Long-Term Sexual Dysfunction and Fertility Outcomes Following Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Testicular Cancer Patients

Long-Term Sexual Dysfunction and Fertility Outcomes Following Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Testicular Cancer Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-Term Sexual Dysfunction and Fertility Outcomes Following Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Testicular Cancer Patients Mesut Altan, Berk Hazir, Hakan Keskin, Durmus Alptug Cosar, Rabia Hizarci, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8228319/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Background Since testicular cancer typically affects relatively young patients, retroperitoneal sympathetic nerve injury following post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) may lead to significant sexual dysfunction. This study aims to assess long-term outcomes related to ejaculatory dysfunction, erectile dysfunction (ED), and fertility in patients who have undergone PC-RPLND for advanced-stage testicular tumors. Methods Patients who underwent PC-RPLND between 2000 and 2021 were retrospectively contacted via telephone or email. Patients' pre-treatment paternity status, sperm cryopreservation, and post-treatment fertility status were evaluated. The impact of factors such as patient age, tumor laterality, surgical approach, and second-line chemotherapy on ED and ejaculatory dysfunction was analyzed. Erectile function was assessed using the Turkish-validated International Index of Erectile Function-5 (IIEF-5). Statistical analyses were performed using SPSS version 23.0. Results The study included patients with a mean surgical age of 28.8 ± 7.7 years and a mean current age of 39.2 ± 9.5 years, with a median follow-up of 116 months (53–290 months). Prior to treatment, 42 patients (38.5%) underwent sperm cryopreservation, while post-treatment, 52 patients (47.7%) expressed a desire for paternity. Paternity status was only predictor for sperm cryopreservation (p = 0.002, OR = 0.186 95%CI 0.062–0.552). Ejaculatory dysfunction (EjD) was reported in 28.4% of patients, with a significantly higher incidence in the fully bilateral template RPLND group compared to the modified template group (67.9% vs. 14.8%, p < 0.001). ED was identified in 37.6% of patients, but no significant associations were found between ED and clinical or surgical variables. Conclusion Long-term sexual dysfunction, particularly ejaculatory disorders, remains a significant issue following PC-RPLND, especially in patients undergoing fully bilateral template dissection. Fertility and ejaculation problems associated with this technique may be mitigated through preoperative sperm cryopreservation. RPLND PC-RPLND Sperm cryopreservation retrograde ejaculation infertility sexual dysfunction INTRODUCTION Testicular tumors account for approximately 1% of adult cancers, and their incidence has been increasing over the years in industrialized countries ( 1 – 3 ). The introduction of cisplatin-based chemotherapy as a cornerstone of multimodal treatment has advanced testicular tumor management, leading to a significant improvement in survival rates, reaching approximately 60% even in advanced-stage patients with poor prognostic factors ( 4 ). Currently, post chemotherapy retroperitoneal lymph node dissection (PC-RPLND) remains a critical component of the multimodal treatment approach for advanced-stage testicular tumors ( 5 ). Retroperitoneal sympathetic nerve injury following PC-RPLND, performed in relatively young patients, highlights the importance of evaluating the risks, incidence, and preventive strategies for potential post-treatment sexual dysfunction, particularly ejaculatory disorders ( 6 ). Ejaculatory dysfunction, primarily retrograde ejaculation due to sympathetic nerve disruption ( 7 ), along with erectile dysfunction resulting from prior retroperitoneal surgery and chemotherapy-induced infertility, are among the most significant sexual complications associated with testicular cancer treatment ( 8 ). This study aims to investigate long-term ejaculatory dysfunction, erectile dysfunction, and fertility trends in patients who underwent PC-RPLND for advanced-stage testicular tumors. METHODS Between 2000 and 2021, patients who underwent PC-RPLND for advanced testicular tumors were contacted via telephone or email. Exclusion criteria included patients treated for recurrent testicular cancer, those diagnosed with extragonadal germ cell tumors, and individuals who did not provide informed consent for participation. Data were collected on 109 patient age, pre-treatment parity, the use of cryopreservation prior to therapy, post-treatment reproductive intentions, fertility status, and methods employed to achieve fertility. Additionally, patients were asked to complete the Turkish-validated version of the International Index of Erectile Function (IIEF-5). All patients underwent evaluation with thoracoabdominal computed tomography and tumor marker analysis following orchiectomy. For patients with non-seminomatous germ cell tumors (NSGCT), these assessments were repeated after receiving first-line platinum-based chemotherapy, while Positron Emission Tomography – Computed Tomography (PET-CT) imaging was performed for seminoma cases. Patients in the NSGCT group with persistently elevated tumor markers proceeded to second-line chemotherapy. PC-RPLND was performed in NSGCT patients presenting with a residual retroperitoneal