About Your Surgery
This guide will help you prepare for your retroperitoneal lymph node dissection (RPLND) at Memorial Sloan Kettering (MSK), and help you understand what to expect during your recovery. Read through this guide at least once before your surgery and then use it as a reference in the days leading up to your surgery. Bring this guide with you every time you come to MSK, including the day of your surgery, so that you and your healthcare team can refer to it throughout your care.
RPLND is a surgery that removes the lymph nodes that are located behind the organs in your abdomen (belly). RPLND is a treatment for testicular cancer, because the retroperitoneal lymph nodes are usually the first place to which testicular cancer spreads. These lymph nodes may also be affected by other types of cancer.
Retroperitoneal lymph nodes are found in the area between your kidneys along a vein, the vena cava, and an artery, the aorta (see Figure 1). The vena cava carries blood to your heart and the aorta carries blood from your heart to the rest of the body.
Figure 1. Your retroperitoneal lymph nodes
During your surgery, your surgeon will make an incision from the bottom of your ribcage to your pubic area. He or she will remove your lymph nodes through this incision. Your surgery will take 3 ½ to 5 hours.
This surgery may affect the nerves that control the way semen exits your body. Semen may go into your bladder instead of out of your penis. This is called retrograde ejaculation and can impact your fertility. For more information, please read Retrograde Ejaculation, located in the “After Your Surgery” section of this guide.
Your surgeon will try to use nerve sparing techniques if possible. This can prevent retrograde ejaculation. However, it can still take between one month and several years before your nerves recover. We strongly recommend that you bank your sperm before your surgery. Your doctor and nurse will talk to you about this in more detail.Back to top
Before Your Surgery
The information in this section will help you prepare for your surgery. Read through this section when your surgery is scheduled and refer to it as your surgery date gets closer. It contains important information about what you need to do before your surgery. Write down any questions you have and be sure to ask your doctor or nurse.
You and your healthcare team will work together to prepare for your surgery.
About Drinking Alcohol
The amount of alcohol you drink can affect you during and after your surgery. It is important that you talk with your healthcare providers about your alcohol intake so that we can plan your care.
- Stopping alcohol suddenly can cause seizures, delirium, and death. If we know you are at risk for these complications, we can prescribe medications to help prevent them.
- If you drink alcohol regularly, you may be at risk for other complications during and after your surgery. These include bleeding, infections, heart problems, greater dependence on nursing care, and longer hospital stay.
Here are things you can do to prevent problems before your surgery:
- Be honest with your healthcare provider about how much alcohol you drink.
- Try to stop drinking alcohol once your surgery is planned. If you develop a headache, nausea, increased anxiety, or cannot sleep after you stop drinking, tell your doctor right away. These are early signs of alcohol withdrawal and can be treated.
- Tell your healthcare provider if you cannot stop drinking.
- Ask us any questions you have about drinking and surgery. As always, all of your treatment information will be kept confidential.
Help us keep you safe during your surgery by telling us if any of the following statements apply to you, even if you aren’t sure.
- I take a blood thinner. Some examples are aspirin, heparin, warfarin (Coumadin®), clopidogrel (Plavix®), enoxaparin (Lovenox®), and tinzaparin (Innohep®). There are others, so be sure your doctor knows all the medications you’re taking.
- I take prescription medications.
- I take any over-the-counter medications, herbs, vitamins, minerals, or natural or home remedies.
- I have a pacemaker, automatic implantable cardioverter-defibrillator (AICD), or other heart device.
- I have sleep apnea.
- I have had a problem with anesthesia in the past.
- I have allergies, including to latex.
- I am not willing to receive a blood transfusion.
- I drink alcohol.
- I smoke.
- I use recreational drugs.
People who smoke can have breathing problems when they have surgery. Stopping even for a few days before surgery can help. If you smoke, your nurse will refer you to our Tobacco Treatment Program. You can also reach the program at 212-610-0507.
About Sleep Apnea
Sleep apnea is a common breathing disorder that causes a person to stop breathing for short periods while sleeping. The most common type is obstructive sleep apnea (OSA). This means that the airway becomes completely blocked during sleep, so no air can get through. OSA can cause serious problems when you have surgery. Please tell us if you have sleep apnea or if you think you may have it. If you use a breathing machine (such as a CPAP) for sleep apnea, bring it with you the day of your surgery.
