Safety and Early Oncologic Effectiveness of Primary Robotic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Testicular Cancer

Retroperitoneal Lymph Node Dissection: Perioperative Management and Updates on Surgical Techniques

Retroperitoneal lymph node dissection (RPLND) has been an integral part of a multimodal treatment strategy in testicular cancer. Surgeons, over the last decade, have advanced the understanding of RPLND by adopting perioperative care pathways, innovative biomarkers, surgical techniques, and developing algorithms for managing complications. This review summarizes updates on various aspects including the enhanced recovery after surgery pathway, imaging techniques, surgical approaches, dissection templates, and the management of complications. We conclude that RPLND has undergone significant evolution and refinement in the modern era and will continue to hold a critical role in the care of patients with testicular cancer.

Primary retroperitoneal lymph node dissection for metastatic non-seminomatous germ cell tumours: outcomes and adjuvant chemotherapy

OBJECTIVES

To compare the outcomes and treatment burden of primary retroperitoneal lymph node dissection (pRPLND) alone versus pRPLND + adjuvant chemotherapy (AC) in patients with pathological stage II (PSII) non-seminomatous germ cell tumours (NSGCT).

PATIENTS AND METHODS

Retrospective review of the Princess Margaret Cancer Center eTestes cancer database identified patients with PSII NSGCT after pRPLND between 1995 and 2020. The primary outcome was relapse-free survival (RFS). Secondary outcomes included disease-specific survival (DSS), burden of relapse treatment, and factors associated with relapse.

RESULTS

A total of 109 PSII patients were included in the study. There were 96 patients treated with pRPLND alone and 13 treated with pRPLND + AC. The median follow-up was 61 months. The 5-year RFS was 72% for the pRPLND-only group vs 92% for the pRPLND + AC group (hazard ratio [HR] 4.372, 95% confidence interval [CI] 0.59-32.36; P = 0.11). Within the pRPLND-only group the 5-year RFS differed by pN stage (pN1 = 94% vs pN2/N3 = 67%, P = 0.03). Despite a higher relapse rate within the pRPLND-only group, the DSS was similar at 5 years (98% pRPLND only vs 100% pRPLND + AC, P = 0.48). Only 24 (25%) of the patients in the pRPLND-only group required any subsequent chemotherapy. Despite achieving similar survival, the cumulative post-RPLND treatment burden was less for the pRPLND-only group than the pRPLND+AC group overall (average 1.23 vs 2.46 cycles of chemotherapy per patient in group).

CONCLUSION

The majority of patients with PSII NSGCT treated with pRPLND alone do not experience a recurrence or require chemotherapy. Despite a lower relapse risk when AC is given, no difference in survival was seen but higher chemotherapy burden was entertained. AC may constitute overtreatment for most patients with PSII NSGCT treated with pRPLND.

Unilateral Post-Chemotherapy Robot-Assisted Retroperitoneal Lymph Node Dissection for Stage II Non-Seminomatous Germ Cell Tumors: Sexual and Reproductive Outcomes

We aimed to report sexual and reproductive outcomes following post-chemotherapy robot-assisted retroperitoneal unilateral lymph node dissection (PC-rRPLND) for non-seminomatous germ cell tumors (NSGCTs) at a high-volume cancer center. We collected records regarding sexual and reproductive outcomes of patients undergoing unilateral PC-rRPLND for stage II NSGCTs from January 2018 to November 2021. Preoperative and postoperative (at 12 months) ejaculatory function as well as erectile function, based on the International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS), were assessed. Only patients with a pre-operative IIEF-5 of ≥22 and EHS of ≥3 were included in this analysis. Overall, 22 patients undergoing unilateral PC-rRPLND met the inclusion criteria. Of these, seven (31.8%) patients presented an andrological disorder of any type after PC-rRPLND. Specifically, retrograde ejaculation was present in three (13.6%) patients and hypospermia was present in one (4.5%) patient. Moreover, three (13.6%) patients yielded erectile dysfunction (IIEF-5 < 22 and/or EHS < 3). Lastly, two (9.1%) succeeded in naturally conceiving a child after PC-rRPLND. Retrograde ejaculation is confirmed to be one of the most common complications of PC-rRPLND. Moreover, a non-negligible number of patients experience erectile dysfunction.

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.

Propensity-matched Analysis of Open Versus Robotic Primary Retroperitoneal Lymph Node Dissection for Clinical Stage II Testicular Cancer

BACKGROUND

Open retroperitoneal lymph node dissection (O-RPLND) is the accepted standard surgical approach to treat retroperitoneal nodal disease in testis cancer. Increasingly, robotic RPLND (R-RPLND) is being performed due to the potential for lower blood loss, shorter length of stay, and accelerated recovery.

OBJECTIVE

We have performed a propensity score matching (PSM) analysis comparing the survival and perioperative outcomes of O- and R-RPLND.

DESIGN, SETTING, AND PARTICIPANTS

Analyzing the data from all patients who underwent primary RPLND at our center between 1990 and 2022, we used PSM to create a 2:1 (O-RPLND:R-RPLND) matched cohort.

INTERVENTION

Primary O-RPLND versus R-RPLND.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was time to relapse. The secondary endpoints included operating time, length of stay, estimated blood loss (EBL), and surgical complications. Relapse-free survival rates were calculated using the Kaplan-Meier method, and log-rank tests were used to compare perioperative outcomes of O-RPLND versus R-RPLND.

KEY FINDINGS AND LIMITATIONS

A total of 178 patients underwent primary RPLND: 137 O-RPLND and 41 R-RPLND. After PSM, 26 patients in the R-RPLND group were matched with 38 in the O-RPLND group. After matching, no significant baseline differences were noted. After a median follow-up of 23.5 mo (interquartile range 4.4-59.2), one (3.8%) relapse was noted in the R-RPLND group versus three (7.8%) in the O-RPLND group; however, this was not significant (hazard ratio 0.65, 95% confidence interval 0.07-6.31, p = 0.7097). No in-field relapses occurred in either cohort. R-RPLND was associated with a shorter length of stay (1 vs 5 d, p < 0.0001) and lower EBL (200 vs 300 ml, p = 0.032), but longer operative time (8.8 vs 4.3 h, p < 0.0001).

CONCLUSIONS

R-RPLND offers low morbidity and improved perioperative outcomes, while maintaining oncologic efficacy of the open approach.

PATIENT SUMMARY

To the best of our knowledge, this is the first study to compare open and robotic retroperitoneal lymph node dissection (R-RPLND) using a propensity score-matched system. We encourage the discussion and inclusion of primary R-RPLND into the standard of care algorithm for patients with de novo clinical stage (CS) II and relapsed CS I with CS II equivalent disease.

