Orchiectomy with surveillance and treatment of relapse produces survival figures that are comparable to those achieved by orchiectomy plus RPLND. As the outcomes in terms of survival appear to be equal across the three management techniques, the adverse effects of these treatments should be compared. RPLND has the disadvantage that patients are hospitalized for 10 to 14 days (less, in US contemporary practice—see Chapter 10), and full recovery usually takes several weeks. Virtually all patients lose ejacula-tory function after traditional bilateral suprahilar node dissection.75 Nerve-sparing node dissection may evade this problem but may be less useful in preventing relapse.76 As noted previously, some of these patients will relapse and will need to undergo chemotherapy.54 This group of patients will need to be observed closely for a few years after the operation. (A contrasting view of surgery is summarized in Chapter 10.)

Other patients are treated with orchiectomy and adjuvant chemotherapy. Those patients who are selected for adjuvant chemotherapy because of their high risk of relapse require two to three cycles of combination chemotherapy. Only one-half of these patients can benefit as only this proportion would, in fact, have relapsed (depending on the selection criteria for chemotherapy). Thus, up to one-half of these patients would be unnecessarily exposed to the toxicities of cytotoxic drugs, which is undesirable. The adjuvant cytotoxic treatment usually recommended is two cycles of bleomycin, etoposide, and cisplatin (BEP).32 Although careful management should preclude most short-term problems, impaired hearing due to auditory toxicity may still reduce the patient's quality of life, and even single doses of bleomycin can precipitate pulmonary fibrosis.

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