mass larger than 1 cm and in seminoma patients with evidence of viable tumor on PET-CT imaging. Full bilateral template or modified template RPLND was performed at the discretion of the attending surgeon ( 4 , 6 ). Sperm cryopreservation was recommended to all patients prior to undergoing orchiectomy and before the initiation of chemotherapy. Patients were stratified into two groups—favorable and non-favorable (comprising intermediate and poor prognosis)—based on the International Germ Cell Cancer Collaborative Group (IGCCCG). The patients were divided into two groups based on primary testicular pathology: seminoma and NSGCT. According to the PC-RPLND pathology, they were categorized into three groups: necrosis, viable tumor, and teratoma. Patients requiring additional procedures during surgery to achieve complete resection, including nephrectomy, bowel repair, aortic or vena caval repair (primary or graft-based), and ureteral repair, were classified as the additional procedure group. This study was approved by the Ethics Committee of Hacettepe University (Approval No: 2024/21 − 02, Date: 30.07.2024).Statistical analysis was performed using SPSS software (version 23.0, Chicago, IL). Parametric data were presented as mean ± standard deviation (SD), while non-parametric data were expressed as median (min–max). Nominal variables were analyzed using the chi-square test. Group comparisons for parametric data were conducted using the t-test . Variables found to be significant in univariate analysis were further evaluated with multivariate analysis using binary logistic regression. RESULTS The mean age at the time of surgery was calculated as 28.8 ± 7.7 years, while the current mean age was determined to be 39.2 ± 9.5 years. The median follow-up period was determined to be 116 months (53–290 months). Prior to treatment, 42 patients (38.5%) underwent sperm cryopreservation. In univariate analysis, treatment age and paternity status were found to be significantly associated with sperm cryopreservation (p = 0.001, p < 0.0001, respectively). However, in multivariate analysis, paternity status was only predictor for sperm cryopreservation (p = 0.002, OR = 0.186 95%CI 0.062–0.552). After PC-RPLND, 52 patients (47.7%) expressed a desire for paternity. No significant association was found between post-treatment paternity desire and prior sperm cryopreservation (p = 0.988). Among these 52 patients, 36 (33%) successfully achieved fatherhood. Fourteen of them had cryopreserved sperm, whereas the remainder had not opted for sperm cryopreservation. Assisted reproductive techniques were required in 7 patients from the cryopreservation group and in 3 patients from the non-cryopreservation group (p = 0.018). Among the study population, a total of 31 patients (28.4%) reported experiencing ejaculation disorders (EjD), while 78 patients (71.6%) reported no issues with ejaculation. The incidence of EjD differed significantly between groups, with a rate of 14.8% in the modified template group and 67.9% in the fully bilateral template group (p < 0.001). No statistically significant associations were identified between EjD and factors such as age, tumor side, pathology (seminoma vs. NSGCT), IGCCCG risk group (favorable vs. non-favorable), additional procedures, second-line chemotherapy, or PC-RPLND pathology (necrosis, teratoma, or viable tumor) (p = 0.681, p = 0.975, p = 0.991, p = 0.400, p = 0.683, p = 0.535, and p = 0.354, respectively) (Table 1 ). Table 1 Association of surgical and clinical parameters with postoperative ejaculatory and erectile dysfunction. Parameters Ejaculator Dysfunction Erectile Dysfunction absent present p absent present p Operation , n(%) Bil. full template 9 (32.1) 19 (67.9) < 0.001 18 (64.3) 10 (35.7) 0.810 Modified Uni. template 69 (85.2) 12 (14.8) 50 (61.7) 31 (38.3) Tumor side , n(%) Right 40 (71.4) 16 (28.6) 0.975 39 (69.6) 17 (30.4) 0.108 Left 38 (71.7) 15 (28.3) 29 (54.7) 24 (45.3) Pathology , n(%) Seminoma 10 (71.4) 4 (28.6) 0.991 8 (57.1) 6 (42.9) 0.664 NSGHTs 68 (71.6) 27 (28.4) 60 (63.2) 35 (36.8) IGCCC risk group , n(%) Favorable 59 (73.8) 21 (26.8) 0.400 53 (66.3) 27 (33.8) 0.167 Non-favorable 19 (65.5) 10 (34.5) 15 (51.7) 14 (48.3) Additional procedures , n(%) Present 17 (73.9) 6 (26.1) 0.683 14 (60.9) 9 (39.1) 0.908 Absent 57 (69.5) 25 (30.5) 51 (62.2) 31 (37.8) Second-line chemotherapy , n(%) Present 9 (64.3) 5 (35.7) 0.535 6 (42.9) 8 (57.1) 0.106 Absent 69 (72.6) 26 (27.4) 62 (65.3) 33 (34.7) PC-RPLND pathology , n(%) Necrosis 31 (79.5) 8 (20.5) 0.354 24 (61.5) 15 (38.5) 0.989 Teratoma 39 (66.1) 20 (33.9) 37 (62.7) 22 (37.3) Viable tumor 8 (72.7) 3 (27.3) 7 (63.6) 4 (37.6) IGCCC: The International Germ Cell Cancer Collaborative Group, PC-RPLND: post chemotherapy retroperitoneal lymph node dissection Analysis of the International Index of Erectile Function-5 (IIEF-5) results revealed that 68 patients (62.4%) had no evidence of ED, while 24 patients (22.0%) experienced mild ED, 14 patients (12.8%) had mild-to-moderate ED, 1 patient (0.9%) exhibited moderate ED, and 2 patients (1.8%) had severe ED. No significant associations were observed between ED and variables such as age, tumor side, surgical approach (modified vs. full template), pathology (seminoma vs. NSGCT), IGCCC risk group, additional procedures, second-line chemotherapy, or PC-RPLND pathology (p = 0.054, p = 0.108, p = 0.664, p = 0.167, p = 0.908, p = 0.106, and p = 0.989, respectively) (Table 1 ). DISCUSSION This study revealed that sperm