Clinical efficacy and safety of robotic retroperitoneal lymph node dissection for testicular cancer: a systematic review and meta-analysis

Background

Retroperitoneal lymph node dissection (RPLND) is an effective treatment for testicular tumors. In recent years, with the development of robotics, many urological procedures performed via standard laparoscopy have been replaced by robots. Our objective was to compare the safety and efficacy of robotic retroperitoneal lymph node dissection (R-RPLND) versus Non-robotic retroperitoneal lymph node dissection (NR-RPLND) in testicular cancer.

Methods

Pubmed, Embase, Scopus, Cochrane Library, and Web of Science databases were searched for literature on robotic surgery for testicular germ cell tumors up to April 2023. The statistical and sensitivity analyses were performed using Review Manager 5.3. Meta-analysis was performed to calculate mean difference (MD), odds ratio(OR), and 95% confidence interval (CI) effect indicators.

Results

Eight studies with 3875 patients were finally included in this study, 453 with R-RPLND and 3422 with open retroperitoneal lymph node dissection (O-RPLND)/laparoscopic retroperitoneal lymph node dissection (L-RPLND). The results showed that R-RPLND had lower rates of intraoperative blood loss (MD = -436.39; 95% CI -707.60 to -165.19; P = 0.002), transfusion (OR = 0.06; 95% CI 0.01 to 0.26; P = 0.0001), total postoperative complication rates (OR = 0.39; 95% CI 0.21 to 0.70; P = 0.002), and length of stay (MD=-3.74; 95% CI -4.69 to -2.78; P<0.00001). In addition, there were no statistical differences between the two groups regarding perioperative and oncological outcomes regarding total operative time, the incidence of postoperative complications grade≥III, abnormal ejaculation rate, lymph node yield, and postoperative recurrence rate.

Conclusions

The R-RPLND and O-RPLND/L-RPLND provide safe and effective retroperitoneal lymph node dissection for testicular cancer. Patients with R-RPLND have less intraoperative bleeding, shorter hospitalization period, fewer postoperative complications, and faster recovery. It should be considered a viable alternative to O-RPLND/L-RPLND.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023411696.

The role of robotic retroperitoneal lymph node dissection in testicular cancer: a systematic review and meta-analysis

OBJECTIVE

To compare the safety and efficacy of robotic-assisted retroperitoneal lymph node dissection (RA-RPLND) versus non-robotic retroperitoneal lymph node dissection in testicular cancer.

METHODS

The statistical analysis software used Stata 17. The weighted mean difference (WMD) represents the continuous variable, and the dichotomous variable chooses the odds ratio, and calculates the 95% CI. This systematic review and cumulative meta-analysis was performed according to PRISMA criteria, and AMSTAR guidelines (assessing the methodological quality of systematic reviews). The Embase, PubMed, Cochrane Library, Web of Science, and Scopus databases were searched. The upper limit of the search time frame was February 2023, and no lower limit was set.

RESULTS

Seven studies involving 862 patients. Compared with open retroperitoneal lymph node dissection, RA-RPLND appears to have a shorter length of stay [WMD=-1.21, 95% CI (-1.66, -0.76), P <0.05], less estimated blood loss [WMD=-0.69, 95% CI (-1.07, -0.32), P <0.05], and lower overall complications [odds ratio=0.45, 95% CI (0.28, 0.73), P <0.05]. RA-RPLND appears to have more lymph node yields than laparoscopic retroperitoneal lymph node dissection [WMD=5.73, 95% CI (1.06, 10.40), P <0.05]. However, robotic versus open/laparoscopic retroperitoneal lymph node dissection had similar results in operation time, lymph node positivity rate, recurrence during follow-up, and postoperative ejaculation disorders.

CONCLUSION

RA-RPLND appears to be safe and effective for testicular cancer, but longer follow-up and more studies are needed to confirm this.

Robotic-assisted retroperitoneal lymph node dissection for testicular cancer

PURPOSE OF REVIEW

Robotic-assisted retroperitoneal lymph node dissection (R-RPLND) is an emerging surgical option for testicular cancer with less morbidity than open RPLND. We outline the operative technique used at our center and review contemporary evidence in the advancement of R-RPLND.

RECENT FINDINGS

R-RPLND is being applied effectively beyond clinical stage I testicular cancer to treat low-volume, clinical stage II disease in both the primary and postchemotherapy setting. Compared with the open approach, R-RPLND offers shorter hospitalization and less blood loss with comparably low complications and oncologic control.

SUMMARY

With ongoing adoption and optimization of R-RPLND, future studies will assess long-term oncologic outcomes and disseminate R-RPLND in the treatment of testicular cancer.

Comparison of laparoscopic, robotic, and open retroperitoneal lymph node dissection for non-seminomatous germ cell tumor: a single-center retrospective cohort study

PURPOSE

To compare the perioperative outcomes of L-RPLND, R-RPLND and O-RPLND, and determine which one can be the mainstream option.

METHODS

We retrospectively reviewed medical records of 47 patients undergoing primary RPLND by three different surgical techniques for stage I-II NSGCT between July 2011 and April 2022 at our center. Standard open and laparoscopic RPLND was performed with usual equipment, and robotic RPLND was operated with da Vinci Si system.

RESULTS

Forty-seven patients underwent RPLND during 2011-2022, and 26 (55.3%) of them received L-RPLND, 14 (29.8%) were operated with robot, while 7 (14.9%) were performed O-RPLND. The median follow-up was 48.0 months, 48.0 months, and 60.0 months, respectively. The oncological outcomes were comparable among all groups. In L-RPLND group, there were 8 (30.8%) cases of low grade (Clavien I-II) complications, and 3 (11.5%) cases of high-grade (Clavien III-IV) complications. In R-RPLND group, one (7.1%) low-grade complication and four (28.6%) high-grade complications were observed. In O-RPLND group, there were 2 (28.5%) cases of low-grade complications and one case (14.2%) of high-grade one. The operation duration of L-RPLND was the shortest. In O-RPLND group, the number of positive lymph nodes were higher than other two groups. Patients undergoing open surgery had lower (p < 0.05) red blood cell count, hemoglobin level, and higher (p < 0.05) estimated blood loss, white blood cell count than those receiving either laparoscopic or robotic surgery.

CONCLUSION

All three surgical techniques are comparable in safety, oncological, andrological, and reproductive outcomes under the circumstance of not using primary chemotherapy. L-RPLND might be the most cost-effective option.

Nerve-sparing technique in RPLND for testicular cancer

PURPOSE OF REVIEW

The management of testicular cancer has evolved over time with multimodal therapy. Retroperitoneal lymph node dissection (RPLND), which is a complex and potentially morbid treatment option, remains the mainstay in surgical treatment. This article reviews the surgical template, approach and anatomical considerations with regards to nerve spare in RPLND.