Before your surgery, you will have an appointment for presurgical testing (PST). The date, time, and location of your PST appointment will be printed on the appointment reminder from your surgeon’s office.
You can eat and take your usual medications the day of your PST appointment. During your appointment, you will meet with a nurse practitioner who works closely with anesthesiology staff (doctors and specialized nurses who will be giving you medication to put you to sleep during your surgery). He or she will review your medical and surgical history with you. You will have tests, including an electrocardiogram (EKG) to check your heart rhythm, a chest x-ray, blood tests, and any other tests necessary to plan your care. Your nurse practitioner may also recommend you see other healthcare providers.
Your nurse practitioner will talk with you about which medications you should take the morning of your surgery. To help you remember, we’ve left space for you to write these medications down in the “The Morning of Your Surgery” section of this guide.
It is very helpful if you bring the following with you to your PST appointment:
- A list of all the medications you are taking, including patches and creams.
- Results of any tests done outside of MSK, such as a cardiac stress test, echocardiogram, or carotid doppler study.
- The name(s) and telephone number(s) of your doctor(s).
Complete a Health Care Proxy Form
If you haven’t already completed a Health Care Proxy form, we recommend you complete one now. A health care proxy is a legal document that identifies the person who will speak for you if you are unable to communicate for yourself. This person is known as your health care agent. If you are interested in completing a Health Care Proxy form, talk with your nurse. If you have completed one already, or if you have any other advanced directive, bring it with you to your next appointment.
Do Breathing and Coughing Exercises
Practice taking deep breaths and coughing before your surgery. You will be given an incentive spirometer to help expand your lungs. For more information, please read How to Use Your Incentive Spirometer, located in the “After Your Surgery” section of this guide. If you have any questions, ask your nurse or respiratory therapist.
Do aerobic exercise every day, such as walking at least 1 mile, swimming, or biking. If it is cold outside, use stairs in your home or go to a mall or shopping market. Walking will help your body get into its best condition for your surgery and make your recovery faster and easier.
Eat a Healthy Diet
You should eat a well-balanced, healthy diet before your surgery. If you need help with your diet talk to your doctor or nurse about meeting with a dietitian.
Stop Taking Certain Medications
If you take vitamin E, stop taking it 10 days before your surgery. If you take aspirin, ask your surgeon whether you should continue. Medications such as aspirin, medications that contain aspirin, and vitamin E can cause bleeding. For more information, please read Common Medications Containing Aspirin and Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs), located in this section.
Purchase Hibiclens® Skin Cleanser
Hibiclens is a skin cleanser that kills germs for 6 hours after using it. Showering with Hibiclens before surgery will help reduce your risk of infection after surgery. Hibiclens is available at your local pharmacy without a prescription.
Stop Taking Herbal Remedies and Supplements
Stop taking herbal remedies or supplements 7 days before your surgery. If you take a multivitamin, talk with your doctor or nurse about whether you should continue. For more information, please read Herbal Remedies and Cancer Treatment, located in this section.
Watch a Virtual Tour
This video will give you an idea of what to expect when you come to Memorial Sloan Kettering ’s main hospital on the day of your surgery.
Stop Taking Certain Medications
Stop taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (e.g., Advil®, Motrin®) and naproxen (e.g., Aleve®). These medications can cause bleeding. For more information, please read Common Medications Containing Aspirin and Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs), located in this section.
Note the Time of Your Surgery
A clerk from the Admitting Office will call you after 2:00 pm the day before your surgery. He or she will tell you what time you should arrive at the hospital for your surgery. If you are scheduled for surgery on a Monday, you will be called on the Friday before. If you do not receive a call by 7:00 pm, please call 212-639-5014.
On the day of your surgery, go to the main hospital at 1275 York Avenue between East 67th and East 68th Streets. Take the B elevator to the 6th Floor to the Presurgical Center (PSC).
Shower With Hibiclens
The night before your surgery, shower using the Hibiclens solution. To use Hibiclens, open the bottle and pour some solution into your hand or a washcloth. Rub it gently over your body from your neck to your waist and rinse. Do not let the solution get into your eyes, ears, mouth, or genital area. Do not use any other soap. Dry yourself off with a clean towel after your shower.
