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

Operative Technique

After appropriate patient selection and preoperative workup, a surgical plan can be developed on the basis of the stage of disease and the available da Vinci robotic platform. All patients should undergo endotracheal intubation, orogastric tube placement, Foley catheter insertion, and deep paralysis prior to positioning. Perioperative antibiotics and deep-vein thrombosis prophylaxis should also be given.

The initial approach to R-RPLND at our institution was an extension of our experience with L-RPLND, and it was performed via a lateral, five-port approach using the da Vinci Si. This approach was utilized for high-risk clinical stage I patients and allowed for a unilateral template dissection. However, if frozen sections of the removed lymph nodes were positive and bilateral dissection was necessary, repositioning was required to complete a full bilateral dissection.

Our technique for R-RPLND ultimately evolved to a supine transperitoneal approach, thus permitting access for a full bilateral dissection. The patient is positioned supine with arms tucked and in 20–30° Trendelenburg. Port placement includes two 12-mm ports (camera port, assistant port) and three 8-mm robot ports (Figure 1). The da Vinci Si (Sunnyvale, CA, USA) is typically docked over the patient's left shoulder, and redocking is required alongside the patient's ipsilateral leg for excision of the spermatic cord. With the introduction of the da Vinci Xi system, the robot can be docked from multiple positions because of the rotating boom. Additionally, the robot arms are designed for multiquadrant access with the ability to reach backward away from the operative field. This allows for removal of the retroperitoneal lymph nodes and spermatic cord with a single docking. Port placement using the da Vinci Xi involves a linear configuration as compared with the staggered ports for the Si (Figure 2). The ports are placed below the level of the umbilicus with one 12-mm assistant port and four 8-mm robot ports. A 0° lens is used initially to create the retroperitoneal exposure and a 30° lens is used for the dissection. Other institutions espouse a supraumbilical linear port array;[15] however, we find access to the spermatic cord with a single docking is facilitated by the infraumbilical approach.

Figure 1.

Port configuration for the supine approach with the da Vinci Si robot. The 'Assist' port and '30° camera' port are 12 mm. The remaining robot ports are 8 mm.

Figure 2.

Port configuration for the supine approach with the da Vinci Xi robot. The 'Assist' port is 12 mm. The '30° camera' port and remaining robot ports are 8 mm.

The key step for the success of the supine approach is exposure of the retroperitoneum by incising the posterior peritoneum from the cecum to the ligament of Treitz. After a flap is created, the right cut edge of the posterior peritoneum is sutured to the right side of the abdominal wall and the left cut edge is sutured to the left abdominal wall. This essentially creates a 'hammock' that prohibits the small bowel from falling into the operative field.[16] The fourth robotic arm instrument can be utilized to provide more exposure during the remaining dissection.

For a right-sided template dissection, the renal vessels represent the upper limit, and the inferior mesenteric artery medially (typically spared) and the crossing of the ureter over the right common iliac vessels laterally represent the lower limits. The split-and-roll technique is employed to remove the paracaval, precaval, retrocaval, interaortocaval, and paraaortic node packets. Locking polymer clips are used to close all lymphatic channels, with care taken to avoid clipping the nodes. For a left-sided template dissection, the limits of dissection are the mirror image of the right side. The paraaortic, preaortic, retroaortic, and interaortocaval nodes above the inferior mesenteric artery are removed. Preservation of the sympathetic postganglionic nerves is routinely performed by identifying the fibers at their origin at the sympathetic chain and tracing them to the hypogastric plexus overlying the distal aorta.

For unilateral dissections, frozen sections of the removed lymph nodes are typically sent, and if positive, a full bilateral template dissection is performed. For postchemotherapy masses, the primary mass is removed along with a full bilateral dissection of all retroperitoneal nodes. The ipsilateral spermatic cord is removed to the cord stump as indicated by the orchiectomy sutures.

Recently, case reports have been published detailing an extraperitoneal approach R-RPLND. These included a lateral flank approach for a right-sided unilateral modified template dissection,[17] as well as an extraperitoneal supine approach in a patient for a postchemotherapy interaortocaval NSGCT residual mass that measured 3 × 2 × 4 cm.[18] The extraperitoneal approach is a novel approach for R-RPLND; however, the ability to reach the contralateral retroperitoneum with limited access raises concerns for the completeness of dissection and the ability to control vascular injury. Larger volume studies with long-term follow-up will be needed to determine its ultimate safety and feasibility.

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