RECENT FINDINGS

The standard full bilateral RPLND template has evolved over time to include the area between the renal hilum, bifurcation of the common iliac vessels, and the ureters. Morbidity with regards to ejaculatory dysfunction has led to further refinements in this procedure. Advancements in anatomical understanding of the retroperitoneal structures and their relationship to the sympathetic chain and hypogastric plexus has allowed for modification of surgical templates. Further refinements in surgical nerve sparing techniques have improved functional outcomes without sacrificing oncological outcomes. Finally, extraperitoneal access to the retroperitoneum and minimally invasive platforms have been implemented to further reduce morbidity.

SUMMARY

RPLND requires strict adherence to oncological surgical principles regardless of template, approach and technique. Contemporary evidence shows that outcomes are best for advanced testis cancer patients when managed at high volume tertiary care facilities with surgical expertise and access to multidisciplinary care.

Robot-assisted retroperitoneal lymph node dissection for post-chemotherapy residual mass in testicular cancer: Long-term experience from a tertiary care centre

Objectives

To present our intermediate to long-term oncological and functional outcomes of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in post-chemotherapy (PC) residual mass in testicular cancers. To the best of our knowledge, this is the largest single-centre experience of RA-RPLND for in such setting.

Methods

Prospectively maintained database of carcinoma testis patients undergoing RA-RPLND from February 2012 to September 2021 was reviewed. Patient demographics, tumour stage and risk groups and chemotherapy details were recorded. Intraoperative details and post-operative complications were also noted. Pathological outcomes included were lymph node yield and histopathology report. Further, follow-up was done for recurrence and antegrade ejaculation status.

Results

Total of 37 cases were done for PC residual masses. International germ cell cancer collaborative group good, intermediate and poor risk proportion was 18 (48.6%), 14 (37.8%) and 5 (13.5%), respectively. Bilateral full template dissection, unilateral modified template dissection and residual mass excision was performed in 59.5% (22/37), 35.1% (13/37) and 5.4% (2/37) patients, respectively. The median size of the excised residual mass was 3.45 cm interquartile range (IQR 2-6 cm), with the largest being 9 cm. The median lymph nodal yield was 19. The most common histology was necrosis (n = 24, 65%), followed by teratoma (n = 11, 30%) and viable malignancy (n = 2, 5%). Antegrade ejaculation was reported in 32 patients (86.4%). After a median follow-up of 41 (IQR 14-64) months, only one patient had a recurrence.

Conclusions

RA-PC-RPLND is thus a safe, feasible and oncologically effective option for selected patients. With increasing experience, larger masses can also be dealt with efficiently.

Comparison of the perioperative outcomes of laparoscopic and open retroperitoneal lymph node dissection for low-stage (stage I/II) testicular germ cell tumors: a systematic review and meta-analysis

OBJECTIVE

Comparison of the perioperative outcomes of laparoscopic retroperitoneal lymph node dissection (L-RPLND) and open retroperitoneal lymph node dissection (O-RPLND) for low-stage (stage I/II) testicular germ cell tumors.

METHODS

The authors performed a systematic review and cumulative meta-analysis of the primary outcomes of interest according to PRISMA criteria, and the quality assessment of the included studies followed the AMSTAR guidelines. Four databases were searched, including Embase, PubMed, the Cochrane Library, and Web of Science. The search period was from the creation of each database to October 2022. The statistical analysis software uses Stata17.

RESULTS

There were nine studies involving 579 patients. Compared with O-RPLND, L-RPLND was associated with shorter length of stay [weighted mean difference (WMD)=-3.99, 95% CI: -4.80 to -3.19, P <0.05], less estimated blood loss (WMD=-0.95, 95% CI: -1.35 to -0.54, P <0.05), shorter time to oral intake after surgery (WMD=-0.77, 95% CI: -1.50 to -0.03, P <0.05), and lower overall complications (odds ratio=0.58, 95% CI: 0.38-0.87, P <0.05). Subgroup analysis found that the complication rate of Clavien-Dindo grade II was lower in L-RPLND (odds ratio=0.24, 95% CI: 0.11-0.55, P <0.05). Interestingly, there was no statistically significant difference between the two groups in terms of operation time, lymph node yields, and recurrence rate during follow-up.

CONCLUSION

L-RPLND is superior to O-RPLND and is worthy of clinical promotion.

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.

Red Out: Bleeding During Robotic Retroperitoneal Lymph Node Dissection and Strategies To Manage It

Robotic retroperitoneal lymph node dissection is emerging as an attractive minimally invasive technique to remove residual and recurrent retroperitoneal masses in patients with germ cell malignancies. It has huge potential benefits for patients in terms of lower rates of blood loss, ileus, postoperative pain, and scarring, and faster return to full activity. Inadvertent injury to the great vessels, lumbar tributaries, and other vessels is not uncommon and requires a calm but strategic management response. A thorough knowledge of the standard anatomy, specific pathology, and anatomic variations will help robotic surgeons in managing intraoperative haemorrhage. We describe the anatomy of the retroperitoneal vessels, surgical case selection, and the technical and nontechnical skills essential for success in this complex and high-risk procedure.

Patient summary

Robot-assisted surgical removal of lymph nodes from the area behind the abdominal cavity is a complex operation that has minimal bleeding if all goes well. However, as it involves operating on the major abdominal blood vessels, there is a risk of life-threatening bleeding that the operating team must be able to rapidly control. Effective teamwork and a range of advanced technical skills are required to respond to any serious bleeding.

Primary Retroperitoneal Lymph Node Dissection for Patients With Pathologic Stage II Nonseminomatous Germ Cell Tumor-N1, N2, and N3 Disease: Is Adjuvant Chemotherapy Necessary?

PURPOSE

According to National Comprehensive Cancer Network guidelines, adjuvant chemotherapy (AC) has been advocated after primary retroperitoneal lymph node dissection (RPLND) to reduce the risk of relapse in pathologic nodal (pN) stage pN2 or pN3, whereas surveillance is preferred for pN1. We sought to explore the oncologic efficacy of primary RPLND alone for pathologic stage II in nonseminomatous germ cell tumors (NSGCTs) to reduce overtreatment with chemotherapy.

METHODS

Patients with pathologic stage II NSGCT after primary RPLND between 2007 and 2017 were identified. Patients were excluded for elevated preoperative serum tumor markers, receipt of AC, or if pure teratoma or primitive neuroectodermal tumor elements were found in the retroperitoneal pathology.

RESULTS

We identified 117 patients with active NSGCT in the retroperitoneum after primary RPLND. We excluded seven patients who lacked meaningful follow-up and 13 patients who received AC. There were 97 patients treated with RPLND alone: 41 pN1, 46 pN2, and 10 pN3. In total, 77 of 97 patients had not recurred after a median follow-up time of 52 months. The 2-year recurrence-free survival (RFS) was 80.3%, and the 5-year RFS was 79%. No differences in RFS were noted among nodal stage-pN1, pN2, and pN3-on Kaplan-Meier analysis. Lymphovascular invasion in the orchiectomy specimen, a high-risk pathologic feature, was also predictive of recurrence after primary RPLND. All 20 patients who recurred were treated with first-line chemotherapy and remained continuously disease free.

