Primary robotic retroperitoneal lymph node dissection following orchiectomy for testicular germ cell tumors: a single-surgeon experience

Lymph Node Dissection in Testicular Cancer: The State of the Art and Future Perspectives

PURPOSE OF REVIEW

This narrative review provides a comprehensive overview of the evolving role of retroperitoneal lymph node dissection (RPLND) in the management of testicular cancer (TC). It explores the significance of RPLND as both a diagnostic and therapeutic tool, highlighting its contribution to accurate staging, its impact on oncological outcomes, and its influence on subsequent treatment decisions.

RECENT FINDINGS

RPLND serves as an essential diagnostic procedure, aiding in the precise assessment of lymph node involvement and guiding personalized treatment strategies. It has demonstrated therapeutic value, particularly in patients with specific risk factors and disease stages, contributing to improved oncological outcomes and survival rates. Recent studies have emphasized the importance of meticulous patient selection and nerve-sparing techniques to mitigate complications while optimizing outcomes. Additionally, modern imaging and surgical approaches have expanded the potential applications of RPLND. In the context of TC management, RPLND remains a valuable and evolving tool. Its dual role in staging and therapy underscores its relevance in contemporary urological practice. This review highlights the critical role of RPLND in enhancing patient care and shaping treatment strategies, emphasizing the need for further research to refine patient selection and surgical techniques.

Robotic-assisted retroperitoneal lymph node dissection for stage II testicular cancer

Objective

To evaluate the perioperative as well as early oncological outcomes of patients undergoing robotic retroperitoneal lymph node dissection for treatment of testicular cancer.

Methods

We conducted a prospective consecutive case series of patients undergoing robotic assisted retroperitoneal lymph node dissection for metastatic testicular cancer between May 2018 and July 2021 at our institution. Data were collected on patient and tumour characteristics, intraoperative and postoperative parameters, and functional and oncological outcomes. Descriptive statistics are presented.

Results

Nineteen patients were identified; 18 (94.7%) completed the procedure robotically and one was converted to open surgery; 78.9% of patients had stage ≥IIB and 12 (63.2%) patients had undergone prior chemotherapy. The median operative time was 300 (interquartile range [IQR] 240-315) min. Median blood loss was 100 (IQR 50-175) mL. Median length of stay was 2 (range 1-11) days. All robotically completed patients commenced diet and passed flatus on Day 1 and were discharged by Day 3. The median lymph node yield was 40.5 (IQR 38-51) nodes. All patients undergoing nerve-sparing procedures recovered antegrade ejaculatory function. One patient had a Clavien-Dindo III complication (chylous ascites requiring drainage). At a median follow-up of 22.3 (IQR 16.3-24.9) months, one patient developed retroperitoneal recurrence, which was successfully treated with second-line chemotherapy; no other patients have had recurrences.

Conclusion

Robotic retroperitoneal lymph node dissection is a safe and feasible alternative to open surgery in appropriately selected patients, offering low morbidity. Early oncological outcomes are promising. Larger cohorts and longer follow-ups are required to validate our institution's findings.

Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors in the lateral decubitus position: oncological and functional outcomes

PURPOSE

Retroperitoneal lymph node dissection (RPLND) is recommended for residual masses following chemotherapy for non-seminomatous germ cell tumors (NSGCT). Recently, aberrant recurrence patterns were reported in patients who underwent robotic RPLND. We aimed to evaluate perioperative safety in addition to functional and early oncological outcomes of postchemotherapy robotic RPLND (pcR-RPLND) for NSGCT.

METHODS

A total of 25 patients with NSGCT who underwent a pcR-RPLND between January 2011 and June 2022 were evaluated retrospectively. Descriptive statistics were provided for demographics, clinical characteristics, intraoperative and postoperative parameters. Functional and oncological outcomes were recorded.

RESULTS

The median patient age was 28.9 years (IQR 21.5-32.4). The median retroperitoneal tumor size was 2.6 cm (IQR 1.5-3.5). Intraoperative complications occurred in only one case and the open conversion rate was 12%. There were seven cases with postoperative complications (Clavien grade II: 5 and IIIa: 2). Patients were followed for a median of 33.2 months (IQR 14.8-43.0). Antegrade ejaculation was preserved in 85.7% of the patients. Two patients (8%) relapsed and both had out-of-field recurrences at unusual sites (perinephric fat and omentum). Of those, one patient died (4%) of testicular cancer.

CONCLUSION

pcR-RPLND is a feasible and technically reproducible procedure with favorable perioperative morbidity, low rate of complications, and acceptable postoperative ejaculatory function. Although the recurrence rate was low (8%), recurrences were observed at unusual sites. Further studies are required to investigate any association between the robotic approach and aberrant recurrence patterns.

Robot-assisted retroperitoneal lymph node dissection: a systematic review of perioperative outcomes

OBJECTIVE

To assess the safety and feasibility of robot-assisted retroperitoneal lymph node dissection (R-RPLND) and to compare the perioperative outcomes of R-RPLND with open RPLND (O-RPLND), as RPLND forms an integral part of the management of testis cancer and R-RPLND is a minimally invasive treatment option for this disease.

MATERIALS AND METHODS

The PubMed^® , Scopus^® , Cochrane Central Register of Controlled Trials, and Web of Science™ databases were searched for studies reporting perioperative outcomes of primary and post-chemotherapy R-RPLND and studies comparing R-RPLND with O-RPLND.

