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

Primary Robotic-assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Low-stage Nonseminomatous Germ Cell Tumor

Nerve-sparing RPLND is therapeutic in up to 85% of high-risk patients with clinical stage 1 NSGCT without the need for chemotherapy.[19] Roughly 30% of these patients will harbor occult retroperitoneal disease that is not apparent on surveillance imaging and can only be staged accurately with RPLND.[20]

Pearce et al.[21] published a multiinstitutional study examining outcomes of primary R-RPLND for patients with low-stage (clinical stage I–IIA) NSGCT over 5 years. Forty-seven patients were treated by six surgeons at four tertiary-care institutions, with the majority of patients (42) having clinical stage I disease, thus constituting the largest multiinstitutional study evaluating R-RPLND in the primary setting. Risk factors for the presence of retroperitoneal disease included lymphovascular invasion and more than 40% involvement of embryonal carcinoma in the orchiectomy specimen. The median operative time was 235 min (interquartile range [IQR]: 212–258) and median estimated blood loss (EBL) was 50 ml (IQR: 50–100). Median lymph node yield was 26 (IQR: 18–32) and the median length of stay was 1 day. There were two (4.3%) intraoperative complications in the series. One required open conversion to repair a vascular injury, whereas the other was a recognized pancreatic injury that resolved with drain placement and conservative management. Early (<30 days) complications occurred in four (8.5%) patients and included two Clavien Grade 1 complications and two Clavien Grade 3 complications. The two Grade 3 complications included a large body wall hematoma requiring transfusion and chylous ascites requiring paracentesis. Ultimately, eight patients (17%) had node positive disease with pN1 in seven patients (15%) and pN2 in one patient (2%). Five of these patients (62%) received adjuvant chemotherapy based on patient preference and the remaining three (38%) were managed with surveillance with none having evidence of disease at a median follow-up of only 6 months. The 2-year recurrence-free survival rate was 97% (95% confidence interval [CI]: 82–100%) in the entire cohort and 100% in those not treated with adjuvant chemotherapy. Perioperative outcomes were similar when compared with contemporary open series indicating feasibility and safety of R-RPLND in experienced hands. With a median follow-up of only 6 months, longer follow-up is necessary to fully determine ultimate oncologic outcomes.[21]

In comparison, the largest single institutional series of R-RPLND published in 2016 included 19 patients who underwent 20 procedures.[16] There were 16 primary and four postchemotherapy procedures with an overall median operative time of 293 min and median EBL of 50 ml. Median hospital length of stay was also 1 day. The only intraoperative complication was a recognized ureteral transection that was repaired primarily and stented. There were no open conversions and no transfusions. Two patients who underwent postchemotherapy bilateral R-RPLND experienced retrograde ejaculation. Eight of 19 patients had pathologic stage II disease. Three of the pathologic stage II patients had teratoma. One patient had pathologic stage IIC disease and another developed a lung recurrence 4 months after RPLND, and both of these patients received adjuvant chemotherapy. The remaining three pathologic stage II patients were followed without receiving chemotherapy and at follow-up of 46, 47, and 91 months had no evidence of disease recurrence. There was no other evidence of retroperitoneal disease recurrence in any patient at a median follow-up of 49 months.[16]

A recent systematic review included data from the two abovementioned studies as well as nine others.[22] The data ultimately included 116 patients. Complications for the vast majority of the studies were classified using the Clavien–Dindo classification system. Overall, complications were noted in 8% (4% Clavien I–II and 4% Clavien III–IV) with retrograde ejaculation in 4.5% of cases. The mean length of stay was 1.3 days, which was much less than contemporary open series. The median lymph node count was 22.3 and average follow-up was 21.2 months with no recurrence of disease.[22] The results confirm the safety, decreased perioperative morbidity, and feasibility of R-RPLND.

R-RPLND as primary treatment for low-stage germ-cell tumors is also being expanded to the adolescent population.[23] This is a population that is understudied with regards to treatment patterns as they typically fall in between ages included in most study designs.[8] The curative potential combined with the decreased morbidity of R-RPLND may make this a more attractive treatment option when compared with primary chemotherapy and the potential long-term side-effects, including neuropathy, cardiovascular issues, and risk of secondary malignancies. R-RPLND may also mitigate the uncertainty of active surveillance given a 30% relapse rate,[24] potential need for prolonged chemotherapy in case of recurrence, and radiation exposure from frequent computed tomography scans.[25]

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