CONCLUSION

Most men with pathologic stage II disease treated with surgery alone in our series never experienced a recurrence. We did not observe a difference in recurrences between patients with pN1 and pN2. The recommendation for AC for pN2 disease may be overtreatment in most patients.

A meta-analysis of clinicopathologic features that predict necrosis or fibrosis at post-chemotherapy retroperitoneal lymph node dissection in individuals receiving treatment for non-seminoma germ cell tumours

Purpose

Post-chemotherapy retroperitoneal lymph node dissection (pcRPLND) for residual nodal masses is a critical component of care in metastatic testicular germ cell tumour (GCT). However, the procedure is not of therapeutic value in up to 50% of individuals in whom histopathology demonstrates post-treatment necrosis or fibrosis alone. Improved diagnostic tools and clinicopathologic features are needed to separate individuals who benefit from pcRPLND and avoid surgery in those who do not.

Methods

A prospectively registered meta-analysis of studies reporting clinicopathologic features associated with teratoma, GCT and/or necrosis/fibrosis at pcRPLND for metastatic non-seminoma GCT (NSGCT) was undertaken. We examined the effect of various clinicopathologic factors on the finding of necrosis/fibrosis at pcRPLND. The log odds ratios (ORs) of each association were pooled using random-effects models.

Results

Using the initial search strategy, 4,178 potentially eligible abstracts were identified. We included studies providing OR relating to clinicopathologic factors predicting pcRPLND histopathology, or where individual patient-level data were available to permit the calculation of OR. A total of 31 studies evaluating pcRPLND histopathology in 3,390 patients were eligible for inclusion, including two identified through hand-searching the reference lists of eligible studies. The following were associated with the presence of necrosis/fibrosis at pcRPLND: absence of teratomatous elements in orchidectomy (OR 3.45, 95% confidence interval [CI] 2.94-4.17); presence of seminomatous elements at orchidectomy (OR 2.71, 95% CI 1.37-5.37); normal pre-chemotherapy serum bHCG (OR 1.96, 95% CI 1.62-2.36); normal AFP (OR 3.22, 95% CI 2.49–4.15); elevated LDH (OR 1.72, 95% CI 1.37-2.17); >50% change in mass during chemotherapy (OR 4.84, 95% CI 3.94-5.94); and smaller residual mass size (<2 cm versus >2 cm: OR 3.93, 95% CI 3.23-4.77; <5 cm versus >5 cm: OR 4.13, 95% CI 3.26-5.23).

Conclusions

In this meta-analysis, clinicopathologic features helped predict the presence of pcRPLND necrosis/fibrosis. Collaboration between centres that provide individual patient-level data is required to develop and validate clinical models and inform routine care to direct pcRPLND to individuals most likely to derive benefits.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021279699

Update on pediatric testicular germ cell tumors

BACKGROUND

Testicular germ cell tumors are uncommon tumors that are encountered by pediatric surgeons and urologists and require a knowledge of appropriate contemporary evaluation and surgical and medical management.

METHOD

A review of the recommended diagnostic evaluation and current surgical and medical management of children and adolescents with testicular germ cell tumors based upon recently completed clinical trials was performed and summarized in this article.

RESULTS

In this summary of childhood and adolescent testicular germ cell tumors, we review the initial clinical evaluation, surgical and medical management, risk stratification, results from recent prospective cooperative group studies, and clinical outcomes. A summary of recently completed clinical trials by pediatric oncology cooperative groups is provided, and best surgical practices are discussed.

CONCLUSIONS

Testicular germ cell tumors in children are rare tumors. International collaborations, data-sharing, and enrollment of patients at all stages and risk classifications into active clinical trials will enhance our knowledge of these rare tumors and most importantly improve outcomes of patients with testicular germ cell tumors.

LEVEL OF EVIDENCE

This is a review article of previously published and referenced level 1 and 2 studies, but also includes expert opinion level 5, represented by the American Pediatric Surgical Association Cancer Committee.

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.

A comparative study of peri-operative outcomes for 100 consecutive post-chemotherapy and primary robot-assisted and open retroperitoneal lymph node dissections

PURPOSE

To describe and compare differences in peri-operative outcomes of robot-assisted (RA-RPLND) and open (O-RPLND) retroperitoneal lymph node dissection performed by a single surgeon where chemotherapy is the standard initial treatment for Stage 2 or greater non-seminomatous germ cell tumour.

METHODS

Review of a prospective database of all RA-RPLNDs (28 patients) and O-RPLNDs (72 patients) performed by a single surgeon from 2014 to 2020. Peri-operative outcomes were compared for patients having RA-RPLND to all O-RPLNDs and a matched cohort of patients having O-RPLND (20 patients). Further comparison was performed between all patients in the RA-RPLND group (21 patients) and matched O-RPLND group (18 patients) who had previous chemotherapy. RA-RPLND was performed for patients suitable for a unilateral template dissection. O-RPLND was performed prior to the introduction of RA-RPLND and for patients not suitable for RA-RPLND after its introduction.

RESULTS

RA-RPLND showed improved peri-operative outcomes compared to the matched cohort of O-RPLND-median blood loss (50 versus 400 ml, p < 0.00001), operative duration (150 versus 195 min, p = 0.023) length-of-stay (1 versus 5 days, p < 0.00001) and anejaculation (0 versus 4, p = 0.0249). There was no statistical difference in complication rates. RA-RPLND had lower median lymph node yields although not significant (9 versus 13, p = 0.070). These improved peri-operative outcomes were also seen in the post-chemotherapy RA-RPLND versus O-RPLND analysis. There were no tumour recurrences seen in either group with median follow-up of 36 months and 60 months, respectively.

CONCLUSIONS

Post-chemotherapy RA-RPLND may have decreased blood loss, operative duration, hospital length-of-stay and anejaculation rates in selected cases and should, therefore, be considered in selected patients. Differences in oncological outcomes require longer term follow-up.

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.

Robotic retroperitoneal lymph node dissection for primary and post-chemotherapy testis cancer

The role of retroperitoneal lymph node dissection (RPLND) in testicular cancer is well established in both the primary and post-chemotherapy setting. The aim of this study was to report our 2 years oncological outcomes of robotic RPLND. A retrospective review was performed of all patients undergoing robotic RPLND by a single surgeon at Princess Margaret Cancer Centre. Demographic, perioperative, and oncologic data were analyzed using descriptive statistics. Between September 2014 and June 2020, 141 patients underwent an RPLND [33 (23.4%) were primary, 108 (76.6%) were post-chemotherapy]. 27 (19.1%) patients underwent a robotic bilateral template nerve-sparing RPLND. RPLND indication was primary (i.e. pre-chemotherapy) in 18 (66.7%), and post-chemotherapy in 9 (33.3%) patients. Stage at RPLND was 2A (n = 15, 55.6%), 2B (n = 9, 33.3%), 2C (n = 1, 3.7%) and 3 (n = 2, 7.4%). Median OR time (incision to closure) was 525 min and blood loss was 200 ml. Nerve sparing was performed in all but one case. Six (22.2%) adjuvant procedures were performed including two (7.4%) vascular repairs. Median length of stay was 2 days. Viable tumor was detected in 17 (63%) and teratoma in 9 (33.3%). Median follow-up was 31.3 months. No adjuvant chemotherapy was given. Three patients (11.1%) relapsed: 2 out-of-field and 1 with both in-field and out-of-field disease. Robotic RPLND can be performed safely. Long-term follow-up of series such as ours, enriched with patients with viable disease and/or teratoma, and not treated with adjuvant chemotherapy is required to ensure oncological outcomes are comparable to the open approach.

