Clinical stage I testicular nonseminomatous germ cell tumours (NSGCT) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines.

CS I is defined negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low risk and in high risk NSGCT with an anticipated relapse rate of about 15% and 50%. The majority of patients will relapse with good and intermediate prognosis tumours which have to be treated with 3 to 4 cycles chemotherapy. About 25% to 30% of these patients will have to undergo postchemotherapy RPLND for residual masses. Primary chemotherapy with 1 -2 cycles PEB is a therapeutic option for high risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. Nerve sparing RPLND, if performed properly, will cure about 85% of all high risk patients with clinical stage I NSGCT without the need for chemotherapy.

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND)plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCT). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a PET scan performed 6-8 weeks after chemotherapy is positive. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication which can be prevented by a nerve sparing or modified template resection. The relapse rate after PC-RPLND is around 12%, however it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemo-refractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.