Robotic Retroperitoneal Lymph Node Dissection for Testicular Cancer

Feasibility and Latest Outcomes

Harsha R. Mittakanti; James R. Porter

Disclosures

Curr Opin Urol. 2019;29(2):173-179. 

In This Article

Abstract and Introduction

Abstract

Purpose of review: Robotic-assisted laparoscopic retroperitoneal lymph node dissection (R-RPLND) is gaining acceptance as an alternative to open and laparoscopic RPLND for the treatment of testicular cancer. We discuss the current state of R-RPLND and summarize the latest relevant literature regarding the feasibility of this operation.

Recent findings: R-RPLND has been utilized effectively for both treatment of high-risk, clinical stage I testicular cancer as well as in the postchemotherapy setting. The feasibility of R-RPLND has been established with complication rates comparable to open RPLND and with decreased postoperative hospital stay and blood loss.

Summary: As R-RPLND continues to evolve and experience grows in high-volume centers, more information will be gained regarding long-term oncologic outcomes. Ultimately, head-to-head trials comparing R-RPLND to open RPLND will be needed to determine the role of R-RPLND in the treatment of testicular cancer.

Introduction

Testicular cancer is the most common solid tumor malignancy in men aged 20–44.[1] Treatment is highly successful across all stages, and choice of therapy is often predicated on the basis of the potential side-effects of treatment. Retroperitoneal lymph node dissection (RPLND) is an established treatment option for patients with high-risk clinical stage I and low-volume clinical stage II nonseminomatous germ-cell tumor (NSGCT). RPLND is also indicated for the removal of postchemotherapy masses more than 1 cm in tumor-marker-negative NSGCT and can be considered in patients with seminoma harboring postchemotherapy masses more than 3 cm with positron emission tomography avidity.[2,3] RPLND has also been utilized as primary treatment for low-volume, low-stage seminoma, although ultimate outcomes are yet to be determined.[4]

Many men opt for chemotherapy or active surveillance in clinical stage I NSGCT because of concerns regarding the morbidity of open RPLND (O-RPLND). Chemotherapy, however, can have significant toxicities,[5,6] including long-term cardiopulmonary issues, infertility, and risk for secondary malignancies.[7] These long-term effects may be even more pronounced in the adolescent population, in which testicular germ-cell tumors are the most common solid tumors.[8]

Laparoscopic RPLND (L-RPLND) was introduced in 1992 as a way to perform RPLND while minimizing the morbidities associated with the open approach.[9] Studies have demonstrated equivalent survival rates; however, critics have voiced concerns regarding shorter follow-up periods with L-RPLND, high rates of postoperative chemotherapy for positive masses, and the lack of dissection posterior to the great vessels leading to lower lymph node yields.[10,11]

Robotic RPLND (R-RPLND) was first performed in 2006,[12] and the safety and feasibility of this approach have been demonstrated by other investigators.[13,14] The robotic platform provides superior vision with three-dimensional optics (compared with the traditional two-dimensional view of a laparoscope) and improved dexterity with instruments containing articulating joints allowing for superior precision. Owing to these benefits, the robotic approach has improved many laparoscopic procedures and is now the preferred method for prostatectomy and partial nephrectomy. The early experience with R-RPLND has demonstrated reduced patient morbidity compared with O-RPLND and superior vascular control compared with L-RPLND.

There have been limited studies examining outcomes of R-RPLND performed by experienced robotic surgeons at centers of excellence. This field is one that continues to evolve as familiarity with the procedure increases. This report will review the feasibility of R-RPLND and the progression of our surgical technique. Additionally, it will examine the current literature (published from January 2017 to July 2018) that addresses R-RPLND.

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