Outcomes of post-chemotherapy robot-assisted retroperitoneal lymph node dissection in testicular cancer: multi-institutional study

OBJECTIVE

To evaluate the perioperative and oncological outcomes after post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-RARPLND).

MATERIALS AND METHODS

We retrospectively reported the perioperative and oncological outcomes of all the patients with testicular cancer who underwent PC-RARPLND at three tertiary teaching centers. Descriptive statistical measures were used to report demographic, clinical, intraoperative, postoperative and oncological outcomes.

RESULTS

There were 43 consecutive patients who underwent PC-RARPLND at the participating institutions. Mean patient age was 29.2 years (± 8.2), BMI was 26.6 kg/m² (± 6.2). The mean size of retroperitoneal mass was 4.1 cm (± 3.5). Full bilateral template dissection was performed in 38 (88.3%) patients. Nerve sparing was attempted in 19 (44.1%) patients. Mean operative time was 374 min (± 132) and estimated blood loss was 292 ml (± 445.6). The mean postoperative LOS was 2.8 days (± 5.9). There was a total of 12 complications in 10 patients (Clavien grade I = 5, II = 3, III = 3 and IV = 1). Postoperative pathology demonstrated 24 patients (55%) with necrosis/fibrosis, 16 (37%) with teratoma and 3 (7%) with viable tumor. Mean lymph node (LN) yield was 26.5 LNs (SD ± 16.1). Patients were followed for a mean of 30.7 months (± 24.7). No deaths were documented during follow-up and 2 pulmonary recurrences were identified. Antegrade ejaculation was preserved in 70.6% of patient who underwent nerve sparing. Limitations included retrospective nature and limited follow up.

CONCLUSION

PC-RAPLND is safe and technically reproducible. It provides improved morbidity and less convalescence.

Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer

Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.

Learning Curve for Robotic-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection

Introduction: Robotic retroperitoneal lymph node dissection (R-RPLND) is a challenging procedure. We hypothesized that surgical times and operative complications would decrease as surgeons became more facile with R-RPLND. Materials and Methods: We retrospectively reviewed 121 consecutive R-RPLNDs performed at Naval Medical Center San Diego and Mayo Clinic Arizona by 4 fellowship trained robotic surgeons between 2008 and 2018. Linear regression was used to analyze independent predictors of setup time, operative time, and lymph node counts. Logistic regression was used to analyze open conversions, overall complications, and high-grade complications. Variables included as independent predictors were: sequential case number, surgeon, clinical stage, chemotherapy status, RPLND template, and body mass index. Univariate and multivariate analyses were conducted. Statistical significance was established at α = 0.05. Results: There was no change in setup time with case number (p = 0.317), but differences were noted between surgeons. Operative times decreased with increasing case number (p < 0.001) but were negatively affected by clinical stage III testis cancer (p = 0.029) and history of chemotherapy exposure (p = 0.050). Surgical times are predicted to decrease by 1 hour after 44 cases. Lymph node counts were dependent only on the surgeon. No factors were predictive of open conversions. Fewer overall complications occurred as experience was gained (p = 0.001), but high-grade complications could not be predicted. Conclusions: Consistent with the learning curves shown for other technologically advanced surgical techniques, experience appears to improve surgical times and lower complication rates for R-RPLND.

Retroperitoneal lymph node dissection for germ cell tumour

Retroperitoneal lymph node dissection (RPLND) is an infrequently used, but important part of the management of men with metastatic germ cell tumours. The surgery aims to remove the lymph nodes from the primary retroperitoneal landing site from testicular tumours, usually accomplished by removing tissue surrounding the great vessels using a split-and-roll technique. RPLND may be carried out as a primary surgical procedure for staging or treatment of metastases. More frequently it is undertaken as a follow-up after chemotherapy for a residual mass that may contain viable tumour or teratoma. RPLND is recognised as a major surgery with significant risks of morbidity and complications, particularly loss of ejaculation secondary to damage to hypogastric nerves. In select cases, especially during primary RPLND, nerve-sparing surgery may help preserve ejaculation, which maybe of importance to the young men usually treated for germ cell tumours. In recent years, the development of minimally invasive approaches have also offered a means for potential improvement in the pain and post-operative recovery from RPLND. We conducted a narrative review of the literature to assess indications for RPLND, along with operative approaches and techniques and related outcomes. The majority of available literature is in the form of relatively small retrospective case series, hence additional research in this area is desirable.

Development and validation of prognostic nomogram for germ cell testicular cancer patients

The purpose of our study was to establish a reliable and practical nomogram based on significant clinical factors to predict the overall survival (OS) and cancer-specific survival (CSS) of patients with germ cell testicular cancer (GCTC). Patients diagnosed with GCTC between 2004 and 2015 were obtained from the SEER database. Nomograms were constructed using the R software to predict the OS and CSS probabilities and the constructed nomograms were validated and calibrated. A total of 22,165 GCTC patients were enrolled in the study, including the training cohort (15,515 patients) and the validation cohort (6,650 patients). In the training cohort, multivariate Cox regression showed that age, race, AJCC stage, SEER stage and surgery were independent prognostic factors for OS, while age, race, AJCC stage, TM stage, SEER stage and radiotherapy were independent prognostic factors for CSS. Based on the above Cox regression results, we constructed prognostic nomograms of OS and CSS in GCTC patients and found that the OS nomograms had higher C-index and AUC compared to TNM stage in the training and validation cohorts. In addition, in the training and external validation cohorts, the calibration curves showed a good consistency between the predicted and actual 3-, 5- and 10-year OS and CSS rates of the nomogram. The current prognostic nomogram can provide a personalized risk assessment for the survival of GCTC patients.

Robot-assisted retroperitoneal lymphadenectomy: The state of art

Objective

To perform a narrative review about the role of robot-assisted retroperitoneal lymphadenectomy (R-RPLND) in the management of testicular cancer.

Methods

A PubMed search for all relevant publications regarding the R-RPLND series up until August 2019 was performed. The largest series were identified, and weighted means calculated for outcomes using the number of patients included in each study as the weighting factor.

