Surgery in stage IIA/IIB seminoma: A "Living systematic review" and meta-analysis of prospective studies.

Introduction: Concerns about the long-term toxicity of chemotherapy and radiotherapy in stage II seminoma have renewed the interest in the surgical management. Retroperitoneal lymph node dissection (RPLND) has emerged as a potential treatment alternative. This systematic review and meta-analysis (SRMA) evaluates the oncological, functional, and peri-operative outcomes of RPLND in stage II seminoma. Methods: A SRMA (systematic review and meta-analysis) of prospective studies was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included prospective trials assessing RPLND in stage II seminoma. Outcomes analyzed were relapse-free survival (RFS), recurrence patterns, functional outcomes, and peri-operative complications. Risk of bias was assessed using the Newcastle--Ottawa Scale. The review was registered in PROSPERO (CRD420250559629). Results: Four prospective phase II studies with 216 patients were included. The pooled 2-year RFS was 85% (95% confidence interval [CI]: 77.8%--92.2%). In-field recurrence occurred in 5.5%, while the rate of out-of-field recurrence was 10.1%. Preservation of antegrade ejaculation was achieved in 92.8% (95% CI: 87.4%--98.1%). Major complications (Clavien-Dindo ≥ IIIA) were reported in 9.6% of the patients. Risk of bias was low to moderate across the studies. Conclusions: Primary RPLND is a feasible and safe treatment for carefully selected patients with stage II seminoma, providing favorable oncological control, high rates of functional preservation, and acceptable morbidity. While short-term outcomes are encouraging, long-term follow-up and randomized comparisons with conventional therapy are required to establish its definitive role.