation of morning serum tes-
on the volume and expertise in the centers at which the tosterone levels. 95,96
surgery is performed. 79,83,84 • Current guidelines recommend testosterone replacement
The contemporary approach to RPLND is through a therapy only for men who have both signs or symptoms
transperitoneal midline laparotomy extending from the of TD AND low serum testosterone levels. In patients with
xiphoid process to a few centimeters below the umbilicus. symptoms of TD without low serum testosterone levels,
Extraperitoneal, laparoscopic and robotic RPLND approach- alternate causes for the symptoms should be investigated
es have been used in an attempt to decrease morbidity; (mood disorders, CVD, other medical conditions, cancer
however, their use has been limited within the Canadian recurrence). For TCS started on testosterone replacement
healthcare system. The transperitoneal midline approach therapy, followup should be done to assess biochemical
85
does leave patients with a large midline laparotomy scar and clinical response. 95,97
and risk of ventral hernia of 1–4%. 79,84 • Exogenous testosterone administration is contraindi-
Scarring within the abdomen can lead to entrapment of cated in TCS seeking future fertility due to the negative
the bowels but long-term rates of small bowel obstruction impacts testosterone replacement therapy can have on
are <2% and cases of ureteral obstruction due to retroperi- sperm production. 96,98
toneal fibrosis have been reported rarely. 79,86 • In men with symptoms of TD who wish to preserve
future fertility, a referral to fertility specialist should be
Management recommendations made for consideration of fertility-preserving therapies,
• Nerve-sparing techniques for RPLND should be such as selective estrogen receptor modulators, aro-
employed when possible. matase inhibitors, and human chorionic gonadotropin
• TCS having undergone open RPLND should be aware hormone. 93,96
of the possibility of ventral hernia and rare risk of bowel
entrapment. 79,84,86 Fertility

4. Testosterone deficiency and fertility TCS may have impaired fertility even prior to initiation of any
treatment, with up to 50% having abnormal semen param-
eters. 99-101 and up to 24% having azoospermia. The impact
102
Testosterone deficiency of orchiectomy on semen parameters is not well-defined,
with some studies demonstrating worse semen parameters
There is limited data on baseline testosterone levels in men or even azoospermia after surgery, while others demon-
103
diagnosed with TC prior to receiving any treatment, although strate improvement after unilateral orchiectomy in patients
87
some patients may have pre-existing testosterone deficiency on surveillance protocols. 104
(TD). Following orchiectomy alone, most patients retain nor- RPLND is associated with reduced fertility rates, although
88
mal serum testosterone levels, with one large cohort study these impacts can be largely mitigated with the use of mod-
showing low testosterone (total testosterone <10 nmol/L) in ern surgical techniques, such as nerve-sparing surgery. The
11% of patients on surveillance for a median of 11.4 years. 89 fertility rate of TCS undergoing nerve-sparing RPLND was
Compared to patients treated with orchiectomy alone, a 62% vs. 37% in TCS who had non-nerve-sparing RPLND. 105
meta-analysis found that the ORs for developing TD were 1.8 Chemotherapy can negatively affect semen quality,
for conventional chemotherapy, 3.1 for non-conventional although the severity depends on the specific treatment
chemotherapy (>4 cycles or the combination of chemother- regimen. 106 The impacts of chemotherapy are lower with
apy and radiation), and 1.6 for infra-diaphragmatic radio- carboplatin vs. cisplatin 102,106-108 and single-dose adjuvant
therapy with followup of two months to 12 years. The rate chemotherapy regimens, 102,109 and higher with more treat-
90
of TD in patients treated with chemotherapy or radiation ment cycles, higher cumulative doses, and use of alkylating
increases over time post-treatment, particularly in older agents. 102,106,110,111 In patients treated with platinum-based
patients and those receiving multimodal therapy. chemotherapy, 20% develop azoospermia at one year,
91
Clinical signs and symptoms of TD include decreased libi- with recovery of some spermatogenesis in 48% and 80%
do, energy level, muscle strength, bone density, and lean body of patients at two and five years, respectively. 106,108,111

CUAJ • August 2022 • Volume 16, Issue 8 263