cryopreservation did not correspond with actual paternity desires after a ten-year follow-up. Use of a modified template RPLND substantially improved ejaculatory outcomes following surgery. No additional factors were found to significantly affect postoperative ejaculatory function. Moreover, although ED may occur after RPLND, neither surgical technique nor patient-related factors such as age or tumor characteristics demonstrated a significant impact on postoperative erectile function. The postganglionic sympathetic fibers responsible for facilitating antegrade ejaculation traverse dorsally to the inferior vena cava and ventrally to the aorta, ultimately converging to form the hypogastric plexus on the ventral aspect of the aorta, caudal to the origin of the inferior mesenteric artery. This sympathetic nerve plexus is situated within the surgical field during RPLND, and intraoperative injury to these fibers may impede the physiological mechanism of antegrade ejaculation. Despite the potential for recurrence beyond standard template boundaries, advances in the understanding of testicular lymphatic drainage have led to the development of template-based dissection models in RPLND ( 7 , 9 – 11 ). These models, characterized by a more restricted contralateral dissection approach, aimed to reduce surgical complications and preserve ejaculatory function. Subsequently, nerve-sparing techniques were adopted to preserve antegrade ejaculation during RPLND ( 12 ). Consistent with these findings, patients in this cohort treated with modified unilateral template PC-RPNL showed positive results on ejaculation. ED occurs at a moderate rate among testicular cancer survivors. In line with our findings, its reported incidence ranges from 12% to 40% ( 8 , 13 – 15 ). Identifying the precise etiology remains challenging, as survivors often undergo different treatment modalities. Proposed contributing factors include both organic and psychological components. Emerging evidence also points to non-vasculogenic mechanisms, potentially influenced by adrenergic activity and anxiety-related pathways ( 8 ). Furthermore, irrespective of the RPLND approach, the procedure itself may impair erectile function. Because recovery of normal erectile function is significantly compromised following both primary and post-chemotherapy RPLND ( 16 ), appropriate andrological evaluation and management are warranted in patients undergoing PC-RPLND. Sperm cryopreservation for fertility preservation is a crucial part of pretreatment management of testicular cancer as the treatment of testicular cancer, especially chemotherapy has a detrimental effect on sperm quality. Even before treatment, semen quality may be low in patients diagnosed with testicular cancer ( 17 ). In a study of 173 semen samples from 67 patients with testicular cancer who cryopreserved sperm prior to treatment, Hotaling et al. reported that men with seminoma exhibited poorer total motility counts after thawing. The authors concluded that patients with seminoma histology or a lower fresh total motility count (< 25–30 million) should consider preserving additional vials before initiating oncologic therapy ( 18 ). This study has several limitations. Its retrospective, single-center design introduces potential recall and selection bias, limiting generalizability. The long study period spanning two decades adds variability due to evolving surgical techniques, chemotherapy protocols, and fertility preservation strategies. Outcomes relied on self-reported data—paternity rather than semen analysis and the brief IIEF-5 tool—which may not fully capture fertility or sexual health. Finally, surgical approach (full bilateral vs. modified template RPLND) was based on surgeon discretion, introducing additional variability. Despite its limitations, this study has several important strengths. It represents one of the largest cohorts reported in the literature, with long-term follow-up offering rare insights into late treatment effects. Clinically relevant outcomes—ejaculatory function, ED, and fertility—were comprehensively evaluated in conjunction with demographic and treatment variables. Notably, comparison of surgical approaches underscores the benefits of modified template RPLND, and the study contributes valuable long-term, real-world evidence to a limited body of literature. CONCLUSION The feasibility of nerve-sparing techniques and modified template dissection may be limited in patients with advanced tumor burden. Given the young age and favorable long-term survival of this cohort, comprehensive preoperative counseling is essential, emphasizing sperm cryopreservation, the risk of retrograde ejaculation, and potential postoperative management. Such measures support informed decision-making and help optimize long-term quality-of-life outcomes. Declarations Competing interests All authors declare no competing interests. Ethics approval and consent to participate: Ethics approval was obtained from the Ethics Committee of Hacettepe University with the study number of SBA 24/787, on 10.12.2024 with 2024/21-02 approval number. 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Capogrosso P, Boeri L, Ferrari M, Ventimiglia E, La Croce G, Capitanio U, et al. Long-term recovery of normal sexual function in testicular cancer survivors. Asian J Androl. 2016;18(1):85–9. Hotaling JM, Lopushnyan NA, Davenport M, Christensen H, Pagel ER, Muller CH, et al. Raw and test-thaw semen parameters after cryopreservation among men with newly diagnosed cancer. Fertil Steril. 