Results

Fifty-six articles of R-RPLND were identified and eight series with more than 10 patients in each were included. The weighted mean age was 31.12 years; primary and post chemotherapy R-RPLND were performed in 50.59% and 49.41% of patients. The clinical stage was I, II and III in 47.20%, 39.57% and 13.23% of patients. A modified R-RPLND template was used in 78.02% of patients, while 21.98% underwent bilateral full template. The weighted mean node yield, operative time and estimated blood loss were, respectively, 22.15 nodes, 277.35 min and 131.94 mL. The weighted mean length of hospital stay was 2 days and antegrade ejaculation was preserved in 92.12% of patients. Major post-operative complications (Clavien III or IV) occurred in 5.34%. Positive pathological nodes were detected in 24.54%, while the recurrence free survival was 95.77% with a follow-up of 21.81 months.

Conclusion

R-RPLND has proven to be a reproducible and safe approach in experienced centers; short-term oncologic outcomes are similar to the open approach with less morbidity and shorter convalescence related to its minimal invasiveness. However, longer follow-up and new trials comparing head-to-head both techniques are expected.

Active surveillance in stage 1 disease: standard of care independent of risk factors?

PURPOSE OF REVIEW

Approximately 30% of clinical stage 1 (CS1) nonseminomatous germ cell tumours (NSGCT) and 15-20% of CS1 seminoma relapse without adjuvant treatment. Despite this, the 5-year survival for CS1 is 99%. The purpose of this review is to assess if active surveillance should be standard for all patients with CS1 testis cancer independent of risk factors.

RECENT FINDINGS

Recent data from Princess Margaret Cancer Centre suggest a nonrisk-adapted surveillance approach avoids treatment in ∼70% of patients. Most relapse early at a median time of 7.4 months. The majority of relapses are confined to the retroperitoneum (66%) and only one modality of treatment is required: chemotherapy only in 61% and RPLND only in 73%.

SUMMARY

Surveillance is the preferred option and a safe proven strategy for the management of CS1 disease independent of risk factors. The prognosis for CS1 disease is excellent and the decision to offer surveillance or adjuvant treatment needs to highlight the treatment-related morbidity in an otherwise fit and healthy young man.

Clinical dilemmas in local and regional testis cancer

At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents, fellows, nurses, patients, and patient advocacy group members.This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe.

Population-based analysis of cost and peri-operative outcomes between open and robotic primary retroperitoneal lymph node dissection for germ cell tumors

PURPOSE

To compare perioperative outcomes and perform the first cost analysis between open retroperitoneal lymph node dissection (O-RPLND) and Robotic-RPLND (R-RPLND) using a national all-payer inpatient care database.

METHODS

Nationwide Inpatient Sample (NIS) was queried between 2013-2016 for primary RPLND and germ cell tumor. We compared cost, length of stay (LOS), and complications between O-RPLND and R-RPLND. Linear regression plots identified point of cost equivalence between R-RPLND and O-RPLND. A multivariable linear regression model was generated to analyze predictors of cost.

RESULTS

44 cases of R-RPLND and 319 cases of O-RPLND were identified. R-RPLND was associated with lower rate of complications (0% vs. 16.6%, p < 0.01) and shorter LOS [Median (IQR): 1.5 (1-3) days vs. 4 (3-6) days, p < 0.01]. Rates of ileus, genitourinary complications, and transfusions were lower with R-RPLND, but did not reach significance. On multivariable analysis, robotic approach independently contributed $4457, while each day of hospitalization contributed to an additional $2,431 to the overall model of cost. Linear regression plots determined point of cost equivalence between an R-RPLND staying a mean of 2 days was 4-5 days for O-RPLND, supporting the multivariable analysis. Total hospitalization cost was equivalent between R-RPLND and O-RPLND [Median (IQR): $15,681($12,735-$21,596) vs $16,718($11,799-$24,403), p = 0.48]-suggesting that the cost equivalency of R-RPLND is, at least in part, attributable to shorter LOS.

CONCLUSION

While O-RPLND remains the gold standard and this study is limited by selection bias of a robotic approach to RPLND, our findings suggest primary R-RPLND may represent a cost-equivalent option with decreased hospital LOS in select cases.

Primary Robot-assisted Retroperitoneal Lymph Node Dissection for Men with Nonseminomatous Germ Cell Tumor: Experience from a Multi-institutional Cohort

BACKGROUND

Primary robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for men with nonseminomatous germ cell tumor (NSGCT) is an alternative to open RPLND for stage I and select stage II patients.

OBJECTIVE

To report the complication rates and oncologic outcomes from a multi-institutional series, and to estimate reduction in chemotherapy by using upfront minimally invasive surgery.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective chart review of men undergoing primary robot-assisted RPLND between 2014 and 2019 in five institutions by eight urologists experienced in testis cancer and robotic surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Variables such as demographic and clinicopathologic information, operative parameters and complication rates, oncologic outcomes, sexual recovery, and hospital length of stay were collected. Descriptive statistics are presented.

RESULTS AND LIMITATIONS

Forty-nine patients were analyzed with a median follow-up of 15.0 mo (interquartile range 6.5-29.1 mo). Median operative time was 288 min, estimated blood loss was 100 ml, and lymph node yield was 32. Median length of stay was 1 d. There were nine postoperative complications, 44% (4/9) of which were Clavien grade 1. There were no Clavien grade IV complications. Twenty-one patients had metastatic NSGCT (42.8%), of whom nine (18.4%) received adjuvant chemotherapy. Four patients experienced recurrence (three out-of-field and one in-field recurrence). Limitations include the retrospective study design and various surgical techniques among surgeons.

CONCLUSIONS

Primary robot-assisted RPLND for NSGCT can be performed safely, with low complication rates and acceptable oncologic outcomes reducing the need for chemotherapy. For a population in which compliance with surveillance is typically challenging, robot-assisted RPLND may improve quality of care and outcomes for patients with NSGCT.

PATIENT SUMMARY

In experienced centers, robot-assisted retroperitoneal lymph node dissection can be performed safely with similar oncologic outcomes to an open approach, while providing an option that may reduce the need for chemotherapy.

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

The objectives were to evaluate the safety and oncologic efficacy of primary robotic retroperitoneal lymph node (R-RPLND) dissection for testicular germ cell tumors. A retrospective analysis was performed on all primary R-RPLND cases performed by a single surgeon, who performs both open and R-RPLND at a high-volume academic institution, between August 2013 and August 2019. Data on patient demographics, operative techniques, perioperative outcomes, and tumor characteristics were obtained. 28 men were identified who underwent primary R-RPLND. The majority of patients (N = 21, 75%) had clinical stage I disease, and a bilateral template was more commonly performed than either single side alone (N = 13, 46%). Of note, two cases involving clinical stage II disease were converted electively from robotic to open procedures at the discretion of the surgeon. R-RPLND patients experienced no intraoperative complications. The median follow-up time was 8 months (interquartile range 4-29 months). One (4%) patient developed a disease recurrence at 10 months after R-RPLND. Conclusion: primary R-RPLND is a safe and efficacious procedure for carefully selected men with stage I and II non-seminomatous germ cell tumors of the testis. Long-term data are needed to evaluate the comparative oncologic efficacy with open surgery and the notably high rate of chylous ascites.