Go to bed early and get a full night’s sleep.
Between midnight and up until 2 hours before your scheduled arrival time, you may drink a total of 12 ounces of clear liquids (see Figure 3).
Examples of clear liquids include:
- Clear broth, bouillon, or consommé (no particles of dried food or seasonings)
- Gelatin, such as Jell-O®
- Clear fruit juices (no pulp), such as white cranberry, white grape, or apple
- Soda, such as 7-Up®, Sprite®, ginger ale, seltzer, or Gatorade®
- Coffee or tea, without milk or cream
Shower With Hibiclens
Shower using Hibiclens just before you leave for the hospital. Use the Hibiclens the same way you did the night before. Do not use any other soap. Do not put on any lotion, cream, powder, deodorant, makeup, or perfume after your shower.
Take Your Medications
If your doctor or nurse practitioner instructed you to take certain medications the morning of your surgery, take only those medications with a small sip of water. Depending on what medications you take and the surgery you’re having, this may be all, some, or none of your usual morning medications.
Things to remember
- Do not put on any lotions, creams, deodorants, makeup, powders, or perfumes.
- Do not wear any metal objects. Remove all jewelry, including body piercings. The equipment used during your surgery can cause burns if it touches metal.
- Leave valuables, such as credit cards, jewelry, or your checkbook at home.
- Before you are taken into the operating room, you will need to remove your eyeglasses, hearing aids, dentures, prosthetic device(s), wig, and religious articles, such as a rosary.
- Wear something comfortable and loose-fitting.
- If you wear contact lenses, wear your glasses instead.
- Sneakers that lace up. You may have some swelling in your feet. Lace-up sneakers can accommodate this swelling.
- A CD player and CDs or an iPod, if you choose. However, someone will need to hold these items for you when you go into surgery.
- Your incentive spirometer, if you have one.
- Your breathing machine for sleep apnea (such as your CPAP), if you have one.
- If you have a case for your personal items, such as eyeglasses, hearing aid(s), dentures, prosthetic device(s), wig, and religious articles such as a rosary, bring it with you.
- Your Health Care Proxy Form, if you have completed one.
- This guide. Your healthcare team will use this guide to teach you how to care for yourself after your surgery.
Parking When You Arrive
Parking at MSK is available in the garage on East 66th Street between York and First Avenues. To reach the garage, turn
onto East 66th Street from York Avenue. The garage is located about a quarter of a block in from York Avenue, on the right- hand (north) side of the street. There is a pedestrian tunnel that you can walk through that connects the garage to the hospital. If you have questions about prices, call 212-639-2338.
There are also other garages located on East 69th Street between First and Second Avenues, East 67th Street between York and First Avenues, and East 65th Street between First and Second Avenues.
Once You’re in the Hospital
You will be asked to state and spell your name and date of birth many times. This is for your safety. People with the same or similar names may be having surgery on the same day.
Get Dressed for Surgery
You will be given a hospital gown, robe, and nonskid socks.
Meet With Your Nurse
A nurse will meet with you before your surgery. Tell him or her the dose of any medications (including patches and creams) you took after midnight and the time you took them.
Meet With Your Anesthesiologist
He or she will:
- Review your medical history with you.
- Talk with you about your comfort and safety during your surgery.
- Talk with you about the kind of anesthesia you will receive.
- Answer any questions you may have about your anesthesia.
Prepare for Surgery
Once your nurse has seen you, 1 or 2 visitors can keep you company as you wait for your surgery to begin. When it is time for your surgery, your visitor(s) will be shown to the waiting area. Your visitors should read Information for Family and Friends for the Day of Surgery, located in this section.
You will walk into the operating room or you can be taken in on a stretcher. A member of the operating room team will help you onto the operating bed. Compression boots will be placed on your lower legs. These gently inflate and deflate to help circulation in your legs.
Your anesthesiologist will place an intravenous (IV) line into a vein, usually in your arm or hand. The IV line will be used to give you fluids and anesthesia (medication to make you sleep) during your surgery.
Once you are fully asleep, a breathing tube will be placed through your mouth and into your windpipe to help you breathe. You will also have a urinary catheter placed to drain urine from your bladder.
