The optimal primary treatment of patients with low volume (< or = 5 cm) retroperitoneal metastases remains a matter of debate. Retroperitoneal lymph node dissection (RPLND) is a common practice in North America whereas chemotherapy is a prevailing approach in Europe. In patients with normal serum tumour markers after orchiectomy, primary RPLND appears to be the most appropriate way of staging. In other patients, neither surgery nor chemotherapy are entirely sufficient as monotherapy since approximately one-third of cases for each approach will need the other for achieving optimal results. Treatment decisions are based on cost/benefit and risk/benefit considerations, including relative toxicity and individual patient preference. The treatment of low volume stage II non-seminomatous germ cell tumours (NSGCT) clearly is a matter of scalpel and drug infusion.