Minimally Invasive Surgery for Patients with Locally Advanced and/or Metastatic Renal Cell Carcinoma

Despite advances in systemic therapy and immunotherapy, surgery continues to have a role in management of advanced renal cell carcinoma (aRCC). Minimally invasive surgery (MIS) is considered standard of care for smaller, localized tumors due to faster recovery without compromising oncologic outcomes. There are concerns about MIS for aRCC due to a potential risk of inferior oncologic outcomes and unusual patterns of disease recurrence. Recent studies, however, suggest that in properly selected patients with aRCC, MIS can provide improved peri-operative outcomes without compromising oncologic control.

Controversies in the management of clinical stage 1 testis cancer

In November 2018, The Canadian Testis Cancer Workshop was convened.  The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician’s assistants, residents and fellows, nurses, patients and patient advocacy groups.   One of the goals of the workshop was to discuss the challenging areas of testis cancer care where guidelines may not be specific.  The objective was to distill through discussion around cases, expert approach to working through these challenges. Herein we present a summary of discussion from the workshop around controversies in the management of clinical stage 1 (CS1) disease. CS1 represents organ confined non-metastatic testis cancer that represents approximately 70-80% of men at presentation. Regardless of management, CS1 has an excellent prognosis. However, without adjuvant treatment, approximately 30% of CS1 nonseminomatous germ cell tumors (NSGCT) and 15% of CS1 seminoma relapse. The workshop reviewed that while surveillance has become the standard for the majority of patients with CS1 disease there remains debate in the management of patients at high-risk of relapse. The controversy in the management of CS1 testis cancer surrounds the optimal balance between the morbidity of overtreatment and the identification of patients who may derive most benefit from adjuvant treatment. The challenge lies in a shared decision process where discussion of options extends beyond the simple risk of relapse but to include the long-term toxicities of adjuvant treatments and the favorable cancer-specific survival.    

Primary and post-chemotherapy robotic retroperitoneal lymph node dissection for testicular cancer: a review

Open retroperitoneal lymph node dissection (RPLND) is the gold standard for surgical management of the retroperitoneum in patients with testicular cancer, and is associated with excellent oncologic outcomes and significant morbidity including length of stay. Minimally invasive RPLND, starting with laparoscopic retroperitoneal lymph node dissection in 1992 and now robotic retroperitoneal lymph node dissection in 2006, endeavor to decrease the morbidity of open RPLND while maintaining excellent oncologic outcomes. This review surveys the literature regarding both primary and post-chemotherapy robotic RPLND, emphasizing that while early outcomes are promising, much work needs to be done before widespread use of this technique is implemented.

Robotic-assisted surgery for the treatment of urologic cancers: recent advances

INTRODUCTION

As the medical field is moving toward personalized and tailored approaches, we entered the era of precision surgery for the management of genitourinary cancers1. This is facilitated by the implementation of new technologies, among which robotic surgery stands out for the significant impact in the surgical field over the last two decades.

AREAS COVERED

This article reviews the latest evidence on robotic surgery for the treatment of urologic cancers, including prostate, kidney, bladder, testis, and penile cancer. Functional and oncologic outcomes, new surgical techniques, new imaging modalities, and new robotic platforms are discussed.

EXPERT OPINION

Robotic surgery had a growing role in the management of genitourinary cancers over the past 10 years. Despite a lack of high-quality evidence comparing the effectiveness of robotic to open surgery, the robotic approach allowed a larger adoption of a minimally invasive surgical approach, translating into lower surgical morbidity and shorter hospital stay. New robotic platforms might allow to explore novel surgical approaches, and new technologies might facilitate surgical navigation and intraoperative identification of anatomical structures, allowing a more tailored and precise surgery. It is an exciting time for robotic surgery, and upcoming technological advances will offer better outcomes to urologic cancer patients.

Robot-assisted laparoscopic retroperitoneal lymph node dissection: a minimally invasive surgical approach for testicular cancer

Retroperitoneal lymph node dissection (RPLND) can been employed as primary treatment for stage I non-seminomatous germ cell tumor (NSGCT) as well as for treatment of post-chemotherapy masses. Open RPLND (O-RPLND) has long been the standard approach for lymphadenectomy, but is associated with significant morbidity. Laparoscopic RPLND (L-RPLND) was developed to mitigate the morbidity associated with O-RPLND, but is a technically challenging procedure requiring significant experience with laparoscopic dissection and suturing to remove lymph nodes behind the great vessels and to control vascular injury. Robotic RPLND (R-RPLND) has gained traction in recent years as an alternative to both O-RPLND and L-RPLND. With superior instrument dexterity and better visualization compared to L-RPLND, and with decreased morbidity, compared to O-RPLND, R-RPLND can be performed safely and effectively. With the latest advances in robotic technology, one can perform a full bilateral dissection without needing to reposition the patient or redock the robot. R-RPLND has been applied for both primary treatment as well as in patients with post-chemotherapy residual abdominal masses.

Simultaneous Vs Sequential Retroperitoneal, Thoracic and Cervical Resection of Post Chemotherapy Residual Masses in Patients With Metastatic Nonseminomatous Germ Cell Tumors of the Testis

OBJECTIVE

To compare a simultaneous vs sequential approach to residual post chemotherapy mass resections in metastatic testis cancer.

METHODS

A retrospective review was performed of patients who underwent retroperitoneal and thoracic/cervical resection of post chemotherapy residual masses between 2002 and 2018. Group 1: "Simultaneous" (Combined Retroperitoneal and Thoracic/Cervical resections on the same date); Group 2: "Sequential" (Retroperitoneal and Thoracic/Cervical resections at separate dates).

RESULTS

During the study period, 35 simultaneous and 17 sequential resections were performed. The median age at surgery was 28 years (Range 16-61). The median follow-up from last surgical procedure was 62.7 months (Range 0.4-194). Histology revealed teratoma in 38 (73.1%) patients, necrosis in 8 (15.4%) and viable tumor in 6 (11.5%). Discordant pathology findings between thoracic/cervical and abdominal resections were noted in 16 (30.8%) patients. No differences were observed between the simultaneous vs sequential groups in median operating time (585 minutes vs 545 minutes, P = .64), blood loss (1300 vs 1300 mls, P = .42), or length of stay (9 vs 11 days, P = .14). There was no difference between the 5-year (65.7% vs 68.6%) relapse-free survival between the 2 groups (P = .84) or the 5-year (88.6% vs 100%) overall and disease-specific survival (P = .25).