Once your surgery is finished, your incisions will be closed with stitches that will absorb as you are healing. Steri-Strips™ (thin pieces of tape) will be placed directly on your incision(s) and covered with a bandage. Your breathing tube is usually taken out while you are still in the operating room.Back to top
After Your Surgery
The information in this section will tell you what to expect after your surgery, both during your hospital stay and after you leave the hospital. You will learn how to safely recover from your surgery. Write down any questions you have and be sure to ask your doctor or nurse.
When you wake up after your surgery, you will be in the Post Anesthesia Care Unit (PACU).
You will receive oxygen through a thin tube that rests below your nose called a nasal cannula. A nurse will be monitoring your body temperature, pulse, blood pressure, and oxygen levels.
You will have a urinary catheter (Foley®) in your bladder to monitor the amount of urine you are making. You will also have compression boots on your lower legs to help your circulation.
You may have a pain pump called a patient-controlled analgesia (PCA) device. For more information, please read Patient-Controlled Analgesia (PCA), located in this section. Your pain medication and fluids will be given through an IV line.
You will have staples along your incision.
Your visitors can see you briefly in the PACU, usually within 90 minutes after you arrive there. A member of the nursing staff will explain the guidelines to them.
You will stay in the PACU for 2 to 4 hours. After your stay in the PACU, you will be taken to your hospital room. Your nurse will tell you how to recover from your surgery. Below are examples of ways you can help yourself recover safely.
- You will be encouraged to walk with the help of your nurse or physical therapist. We will give you medication to relieve pain. Walking helps reduce the risk for blood clots and pneumonia. It also helps to stimulate your bowels so they begin working again.
- Use your incentive spirometer. This will help your lungs expand, which prevents pneumonia. For more information, please read How to Use Your Incentive Spirometer, located in this section. Continue to perform your breathing and coughing exercises every 1 to 2 hours while you are awake. Your nurse will teach you to splint your incision. This will reduce the movement of your stomach muscles and decrease pain while you do the coughing exercises.
The following section covers common questions people ask after having a retroperitoneal lymph node dissection. Speak with your doctor or nurse if you have any additional questions or if any of this information is unclear.
Will I have pain after my surgery?
You will have some pain after your surgery. Your doctor and nurse will ask you about your pain often. You will be given medication to manage your pain as needed. If your pain is not relieved, please tell your doctor or nurse. It is important to control your pain so you can cough, breathe deeply, use your incentive spirometer, and get out of bed and walk.
Why is it important to walk?
Walking will help prevent blood clots in your legs. It also decreases your risk of having other complications such as pneumonia.
Will I be able to eat?
You will not be able to eat anything for 2 to 3 days after your surgery. After that, you can begin taking sips of clear liquids. You will then progress to your regular diet, as tolerated.
You will not be allowed to eat nuts, corn, or popcorn for 1 year after surgery, because these foods are often difficult to digest.
You will also need to avoid all laxatives.
If you have questions about your diet, ask to see a dietitian.
How long will I be in the hospital?
Most people are in the hospital for 7 to 10 days after this surgery.
Will I have pain when I am home?
The length of time each person has pain or discomfort varies. You may still have some incisional pain when you go home and will probably be taking pain medication. Follow the guidelines below.
- Take your medications as directed and as needed.
- Call your doctor if the medication prescribed for you doesn’t relieve your pain.
- Do not drive or drink alcohol while you are taking prescription pain medication.
- As your incisions heal, you will have less pain and need less pain medication. A mild pain reliever such as acetaminophen (Tylenol) or ibuprofen (Advil) will relieve aches and discomfort. However, large quantities of acetaminophen may be harmful to your liver. Do not take more acetaminophen than the amount directed on the bottle or as instructed by your doctor or nurse.
- Pain medication should help you as you resume your normal activities. Take enough medication to do your exercises comfortably. Pain medication is most effective 30 to 45 minutes after taking it.
- Keep track of when you take your pain medication. Taking it when your pain first begins is more effective than waiting for the pain to get worse.
How can I prevent constipation?
Your usual bowel pattern will change after surgery. You may have trouble passing stool (feces). This is a common side effect of pain medication. Please review the material your nurse gave you about fiber and constipation.
