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

Postchemotherapy Robotic-assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumor

In those patients receiving primary chemotherapy for NSGCT and who develop a residual mass in the retroperitoneum, RPLND is indicated for removal of the mass. Even patients with aggressive germ-cell tumors that are refractory to chemotherapy may benefit from a complete RPLND.[26] Laparoscopic postchemotherapy retroperitoneal lymph node dissection has been shown to be well tolerated, albeit technically challenging, when performed at high-volume centers with laparoscopic expertise.[27] There is significant fibrosis and adhesion of the postchemotherapy mass to the aorta and vena cava, creating potential for vascular injury that can be difficult to repair with standard laparoscopic instruments. R-RPLND offers benefit over the laparoscopic approach with superior instrument dexterity and visualization and facilitates vascular control, therefore improving the margin of safety in the postchemotherapy patient.[28–30]

A single institutional study recently reviewed R-RPLND utilizing a single-docking lateral approach for postchemotherapy NSGCT residual masses over a 3-year period.[31] Using the da Vinci Si system, an ipsilateral unilateral modified template dissection was performed. Eleven patients with a median residual mass size of 2 cm underwent R-RPLND. Median operative time was 150 min, EBL was 120 ml, and median node count was seven (range from 1 to 24). There were no intraoperative complications and only one Clavien I postoperative complication (lymph leak conservatively managed) was reported. Twenty-four month recurrence-free survival data was available for six patients, and there was no evidence of recurrence. Ejaculatory status was preserved in 72.7% of patients, although this seems low given the unilateral dissection. The majority of patients were discharged on hospital day 3.[31]

Another single institution study of R-RPLND over a 5-year period was recently reported by Singh et al..[32] There were three different approaches reported: a lateral approach with unilateral modified template dissection performed in 11 patients, a lateral approach with repositioning and redocking for a bilateral template performed in one patient, and a supine approach for a bilateral template dissection performed in one patient. Median operative time was 200 min, median EBL was 120 ml, and median lymph node yield was 20. There was one intraoperative complication (aortic injury requiring suture repair) and no open conversions. The median length of stay was 4 days. Four (36%) patients developed chylous leak in the postoperative period with two of these patients ultimately requiring reexploration for ligation of lymphatic channels. Five (45%) patients suffered an ileus. The authors did not note a specific standardized complication grading system. Pathology demonstrated that three patients had positive nodes for teratoma with the remaining eight patients having necrosis. Median follow-up for the group was 23 months with no recurrence of disease noted.[32]

These studies highlight that postchemotherapy lymph node dissection performed robotically is feasible, although larger series with longer term follow-up are needed. Additionally, a unilateral dissection in the postchemotherapy setting may represent undertreatment, and based on National Comprehensive Cancer Network guidelines, a full bilateral template dissection should be performed for postchemotherapy NSGCT masses.[3] Retrospective reviews examining the use of modified templates for the removal of postchemotherapy masses indicate a low risk of recurrence in the retroperitoneum (≤1%); however, other studies report a higher rate of recurrence.[33] A lateral approach can make performing a bilateral dissection more difficult, as repositioning and redocking is typically required. Our experience with the supine approach using the da Vinci Xi allows a full bilateral dissection to be performed with one patient position and one docking. Ultimately, R-RPLND, much like O-RPLND, will need to be performed by high-volume surgeons at centers of excellence for the best outcomes, especially in the postchemotherapy setting.[34]

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