RESULTS

The search yielded 42 articles describing R-RPLND, including five comparative studies. The systematic review included 4222 patients (single-arm studies, n = 459; comparative studies, n = 3763). Of 459 patients in the single-arm studies, 271 underwent primary R-RPLND and 188 underwent post-chemotherapy R-RPLND. For primary R-RPLND, the operative time ranged from 175 to 540 min and the major complication rate was 4.1%. For post-chemotherapy R-RPLND, the operative time ranged from 134 to 550 min and the major complication rate was 8.5%. The conversion rate to open surgery was 2.2% in primary R-RPLND and 9.0% in post-chemotherapy R-RPLND. In comparison with O-RPLND, R-RPLND was associated with a lower transfusion rate (14.5% vs 0.9%, P < 0.001) and a lower complication rate (18.5% vs 7.8%, P = 0.002).

CONCLUSION

Robot-assisted RPLND has acceptable perioperative outcomes in both the primary and post-chemotherapy settings but a notable rate of conversion to open surgery in the post-chemotherapy setting. Compared with O-RPLND, R-RPLND is associated with a lower transfusion rate and fewer overall complications. Given the potential impact of selection bias, the optimal patient selection criteria for R-RPLND remain to be elucidated.

Robotic retroperitoneal lymph node dissection for testicular cancer at a national referral centre

Objectives

We aim to determine if robot-assisted retroperitoneal lymph node dissection (R-RPLND) can be performed as a safe option to open RPLND in selected patients with metastatic germ cell cancer.

Patients and methods

This population-based prospective study was performed at a one of two national referral centres for RPLND in Sweden. All patients referred during January 2017-March 2021 were screened for possible inclusion. R-RPLND was performed using the Da Vinci Xi surgical system. Perioperative parameters, postoperative complications (Clavien-Dindo), final pathology, preservation of antegrade ejaculation and relapse rates were evaluated. Classifiers for selecting patients to open versus robotic RPLND were analysed by logistic regression modelling. The median follow-up was 23 months.

Results

Of 87 patients referred, 29 were selected for R-RPLND, 19 in a post-chemotherapy setting. In median, retroperitoneal tumour diameter was 18 mm, BMI 24 kg/m2, operative time 433 min, estimated blood loss 50 ml and length of stay 3 days. One patient underwent open conversion due to failure to progress. Four patients had Clavien-Dindo grade 3 complications, of which three were chylous-related. No in-field recurrences occurred during follow-up.

Conclusion

This population-based study suggests that R-RPLND can be safely performed in at least one third of patients referred for an RPLND. A relatively high rate of lymph-leakage may represent a potential drawback. Tumour size may be the most important discriminator when deciding on robotic versus open RPLND. Further studies with longer follow-up are needed to validate the results.

Robotic RPLND for stage IIA/B nonseminoma: the Princess Margaret Experience

PURPOSE

Retroperitoneal lymph node dissection (RPLND) is a treatment option for men in a primary and post-chemotherapy setting. The aim of this review was to explore the published data looking at feasibility, safety and outcomes of robotic RPLND for CSI/II NSGCT but we will in particular highlight how we have approached adoption of robotic RPLND at the Princess Margaret.

METHODS

A review and summary of the published data to date was performed regarding the role of robotic RPLND for stage IIA/B nonseminoma.

RESULTS

Published series of robotic RPLND to date have proven feasibility and safety in experienced centres. Less blood loss, shorter length of stay and decreased morbidity are promising findings. Our data from Princess Margaret strengthen the argument of oncologic efficacy as we operated only on patients with known retroperitoneal disease (Stage at RPLND was IIA (n = 15, 55.6%), IIB (n = 9, 33.3%), IIC (n = 1, 3.7%) and III (n = 2, 7.4%)), did not use adjuvant chemotherapy and found a relapse rate (11%) similar to open RPLND.

CONCLUSIONS

The debate is ongoing regarding the role of robotic RPLND- the excellent oncological outcomes achieved by an open RPLND are the minimum starting point for robotic RPLND. Until such time that robotic RPLND is proven to be gold standard it should be performed in experienced centres by high volume RPLND surgeons and in the setting of a protocol.

Indications, feasibility and outcome of robotic retroperitoneal lymph node dissection for metastatic testicular germ cell tumours

Data on robotic retroperitoneal lymph node dissection (R-RPLND) for metastatic testicular germ cell tumours (mTGCTs) are scarce and the use of R-RPLND itself is still under debate. The aim of our study was to evaluate the indications, feasibility and outcomes of R-RPLND, with special emphasis on differences between primary R-RPLND (pR-RPLND) and post-chemotherapeutic R-RPLND (pcR-RPLND) in mTGCTs. We retrospectively analysed the data of patients who underwent R-RPLND for mTGCT between November 2013 and September 2019 in two centres in Germany. Indications, operative technique, intra- and postoperative complications and oncologic outcome were analysed. Twenty-three mTGCT patients underwent R-RPLND (7 pR-RPLND, 16 pcR-RPLND). For pR-RPLND versus pcR-RPLND, median time of surgery was 243 min [interquartile range (IQR) 123-303] versus 359 min (IQR 202-440, p = 0.154) and median blood loss 100 mL (IQR 50-200) versus 275 mL (IQR 100-775, p = 0.018). Intra- and postoperative complications were more frequent in pcR-RPLND (pcR-RPLND: intra/post: 44%/44%; pR-RPLND: intra/post: 0%/29%). However, these were only statistically significant in the case of intraoperative complications (intra: p = 0.036, post: p = 0.579). Intraoperative complications (n = 7), conversions (n = 4) and transfusions (n = 4) occurred in pcR-RPLND patients only. After a median follow-up of 16.3 months (IQR 7.5-35.0) there were no recurrences or deaths. R-RPLND displays a valuable, minimally invasive treatment option in mTGCT. However, R-RPLND is challenging and pcR-RPLND especially bears a considerable risk of complications. This operation should be limited to patients with an easily accessible residual tumour mass and to surgeons experienced in robotic surgery and TGCT treatment.