TABLE 3.

Summary for surgical management of paratesticular rhabdomyosarcoma: INSTRuCT consensus opinion document

Item	Recommendation	Quality	Strength
Primary Inguinal Orchidectomy	Remove paratesticular RMS by radical inguinal orchidectomy	Moderate	Strong
	Remove the tumor as a single specimen incorporating the entire cord up to the internal ring and without breaching the tunica vaginalis	High	Strong
	The cord should be clamped at the internal ring before mobilization of the tumor	Low	Weak
	The cord is ligated using a non-absorbable suture	Low	Weak
	When scrotal skin is fixed or grossly invaded by tumor, it should be resected en-bloc with the specimen	High	Strong
	Testicle preserving approaches should be avoided	High	Strong
Primary Re-Excision	Primary re-excision (PRE) is indicated when the initial procedure did not include en-bloc complete gross resection of the tumor, testis and spermatic cord up to the internal ring	Moderate	Strong
	Patients with microscopic residual disease after initial resection (IRS Group II) may undergo PRE when there is microscopic disease at the cord margin	Moderate	Strong
Management of Large Tumors	For large tumors that are difficult to excise through a standard inguinal incision, it is better to extend the inguinal incision down to the scrotum or use a combined inguinal and scrotal approach to facilitate a complete gross total tumor resection	Moderate	Strong
	If there is proximal extension of the tumor through the inguinal canal, or extension into the urethra and base of the penis, the tumor is primarily irresectable and should be biopsied through an inguinal approach	Low	Strong
Trans-scrotal excision, scrotal violation, hemi-scrotectomy, scrotal RT	A trans-scrotal approach to tumor resection should be avoided since it makes complete resection more difficult	Moderate	Strong
	A trans-scrotal biopsy should be avoided since it may result in a potential increased risk of tumor spill	Low	Weak
	Hemi-scrotectomy is not indicated if patients have a scrotal violation or microscopic residual disease (Clinical group II) present in the scrotum after gross tumor resection	Low	Weak
	Scrotal skin should be removed en-bloc with the tumor excision if the tumor invades or extends into the scrotal skin	High	Strong
	If scrotal RT is required due to Clinical group III disease, then temporary transposition of the remaining normal testis should be done to preserve function	Moderate	Strong
Retroperitoneal Lymph Node (RPLN) Assessment and Management	All patients ≥ 10 years old should undergo ipsilateral infrarenal surgical lymph node evaluation, regardless of imaging results, to identify patients with pathologic disease	Moderate	Strong
	Patients <10 years old with no nodal enlargement should not undergo surgical RPLN evaluation given the low rate of pathologic nodal involvement	High	Strong
	The rare patients who have alveolar histopathology, irrespective of age or tumor size, should undergo surgical nodal staging procedure	Low	Weak
	Nodal sampling of 7-12 nodes from within the template area appears to be sufficient to identify disease presence	Moderate	Strong
	Sentinel nodal evaluation, may be used to help identify the positive node. The patient should still have additional nodes sampled to achieve at least 7 RPLN	Low	Weak