Patient Name:

Age:

Date:

Procedure: roperitoneal Lymph Node Dissection (RPLND)

Indications:

Patient is a male diagnosed with a symptomatic or asymptomatic testicular mass on physical exam and testicular ultrasound confirmation was obtained. CXR and tumor markers were drawn pre-op (B-HCG, AFP and LFT�s). Patient has undergone a previous radical orchiectomy and pathology revealed a non-seminomatous germ cell testicular tumor. CT of the abdomen/pelvis was obtained with no evidence of detectable lymph nodes or less than 2cm in diameter. Repeat tumor markers are undetectable or decaying at a rate consistent with the half-life decay of B-HCG(1.5 days) and AFP(5 days). Discussed were semen banking for future fertility.

Alternatives:

Alternative is observation with monthly CXR and tumor markers for two years and then q 2 months X 1year, Q 4 months X 1 year and then Q 6 months X 1 year then Q 1year for the rest of your life, laparoscopic PLND in experienced hands and chemotherapy if any lymph nodes are noted on CT scan of Abdomen or pelvis.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: prolonged wound drainage, possible injury to the ilioinguinal nerve is also possible and could lead to anesthetic areas on the scrotal, penile and inguinal skin, possible tumor seeding and possible positive microscopic nodal metastasis which would require two cycles of chemotherapy (PEB), loss of seminal emission, infertility, may need to use artificial reproductive techniques with banked frozen sperm for biological children, lymphoceole, lower extremity edema, major vascular injury, possible resection of vena cava and aortic graft/prosthetic placement if vessels are incased with tumor, If incidental large lymph nodes are noted during surgery and crossover of disease is highly probable the template would be expanded to a complete bilateral lymph node dissection, injury to bowel, vascular supply to bowel, kidney, pancreas, spleen, liver, gonadal artery and possible atrophy or loss of remaining testicle.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________