CONCLUSION

Simultaneous resection of retroperitoneal and thoracic/cervical post chemotherapy metastases is a feasible in some patients. It requires multidisciplinary collaboration and a longer primary procedure.

Centralization tendencies of retroperitoneal lymph node dissection for testicular cancer in Germany? A total population-based analysis from 2006 to 2015

INTRODUCTION

Retroperitoneal lymph node dissection (RPLND) is a standard treatment in the management of metastatic testicular cancer. Due to modified treatment algorithms, it is becoming less frequent.

MATERIALS AND METHODS

We analyzed data from the nationwide German hospital billing database covering 2006-2015. Cases with a testicular cancer diagnosis combined with RPLND were included. We assessed the length of hospital stay (LOS), blood transfusion, and in-hospital mortality stratified for surgical approach, hospital characteristics, and annual caseload. Annual hospital caseload categories were defined as low (< 4), medium (4-10), and high (> 10). We supplemented tumor incidence and staging data from the German cancer registry (60% of population).

RESULTS

4926 cases were included with decreasing annual caseload numbers from 623 in 2006 to 382 in 2015. The incidence of testicular cancer and higher tumor stages remained stable. High-volume hospitals performed 19.4%, medium-volume hospitals 43.7%, and low-volume hospitals 36.8% RPLNDs. Low- abd medium-volume hospitals declined, while high-volume hospitals (n = 5) maintained their annual caseload. Overall in-hospital mortality was 0.47%. Blood transfusion rates were higher in high-volume centers assumedly due to selection of more complex cases. However, high-volume hospitals showed a shorter LOS with 10.5 vs. 11.2 (medium volume), and 12.7 days (low volume).

CONCLUSION

Total numbers of RPLND have declined from 2006 to 2015, while tumor incidences and stages remained fairly stable. Constant reduction of indication in guidelines contributes to this finding. High-volume hospitals achieve shorter hospital stays in spite of assumedly more complex and extensive cases. There is a modest trend towards unregulated centralization.

Primary robotic RLPND for nonseminomatous germ cell testicular cancer: a two-center analysis of intermediate oncologic and safety outcomes

OBJECTIVE

To evaluate the intermediate-term oncologic outcomes and safety profile of the largest case series of primary robotic retroperitoneal lymphadenectomy for low-clinical-stage non-seminomatous germ cell testicular cancer.

METHODS

This was a two-center retrospective analysis of robotic RPLND cases for low-clinical-stage (stage I-IIB) non-seminomatous germ cell testicular cancer in the primary setting. Demographic, perioperative, operative and oncologic variables were collected between March 2008 and May 2019. Descriptive analyses were performed and presented as medians with interquartile ranges for continuous variables and frequency and proportions for categorical variables. A survival analysis of time to recurrence was performed using Cox proportional hazards model. Using logistic regression, risk factors for complications were analyzed. Both univariate and multivariate analyses were performed.

RESULTS

A total of 58 patients (CS 1 = 56, CS IIA = 2, CS IIB = 0) were identified. The median follow-up was 47 months and the 2-year recurrence-free survival rate was 91%. The five recurrences were all out of the performed dissection template (pelvis = 1 and lung = 4). Only five patients (29%) with occult metastasis underwent adjuvant chemotherapy. The median operative time was 319 min [interquartile range (IQR) 276-355 min], estimated blood loss was 100 ml (IQR 75-200 ml), node count was 26 (IQR 20-31), and length of stay 2 d (IQR 1-3 days). There were 2 (3.3%) intraoperative complications, 19 (32.7%) 30-day postoperative complications to include 14 (24.1%) Clavien grade I, 4 (6.9%) Clavien grade II, 1 (1.7%) Clavien grade III and 0 Clavien grade IV complications. No statistical significance was found on multivariate or univariate analysis for survival analysis of time to recurrence and risk factors for complications.

CONCLUSIONS

This study represents the largest case series of primary R-RPLND for the treatment of low-stage non-seminomatous germ cell tumors (NSGCT). With 47 months of follow-up and a low rate of adjuvant chemotherapy, intermediate oncologic efficacy appears to be comparable to the gold standard open approach.

Robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy for metastatic mixed testicular germ cell cancer: a case report

BACKGROUND

The robot-assisted laparoscopic management of post-chemotherapy retroperitoneal metastasis and inferior vena cava tumor thrombus secondary to testicular cancer is a challenging task for urologists.

CASE PRESENTATION

A pathological examination of a 36-year-old Caucasian man who had undergone a right radical orchiectomy showed mixed testicular germ cell cancer (70% embryonal cancer and 30% seminoma); he had undergone four prior courses of cisplatin, etoposide, and bleomycin chemotherapy and was found to have residual retroperitoneal enlarged lymph nodes close to the right renal hilum and a 9.8 cm inferior vena cava tumor thrombus (pT1, N2, M1, S2). Pre-surgical three-dimensional image reconstruction was performed based on contrast computed tomography data. The inferior vena cava tumor thrombus was found in the vena cava at the level of the celiac trunk and the inferior mesenteric artery. Our patient accepted treatment with robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and cava reconstruction on September 12, 2018. During the procedure, a drop-in robotic ultrasound probe was used to define the thrombus. Vena cavoscopy using a flexible ureteroscope found that the tumor thrombus adhered to the cava wall in all directions. The tumor thrombus was dissected free from the inferior vena cava lumen, and vena cava reconstruction was achieved using the da Vinci™ Si HD surgical system. The operative time was 550 minutes. The intraoperative estimated blood loss was 2300 ml. Intraoperative blood transfusions consisted of 10 units of red blood cells (Clavien-Dindo grade II). No Clavien-Dindo grade III or above perioperative complications occurred. The length of hospital stay was 7 days. Pathology revealed no viable cancer cells in any of the residual lymph node tissues or in the vena cava tumor thrombus.

CONCLUSION

This is the first case of robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and reconstruction for metastatic mixed testicular germ cell cancer published to date. This complicated surgical procedure was facilitated by the innovative usage of three-dimensional image reconstruction for defining the vena cava tumor thrombus, a robotic ultrasound probe for intraoperatively defining the vena cava tumor thrombus, and vena cavoscopy using a flexible ureteroscope.

Management of Stage II Germ Cell Tumors

There are several treatment approaches for stage II germ cell tumors (GCTs), and a thorough understanding of the staging classification and histologic differences in tumor biology and therapeutic responsiveness is critical to determine an effective, multimodal management strategy that involves urologists, medical oncologists, and radiation oncologists. This article discusses contemporary management strategies for stage II GCTs, including chemotherapy, radiotherapy, retroperitoneal lymph node dissection (RPLND), and surveillance. Patient selection, histology, and extent of lymphadenopathy drive management, and, as both treatment and detection strategies continue to emerge and be refined, the management of patients with stage II GCT continues to evolve.