2013;99(2):464–9. Hotaling JM, Patel DP, Vendryes C, Lopushnyan NA, Presson AP, Zhang C, et al. Predictors of sperm recovery after cryopreservation in testicular cancer. Asian J Androl. 2016;18(1):35–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 29 Dec, 2025 Reviews received at journal 29 Dec, 2025 Reviews received at journal 20 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviewers agreed at journal 16 Dec, 2025 Reviewers agreed at journal 15 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviews received at journal 11 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers invited by journal 11 Dec, 2025 Editor assigned by journal 10 Dec, 2025 Submission checks completed at journal 10 Dec, 2025 First submitted to journal 28 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Patients","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTesticular tumors account for approximately 1% of adult cancers, and their incidence has been increasing over the years in industrialized countries (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The introduction of cisplatin-based chemotherapy as a cornerstone of multimodal treatment has advanced testicular tumor management, leading to a significant improvement in survival rates, reaching approximately 60% even in advanced-stage patients with poor prognostic factors (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Currently, post chemotherapy retroperitoneal lymph node dissection (PC-RPLND) remains a critical component of the multimodal treatment approach for advanced-stage testicular tumors (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRetroperitoneal sympathetic nerve injury following PC-RPLND, performed in relatively young patients, highlights the importance of evaluating the risks, incidence, and preventive strategies for potential post-treatment sexual dysfunction, particularly ejaculatory disorders (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Ejaculatory dysfunction, primarily retrograde ejaculation due to sympathetic nerve disruption (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), along with erectile dysfunction resulting from prior retroperitoneal surgery and chemotherapy-induced infertility, are among the most significant sexual complications associated with testicular cancer treatment (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to investigate long-term ejaculatory dysfunction, erectile dysfunction, and fertility trends in patients who underwent PC-RPLND for advanced-stage testicular tumors.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eBetween 2000 and 2021, patients who underwent PC-RPLND for advanced testicular tumors were contacted via telephone or email. Exclusion criteria included patients treated for recurrent testicular cancer, those diagnosed with extragonadal germ cell tumors, and individuals who did not provide informed consent for participation. Data were collected on 109 patient age, pre-treatment parity, the use of cryopreservation prior to therapy, post-treatment reproductive intentions, fertility status, and methods employed to achieve fertility. Additionally, patients were asked to complete the Turkish-validated version of the International Index of Erectile Function (IIEF-5).\u003c/p\u003e \u003cp\u003eAll patients underwent evaluation with thoracoabdominal computed tomography and tumor marker analysis following orchiectomy. For patients with non-seminomatous germ cell tumors (NSGCT), these assessments were repeated after receiving first-line platinum-based chemotherapy, while Positron Emission Tomography \u0026ndash; Computed Tomography (PET-CT) imaging was performed for seminoma cases. Patients in the NSGCT group with persistently elevated tumor markers proceeded to second-line chemotherapy. PC-RPLND was performed in NSGCT patients presenting with a residual retroperitoneal mass larger than 1 cm and in seminoma patients with evidence of viable tumor on PET-CT imaging. Full bilateral template or modified template RPLND was performed at the discretion of the attending surgeon (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSperm cryopreservation was recommended to all patients prior to undergoing orchiectomy and before the initiation of chemotherapy. Patients were stratified into two groups\u0026mdash;favorable and non-favorable (comprising intermediate and poor prognosis)\u0026mdash;based on the International Germ Cell Cancer Collaborative Group (IGCCCG). The patients were divided into two groups based on primary testicular pathology: seminoma and NSGCT. According to the PC-RPLND pathology, they were categorized into three groups: necrosis, viable tumor, and teratoma. Patients requiring additional procedures during surgery to achieve complete resection, including nephrectomy, bowel repair, aortic or vena caval repair (primary or graft-based), and ureteral repair, were classified as the additional procedure group.\u003c/p\u003e \u003cp\u003e This study was approved by the Ethics Committee of Hacettepe University (Approval No: 2024/21\u0026thinsp;\u0026minus;\u0026thinsp;02, Date: 30.07.2024).Statistical analysis was performed using SPSS software (version 23.0, Chicago, IL). Parametric data were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while non-parametric data were expressed as median (min\u0026ndash;max). Nominal variables were analyzed using the chi-square test. Group comparisons for parametric data were conducted using the \u003cem\u003et-test\u003c/em\u003e. Variables found to be significant in univariate analysis were further evaluated with multivariate analysis using binary logistic regression.