To avoid constipation, take a stool softener such as docusate sodium (Colace®) 3 times a day. Continue taking it until you are no longer taking pain medication. Drink plenty of liquids and eat more foods with fiber such as fruits and vegetables. If you feel bloated, avoid foods that can cause gas, such as beans, broccoli, onions, cabbage, and cauliflower. Do not take any over-the-counter laxatives. Please contact your doctor’s office if you are experiencing constipation.
Can I shower?
Yes, taking a warm shower is relaxing and can help decrease muscle aches. Use soap when you shower and gently wash all of your incisions. Pat the areas dry with a towel after showering, and leave your incision uncovered (unless there is drainage). Call your doctor if you see any redness or drainage from your incision.
Do not take tub baths until you discuss it with your doctor at the first appointment after your surgery.
Can I drink alcohol after surgery?
Do not drink alcohol while you are taking pain medications.
How do I care for my incisions?
It is normal to have numbness of the skin below your incision because some of the nerves were cut; this sensation will lessen over time. Some people experience swelling in both of their lower legs following surgery. This will also get better with time.
- By the time you are ready to leave the hospital, your staples will have been removed and replaced with small strips of tape called Steri-Strips. Your nurse will show you how to clean your incision at home.
- You and your caregiver should look at your incision with your nurse before you leave the hospital so you know what it looks like.
- If any liquid is draining from your incision, write down the amount and color.
Your Steri-Strips will loosen and fall off by themselves. If they haven’t fallen off within 10 days, you may remove them.
Is it normal to feel tired after surgery?
Feeling tired (fatigue) is an expected side effect. You may need a nap during the day, but try to stay out of bed as much as possible. That will help you sleep at night. It usually takes 6 to 8 weeks until your energy level returns to normal.
Can I resume my activities?
It is important for you to resume your activities after surgery. Spread them out over the course of the day.
You can do light household tasks. Try dusting, washing dishes, preparing light meals, and other activities as you are able.
You may return to your usual sexual activity as soon as your incisions are well healed and you can do so without pain or fatigue.
Your body is an excellent guide for telling you when you have done too much. When you increase your activity, monitor your body’s reaction. You may find that you have more energy in the morning or the afternoon. Plan your activities for times of the day when you have more energy.
When is it safe for me to drive?
You can drive 1 month after your surgery.
When can I return to work?
The time it takes to return to work depends on the type of work you do, the type of surgery you had, and how fast your body heals. Usually you can return to work 3 to 6 weeks after surgery. However, if your job requires heavy lifting or physical labor, it may be 3 months before you can return to work.
What exercises can I do?
Exercise will help you gain strength and feel better. Walking and stair climbing are excellent forms of exercise. Gradually increase the distance you walk. Climb stairs slowly, resting or stopping as needed. Ask your doctor or nurse before starting more strenuous exercises.
When can I lift heavy objects?
Check with your doctor before you do any heavy lifting. Normally, you should not lift anything heavier than 5 pounds (2.3 kilograms) for at least 6 weeks. Ask your doctor how long you should avoid heavy lifting.
How can I cope with my feelings?
After surgery for a serious illness, you may have new and upsetting feelings. Many people say they felt weepy, sad, worried, nervous, irritable, and angry at one time or another. You may find that you cannot control some of these feelings. If this happens, it’s a good idea to seek emotional support.
The first step in coping is to talk about how you feel. Family and friends can help. Your nurse, doctor, and social worker can reassure, support, and guide you. It is always a good idea to let these professionals know how you, your family, and your friends are feeling emotionally. Many resources are available to patients and their families. Whether you are in the hospital or at home, the nurses, doctors, and social workers are here to help you and your family and friends handle the emotional aspects of your illness.
When is my first appointment after my surgery?
Your first appointment after surgery will be 3 to 4 weeks after your surgery. Your nurse will give you instructions on how to make this appointment, including the phone number to call.
During this appointment, your doctor will discuss the pathology results with you in detail.
- A temperature of 101° F (38.3° C) or higher
- Pain that does not get better with your medications
- Redness, swelling, or drainage from your incisions that is foul smelling or pus-like
- Diarrhea or constipation
- Calf pain
- Nausea or vomiting
- Any new symptom or physical change
- Any questions or concerns
After 5:00 pm, during the weekend, and on holidays, call 212-639-2000. Ask to speak to the doctor on call for your doctor.Back to top
This section contains a list of MSK support services, as well as the resources that were referred to throughout this guide. These resources will help you prepare for your surgery and recover safely. Write down any questions you have and be sure to ask your doctor or nurse.
