Society For Pediatric Urology

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Delayed return of ejaculatory function in adolescent males treated with RPLND and adjuvant therapy for paratesticular rhabdomyosarcoma
James Rague, MD1, Briony Varda, MD2, Andrew Wagner, MD3, Richard Lee, MD2.
1Boston Medical Center, Boston, MA, USA, 2Boston Children's Hospital, Boston, MA, USA, 3Beth Israel Deconess Medical Center, Boston, MA, USA.

BACKGROUND: Due to the rarity of the disease and evolving treatment strategies, adverse events related to ejaculatory function following the management of paratesticular rhabdomyosarcoma (ptRMS) with multi-modal therapy in adolescents are rarely discussed. We sought to analyze the effect of nerve-sparing retroperitoneal lymph node dissection (NS-RPLND), chemotherapy, and radiotherapy on ejaculatory function in adolescent males and potential for delayed recovery of function after cessation of all therapies.
METHODS: A single-institution retrospective case report was performed. Patient’s with ptRMS who underwent surgical resection followed by multi-modal therapy with the side-effect of delayed return of ejaculatory function were assessed. Ejaculatory function was determined via patient interview during follow-up visits over a >2 year period. Two adolescent males, ages 15 and 17 at the time of diagnosis were reviewed. Each underwent radical orchiectomy followed by NS-RPLND and adjuvant chemotherapy with vincristine, actinomycin and cyclophosphamide. One of the two patients also underwent adjuvant pelvic radiation. We sought to assess the effects of each aspect of multi-modal therapy on the observed side-effect.
RESULTS: Two patients with ptRMS who underwent multi-modal therapy with initial loss of antegrade ejaculation after NS-RPLND had spontaneous return of ejaculatory function first reported 18 months from the initial diagnosis and 1 year from completion of all adjuvant therapy. Nerve sparing RPLND (NS-RPLND) is a well described technique with a high success rate particularly for low stage germ cell tumors (GCT). However, ptRMS requires postoperative adjuvant therapy (chemotherapy +/- radiotherapy) that differs significantly from GCT treatment algorithms. NS-RPLND has been shown to have high rates of preservation of post-operative ejaculatory function. While chemotherapy may have neurotoxic effects, autonomic toxicity appears to be uncommon. Likewise, there are few reports of abdominal and pelvic radiation leading to acute neurotoxicity. Any radiation effect on ejaculation reported in the adult population appears to be long-term. The cumulative effect of multi-modal therapy on ejaculatory function is somewhat difficult to assess, however may contribute to a temporary loss of normal ejaculatory function in adolescent males.
CONCLUSIONS: Ejaculatory function outcomes after NS-RPLND for ptRMS is poorly reported. We observed an extended loss of antegrade ejaculatory function after bilateral NS-RPLND and adjuvant chemotherapy +/- radiotherapy. Both cases had a delayed spontaneous return of ejaculatory function after resolution of the side effects of the adjuvant therapy. Physicians treating ptRMS should be aware that after NS-RPLND, ejaculatory function may still return after the completion of adjuvant therapy if initially lost. Validated questionnaires at time of follow-up may be helpful to capture specific areas of dysfunction as they occur.

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