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe mean age at the time of surgery was calculated as 28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 years, while the current mean age was determined to be 39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5 years. The median follow-up period was determined to be 116 months (53\u0026ndash;290 months).\u003c/p\u003e \u003cp\u003ePrior to treatment, 42 patients (38.5%) underwent sperm cryopreservation. In univariate analysis, treatment age and paternity status were found to be significantly associated with sperm cryopreservation (p\u0026thinsp;=\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, respectively). However, in multivariate analysis, paternity status was only predictor for sperm cryopreservation (p\u0026thinsp;=\u0026thinsp;0.002, OR\u0026thinsp;=\u0026thinsp;0.186 95%CI 0.062\u0026ndash;0.552).\u003c/p\u003e \u003cp\u003eAfter PC-RPLND, 52 patients (47.7%) expressed a desire for paternity. No significant association was found between post-treatment paternity desire and prior sperm cryopreservation (p\u0026thinsp;=\u0026thinsp;0.988). Among these 52 patients, 36 (33%) successfully achieved fatherhood. Fourteen of them had cryopreserved sperm, whereas the remainder had not opted for sperm cryopreservation. Assisted reproductive techniques were required in 7 patients from the cryopreservation group and in 3 patients from the non-cryopreservation group (p\u0026thinsp;=\u0026thinsp;0.018).\u003c/p\u003e \u003cp\u003eAmong the study population, a total of 31 patients (28.4%) reported experiencing ejaculation disorders (EjD), while 78 patients (71.6%) reported no issues with ejaculation. The incidence of EjD differed significantly between groups, with a rate of 14.8% in the modified template group and 67.9% in the fully bilateral template group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No statistically significant associations were identified between EjD and factors such as age, tumor side, pathology (seminoma vs. NSGCT), IGCCCG risk group (favorable vs. non-favorable), additional procedures, second-line chemotherapy, or PC-RPLND pathology (necrosis, teratoma, or viable tumor) (p\u0026thinsp;=\u0026thinsp;0.681, p\u0026thinsp;=\u0026thinsp;0.975, p\u0026thinsp;=\u0026thinsp;0.991, p\u0026thinsp;=\u0026thinsp;0.400, p\u0026thinsp;=\u0026thinsp;0.683, p\u0026thinsp;=\u0026thinsp;0.535, and p\u0026thinsp;=\u0026thinsp;0.354, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of surgical and clinical parameters with postoperative ejaculatory and erectile dysfunction.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eEjaculator Dysfunction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eErectile Dysfunction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eabsent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eabsent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eOperation\u003c/b\u003e, \u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBil. full template\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModified Uni. template\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (85.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e50 (61.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e31 (38.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTumor side\u003c/b\u003e, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e17 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (71.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (28.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29 (54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e24 (45.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePathology\u003c/b\u003e, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeminoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSGHTs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (71.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27 (28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60 (63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e35 (36.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eIGCCC risk group\u003c/b\u003e, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFavorable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (73.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e53 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e27 (33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-favorable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (65.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14 (48.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAdditional procedures\u003c/b\u003e, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (73.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.683\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14 (60.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.908\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (69.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e51 (62.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e31 (37.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSecond-line chemotherapy\u003c/b\u003e, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (72.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62 (65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e33 (34.