Robotic retroperitoneal lymph node dissection for testicular cancer: feasibility and latest outcomes

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.

Testicular Cancer Treatments and Sexuality: A Narrative Review

The incidence of testicular cancer (TC) has been rapidly increasing over the past years. Diagnosis and early treatment have shown good oncological control, guaranteeing the patient different treatment approaches according to histology and tumor stage. Currently, physicians usually prioritize oncological outcomes over sexual outcomes and quality of life, considering as a first aim the overall survival of the patients; however, differently from other neoplasms, quality of life is still strongly affected among TC patients, and sexual outcomes are frequently compromised after each TC treatment. Several studies have suggested that each treatment approach may be associated with sexual dysfunctions, including erectile dysfunction, ejaculatory disorders, fertility issues, and hormonal changes. Since testicular cancer patients are more frequently young men, the subject of this work is substantial and should be analyzed in detail to help specialists in the management of this disease. The aim of the current narrative review is to generally describe every treatment for TC, including surgery, chemotherapy, radiotherapy, and retroperitoneal lymph node dissection, and to establish which sexual dysfunction may be specifically associated with each therapy.

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.

Treatment de-escalation for stage II seminoma

International Germ Cell Cancer Collaborative Group good-risk metastatic seminoma has cure rates of >95%. Within this risk group, patients with stage II disease exhibit the best oncological outcomes with the standard-of-care treatment strategies of radiotherapy or combination chemotherapy. However, these treatments can be associated with substantial early and late toxic effects. Therapy de-escalation aims to reduce treatment morbidity whilst preserving oncological outcomes. The evidence supporting such approaches is largely from non-randomized institutional data, and therefore this strategy is not recognized as standard of care. Current de-escalation approaches for stage II seminoma include single-agent chemotherapy, radiotherapy and surgery based on early data from clinical studies. Increased recognition of emerging data on treatment modification to reduce morbidity whilst maintaining cure rates and consideration of therapy de-escalation could improve patient survivorship outcomes.

Robotic retroperitoneal lymph node dissection in colorectal cancer

In select colorectal cancer patients with metastatic retroperitoneal lymph node disease, surgical resection can be performed. We discuss our robotic technique.

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.

Intricacies of retroperitoneal lymph node dissection for testis cancer

PURPOSE OF REVIEW

Retroperitoneal lymph node dissection (RPLND) and retroperitoneal tumor resection for germ cell cancer are complex operations requiring experience and expertise in surgical techniques necessary to achieve complete resection while minimizing morbidity. This article reviews the intricacies of RPLND for testis cancer.

RECENT FINDINGS

Surgical management of advanced testis cancer begins with an intimate understanding of retroperitoneal anatomy and the various techniques necessary to safely extirpate tumors. Preoperatively patients should undergo comprehensive counseling and obtain up-to-date imaging along with tumor markers to assist in surgical planning and evaluation of extraretroperitoneal (ERP) disease. Surgeons must be well versed in nerve-sparing techniques to maintain ejaculatory function. Newer techniques using a midline extraperitoneal technique minimizes morbidity and length of hospital stay. Special consideration should be given to the possibility of encountering ERP disease in advanced germ cell tumors, with management of these cases in tertiary care centers with multidisciplinary teams.

SUMMARY

The perioperative care of the testis cancer patient undergoing RPLND is complex. The goal is to achieve complete resection to render patients disease free while minimizing surgical and long-term morbidity. Advanced testis cancer patients should be managed at tertiary care facilities with surgical expertise and access to multidisciplinary care.

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.

The impact of tiredness on virtual reality robotic surgical skills

Introduction

The effect of tiredness has been proved for the surgeons’ musculature performing laparoscopic or robotic procedures (physical stress). Mental stress after robotic surgery has been reported as well. It is still unclear how much the surgical skills are altered and which types of skills are more affected at the final steps of long, complex robotic surgical procedures.

Aim

To evaluate to what extent the surgeon’s skills are influenced by long procedures, using the objective assessment of different surgical skills by a virtual reality robotic simulator.

Material and methods

Fifteen surgeons were asked to perform a continuous 4 h virtual robotic surgical simulator training session. At the beginning of simulator training and at the end of each of the 4 h of training, three exercises of increasing difficulty were selected to be performed in order to assess the surgeons’ skills.

Results

There were statistically significant differences between the initial and final overall scores for all the three exercises, the final outcomes being inferior. The specific metrics for each exercise slightly improved within 1 h from the beginning and thereafter decreased to a statistically significantly inferior value.

Conclusions

The specific metrics on the virtual reality robotic surgical simulator were altered after a 4-hour console training period. Further larger and more complex studies are necessary to evaluate the translation from the simulator to real-life robotic surgery.

Advanced Testis Cancer

Management of advanced testis cancer requires dedicated attention to the nuances of the disease to not only optimize cure but also ensure lifelong health. We are rapidly entering an era of precision medicine with novel biomarker discoveries that will undoubtedly change the treatment paradigm in both early- and late-stage disease.