Call to discuss private room or luxury suite options. If you want to change your room choice after your presurgical testing visit, call 212-639-7873 or 212-639-7874.
Call with questions about anesthesia.
Call for more information if you are interested in donating blood or platelets.
MSK welcomes patients from around the world. If you are an international patient, call the International Center for help coordinating your care.
At MSK, our chaplains are available to listen, help support family members, pray, contact community clergy or faith groups, or simply be a comforting companion and a spiritual presence. Anyone can request spiritual support, regardless of formal religious affiliation. The interfaith chapel is located near the main lobby of Memorial Hospital, and is open 24 hours a day. If you have an emergency, please call the hospital operator and ask for the chaplain on call.
Many people find counseling helpful. We provide counseling for individuals, couples, families, and groups, as well as medications to help if you feel anxious or depressed.
Integrative Medicine Service offers patients many services to complement traditional medical care, including music therapy, mind/body therapies, dance and movement therapy, yoga, and touch therapy.
You may find it comforting to speak with a cancer survivor or caregiver who has been through a similar treatment. Through our Patient-to-Patient Support Program, we are able to offer you a chance to speak with former patients and caregivers.
Call Patient Billing with any questions about preauthorization from your insurance company. This is also called preapproval.
Call if you have any questions about the Health Care Proxy form or if you have any concerns about your care.
Call if you have any questions about MSK releasing any information while you are having surgery.
Patients may request private nurses or companions. Call for more information.
At MSK, care doesn’t end after active treatment. The RLAC Program is for patients and their families who have finished treatment. This program has many services, including seminars, workshops, support groups, counseling on life after treatment, and help with insurance and employment issues.
Social workers help patients, family, and friends deal with issues that are common for cancer patients. They provide individual counseling and support groups throughout the course of treatment, and can help you communicate with children and other family members. Our social workers can also refer you to community agencies and programs, as well as financial resources if you’re eligible.
If you want to quit smoking MSK has specialists who can help. Call for more information.
The following are resources outside of MSK that you may find helpful:
In New York City, the MTA offers a shared ride, door-to-door service for people with disabilities who are unable to take the public bus or subway.
Provides travel to treatment centers.
Offers a variety of information and services, including Hope Lodge, a free place for patients and caregivers to stay during cancer treatment.
A comprehensive resource for education, tools, and events for employees with cancer.
275 Seventh Avenue (between West 25th & West 26th Streets)
Provides counseling, support groups, educational workshops, publications, and financial assistance.
Provides support and education to people affected by cancer.
Provides education and support for those who care for loved ones with a chronic illness or disability.
Free travel to treatment across the country using empty seats on corporate jets.
Provides reproductive information and support to cancer patients and survivors whose medical treatments have risks associated with infertility.
A place where men, women, and children living with cancer find social and emotional support through networking, workshops, lectures, and social activities.
Offers financial assistance to pay for copayments during treatment. Patients must have medical insurance, meet the income criteria, and be prescribed medication that is part of the Good Days formulary.
Provides financial assistance to cover copayments, health care premiums, and deductibles for certain medications and therapies.
Provides a list of places to stay near treatment centers for people with cancer and their families.
Provides support and advocacy for the LGBT community, including a online support groups and a database of
LGBT friendly clinical trials.
Free cancer legal advocacy program.
Provides education, training, and advocacy for LGBT cancer survivors and those at risk.
Lists Patient Assistance Programs for brand and generic name medications.
Provides prescription benefits to eligible employees and retirees of public sector employers in New York State.
Helps qualifying patients without prescription drug coverage get free or low-cost medications.
Provides assistance with copayments for patients with insurance.
Provides access to care, financial assistance, insurance assistance, job retention assistance, and access to the national underinsured resource directory.
Provides assistance to help people obtain medications that they have trouble affording.
- Common Medications Containing Aspirin and Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
- Herbal Remedies and Cancer Treatment
- Information for Family and Friends for the Day of Surgery
- How to Use Your Incentive Spirometer
- Patient-Controlled Analgesia (PCA)
- Retrograde Ejaculation