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePC-RPLND pathology\u003c/b\u003e, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNecrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeratoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (66.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37 (62.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e22 (37.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eViable tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4 (37.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eIGCCC: The International Germ Cell Cancer Collaborative Group, PC-RPLND: post chemotherapy retroperitoneal lymph node dissection\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnalysis of the International Index of Erectile Function-5 (IIEF-5) results revealed that 68 patients (62.4%) had no evidence of ED, while 24 patients (22.0%) experienced mild ED, 14 patients (12.8%) had mild-to-moderate ED, 1 patient (0.9%) exhibited moderate ED, and 2 patients (1.8%) had severe ED. No significant associations were observed between ED and variables such as age, tumor side, surgical approach (modified vs. full template), pathology (seminoma vs. NSGCT), IGCCC risk group, additional procedures, second-line chemotherapy, or PC-RPLND pathology (p\u0026thinsp;=\u0026thinsp;0.054, p\u0026thinsp;=\u0026thinsp;0.108, p\u0026thinsp;=\u0026thinsp;0.664, p\u0026thinsp;=\u0026thinsp;0.167, p\u0026thinsp;=\u0026thinsp;0.908, p\u0026thinsp;=\u0026thinsp;0.106, and p\u0026thinsp;=\u0026thinsp;0.989, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study revealed that sperm cryopreservation did not correspond with actual paternity desires after a ten-year follow-up. Use of a modified template RPLND substantially improved ejaculatory outcomes following surgery. No additional factors were found to significantly affect postoperative ejaculatory function. Moreover, although ED may occur after RPLND, neither surgical technique nor patient-related factors such as age or tumor characteristics demonstrated a significant impact on postoperative erectile function.\u003c/p\u003e \u003cp\u003eThe postganglionic sympathetic fibers responsible for facilitating antegrade ejaculation traverse dorsally to the inferior vena cava and ventrally to the aorta, ultimately converging to form the hypogastric plexus on the ventral aspect of the aorta, caudal to the origin of the inferior mesenteric artery. This sympathetic nerve plexus is situated within the surgical field during RPLND, and intraoperative injury to these fibers may impede the physiological mechanism of antegrade ejaculation. Despite the potential for recurrence beyond standard template boundaries, advances in the understanding of testicular lymphatic drainage have led to the development of template-based dissection models in RPLND (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These models, characterized by a more restricted contralateral dissection approach, aimed to reduce surgical complications and preserve ejaculatory function. Subsequently, nerve-sparing techniques were adopted to preserve antegrade ejaculation during RPLND (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Consistent with these findings, patients in this cohort treated with modified unilateral template PC-RPNL showed positive results on ejaculation.\u003c/p\u003e \u003cp\u003eED occurs at a moderate rate among testicular cancer survivors. In line with our findings, its reported incidence ranges from 12% to 40% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Identifying the precise etiology remains challenging, as survivors often undergo different treatment modalities. Proposed contributing factors include both organic and psychological components. Emerging evidence also points to non-vasculogenic mechanisms, potentially influenced by adrenergic activity and anxiety-related pathways (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, irrespective of the RPLND approach, the procedure itself may impair erectile function. Because recovery of normal erectile function is significantly compromised following both primary and post-chemotherapy RPLND (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), appropriate andrological evaluation and management are warranted in patients undergoing PC-RPLND.\u003c/p\u003e \u003cp\u003eSperm cryopreservation for fertility preservation is a crucial part of pretreatment management of testicular cancer as the treatment of testicular cancer, especially chemotherapy has a detrimental effect on sperm quality. Even before treatment, semen quality may be low in patients diagnosed with testicular cancer (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In a study of 173 semen samples from 67 patients with testicular cancer who cryopreserved sperm prior to treatment, Hotaling et al. reported that men with seminoma exhibited poorer total motility counts after thawing. The authors concluded that patients with seminoma histology or a lower fresh total motility count (\u0026lt;\u0026thinsp;25\u0026ndash;30\u0026nbsp;million) should consider preserving additional vials before initiating oncologic therapy (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study has several limitations. Its retrospective, single-center design introduces potential recall and selection bias, limiting generalizability. The long study period spanning two decades adds variability due to evolving surgical techniques, chemotherapy protocols, and fertility preservation strategies. Outcomes relied on self-reported data\u0026mdash;paternity rather than semen analysis and the brief IIEF-5 tool\u0026mdash;which may not fully capture fertility or sexual health. Finally, surgical approach (full bilateral vs. modified template RPLND) was based on surgeon discretion, introducing additional variability.\u003c/p\u003e \u003cp\u003eDespite its limitations, this study has several important strengths. It represents one of the largest cohorts reported in the literature, with long-term follow-up offering rare insights into late treatment effects. Clinically relevant outcomes\u0026mdash;ejaculatory function, ED, and fertility\u0026mdash;were comprehensively evaluated in conjunction with demographic and treatment variables. Notably, comparison of surgical approaches underscores the benefits of modified template RPLND, and the study contributes valuable long-term, real-world evidence to a limited body of literature.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe feasibility of nerve-sparing techniques and modified template dissection may be limited in patients with advanced tumor burden. Given the young age and favorable long-term survival of this cohort, comprehensive preoperative counseling is essential, emphasizing sperm cryopreservation, the risk of retrograde ejaculation, and potential postoperative management. Such measures support informed decision-making and help optimize long-term quality-of-life outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eEthics approval was obtained from the Ethics Committee of Hacettepe University with the study number of SBA 24/787, on 10.12.2024 with 2024/21-02 approval number.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePark JS, Kim J, Elghiaty A, Ham WS. Recent global trends in testicular cancer incidence and mortality. Med (Baltim). 2018;97(37):e12390.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNigam M, Aschebrook-Kilfoy B, Shikanov S, Eggener S. Increasing incidence of testicular cancer in the United States and Europe between 1992 and 2009. World J Urol. 2015;33(5):623\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurney JK, Florio AA, Znaor A, Ferlay J, Laversanne M, Sarfati D, et al. International Trends in the Incidence of Testicular Cancer: Lessons from 35 Years and 41 Countries. Eur Urol. 2019;76(5):615\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAltan M, Haberal HB, Aş\u0026ccedil;ı A, G\u0026uuml;deloğlu A, Doğrul AB, Yazıcı MS, et al. Determination of risk factors for progression in patients with viable tumor at post-chemotherapy lymph node dissection due to disseminated non-seminomatous germ-cell tumors. Int J Clin Oncol. 2021;26:186\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilligan T, Lin DW, Aggarwal R, Chism D, Cost N, Derweesh IH, et al. Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019;17(12):1529\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobsen N-EB, Foster RS, Donohue JP. Retroperitoneal lymph node dissection in testicular cancer. Surg Oncol Clin N Am. 2007;16(1):199\u0026ndash;220.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeidenreich A, Pfister D, Witthuhn R, Th\u0026uuml;er D, Albers P. Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection. Eur Urol. 2009;55(1):217\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTal R, Stember DS, Logmanieh N, Narus J, Mulhall JP. Erectile dysfunction in men treated for testicular cancer. BJU Int. 2014;113(6):907\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarayan P, Lange PH, Fraley EE. Ejaculation and fertility after extended retroperitoneal lymph node dissection for testicular cancer. J Urol. 1982;127(4):685\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck SD, Foster RS, Bihrle R, Donohue JP, Einhorn LH. Is full bilateral retroperitoneal lymph node dissection always necessary for postchemotherapy residual tumor? Cancer. 2007;110(6):1235\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEggener SE, Carver BS, Sharp DS, Motzer RJ, Bosl GJ, Sheinfeld J. Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer. J Urol. 2007;177(3):937\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonohue J, Foster R, Rowland R, Bihrle R, Jones J, Geier G. Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation. J Urol. 1990;144(2):287\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEberhard J, St\u0026aring;hl O, Cohn-Cedermark G, Cavallin-St\u0026aring;hl E, Giwercman Y, Rylander L, et al. Sexual function in men treated for testicular cancer. J Sex Med. 2009;6(7):1979\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiechno P, Demkow T, Kubiak K, Sadowska M, Kamińska J. The quality of life and hormonal disturbances in testicular cancer survivors in Cisplatin era. Eur Urol. 2007;52(5):1448\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDimitropoulos K, Karatzas A, Papandreou C, Daliani D, Zachos I, Pisters LL, et al. Sexual dysfunction in testicular cancer patients subjected to post-chemotherapy retroperitoneal lymph node dissection: a focus beyond ejaculation disorders. Andrologia. 2016;48(4):425\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCapogrosso P, Boeri L, Ferrari M, Ventimiglia E, La Croce G, Capitanio U, et al. Long-term recovery of normal sexual function in testicular cancer survivors. Asian J Androl. 2016;18(1):85\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHotaling JM, Lopushnyan NA, Davenport M, Christensen H, Pagel ER, Muller CH, et al. Raw and test-thaw semen parameters after cryopreservation among men with newly diagnosed cancer. Fertil Steril. 2013;99(2):464\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHotaling JM, Patel DP, Vendryes C, Lopushnyan NA, Presson AP, Zhang C, et al. Predictors of sperm recovery after cryopreservation in testicular cancer. Asian J Androl. 2016;18(1):35\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"basic-and-clinical-andrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"andr","sideBox":"Learn more about [Basic and Clinical Andrology](https://bacandrology.biomedcentral.com/)","snPcode":"12610","submissionUrl":"https://submission.nature.com/new-submission/12610/3","title":"Basic and Clinical Andrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"RPLND, PC-RPLND, Sperm cryopreservation, retrograde ejaculation, infertility, sexual dysfunction","lastPublishedDoi":"10.21203/rs.3.rs-8228319/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8228319/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSince testicular cancer typically affects relatively young patients, retroperitoneal sympathetic nerve injury following post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) may lead to significant sexual dysfunction. This study aims to assess long-term outcomes related to ejaculatory dysfunction, erectile dysfunction (ED), and fertility in patients who have undergone PC-RPLND for advanced-stage testicular tumors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who underwent PC-RPLND between 2000 and 2021 were retrospectively contacted via telephone or email. Patients' pre-treatment paternity status, sperm cryopreservation, and post-treatment fertility status were evaluated. The impact of factors such as patient age, tumor laterality, surgical approach, and second-line chemotherapy on ED and ejaculatory dysfunction was analyzed. Erectile function was assessed using the Turkish-validated International Index of Erectile Function-5 (IIEF-5). Statistical analyses were performed using SPSS version 23.0.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study included patients with a mean surgical age of 28.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 years and a mean current age of 39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5 years, with a median follow-up of 116 months (53\u0026ndash;290 months). Prior to treatment, 42 patients (38.5%) underwent sperm cryopreservation, while post-treatment, 52 patients (47.7%) expressed a desire for paternity. Paternity status was only predictor for sperm cryopreservation (p\u0026thinsp;=\u0026thinsp;0.002, OR\u0026thinsp;=\u0026thinsp;0.186 95%CI 0.062\u0026ndash;0.552). Ejaculatory dysfunction (EjD) was reported in 28.4% of patients, with a significantly higher incidence in the fully bilateral template RPLND group compared to the modified template group (67.9% vs. 14.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). ED was identified in 37.6% of patients, but no significant associations were found between ED and clinical or surgical variables.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLong-term sexual dysfunction, particularly ejaculatory disorders, remains a significant issue following PC-RPLND, especially in patients undergoing fully bilateral template dissection. Fertility and ejaculation problems associated with this technique may be mitigated through preoperative sperm cryopreservation.\u003c/p\u003e","manuscriptTitle":"Long-Term Sexual Dysfunction and Fertility Outcomes Following Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Testicular Cancer Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 10:38:42","doi":"10.21203/rs.3.rs-8228319/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-29T10:40:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-29T07:31:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-20T10:31:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T08:28:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60039794418634535626763141177442111196","date":"2025-12-16T06:46:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128935121009852932988796814380673858249","date":"2025-12-15T13:48:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339443723361792163220049985398804458922","date":"2025-12-12T11:10:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-11T11:13:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285947068745249704315491705172098300337","date":"2025-12-11T11:04:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-11T10:51:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-10T10:25:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-10T10:20:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Basic and Clinical Andrology","date":"2025-11-28T08:34:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"basic-and-clinical-andrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"andr","sideBox":"Learn more about [Basic and Clinical Andrology](https://bacandrology.biomedcentral.com/)","snPcode":"12610","submissionUrl":"https://submission.nature.com/new-submission/12610/3","title":"Basic and Clinical Andrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f57cdadb-df9b-4f92-9302-8d6a176b42d6","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T10:53:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 10:38:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8228319","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8228319","identity":"rs-8228319","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}