Robot - assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor

Abstract

_______________________________________________________________________________________Introduction and objective: Retroperitoneal lymph node dissection (RPLND) is indicated for patients with non-seminomatous germ cell tumor (NSGCT) with residual disease after chemotherapy. Although the gold standard approach is still the open surgery, few cases of robot-assisted laparoscopic RPLND have been described. Herein, we aim to present the surgical technique for robot-assisted laparoscopic RPLND. Patient and method: A 30 year-old asymptomatic man presented with left testicular swelling for 2 months. Physical examination revealed an enlarged and hard left testis. Alpha-fetoprotein (>1000ng/mL) and beta-HCG (>24.000U/L) were increased. Beta-HCG increased to >112.000U/L in less than one month. The patient underwent a left orchiectomy. Pathological examination showed a mixed NSGCT (50% embryonal carcinoma; 30% teratoma; 10% yolk sac; 10% choriocarcinoma). Computed tomography scan revealed a large tumor mass close to the left renal hilum (10x4x4cm) and others enlarged paracaval and paraortic lymph nodes (T2N3M1S3-stage III). Patient was submitted to 4 cycles of BEP with satisfactory response. Residual mass was suggestive of teratoma. Based on these findings, he was submitted to a robot-assisted RPLND. Results: RPLND was uneventfully performed. Operative time was 3.5 hours. Blood loss was minimal, and there were no intra-or postoperative complications. The patient was discharged from hospital in the 1 st postoperative day. Pathological examination showed a pure teratoma. After 6 months of follow-up, patient is asymptomatic with an alpha-fetoprotein of 2.9ng/mL and an undetectable beta-HCG. Conclusion: Robot-assisted laparoscopic RPLND is a feasible procedure with acceptable morbidity even for post chemotherapy patients when performed by an experienced surgeon.

Robot-assisted retroperitoneal lymphadenectomy: The state of art

“…Of note, oncologic outcomes do not seem to be compromised by the minimally invasive technique. Also, the node yield, which usually reflects the effectiveness of oncologic surgery, presented a weighted mean of 22.15 nodes in our review and was comparable with recent publications on the O-RPLND series that reported a median 28 [ [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] ] nodes removed [ 41 , 44 ].…”

“…As a result, multiple series of R-RPLND have been successfully reported recently in multiple experienced centers around the world, showing the potential of this surgical approach to increase the number of well-trained surgeons performing minimally invasive RPLND [ 10 , 11 , [13] , [14] , [15] , [16] , [17] , [18] ]. Even challenging cases as bulky CS III disease with concomitant inferior vena cava thrombectomy for metastatic GCT have already been managed successfully with a robotic approach by high-volume surgeons [ [23] , [24] , [25] , [26] , [27] ]. With regards to patient positioning, the initial series described the R-RPLND approach with the patient in flank position and trocar placement and docking similar to a partial nephrectomy [ 4 ].…”

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

“…A total of 37 studies [7,21–56] were included. Of these, 12 studies [7,21,23–25,28–32,34,35] described patients who underwent primary R‐RPLND only, 16 [38–53] described patients who underwent post‐chemotherapy R‐RPLND only, and six [22,26,27,33,36,37] included patients who underwent R‐RPLND in either of these settings.…”

Role of laparoscopy in the era of robotic surgery in urology in developing countries

“…[ 43 ] However, RA-RPLND is mostly supported by case reports and small retrospective series. [ 44 ] In a review of retrospective studies (116 patients) by Tselos et al .,[ 38 ] the authors found similar outcomes as the L-RPLND. Median LN yield was 22.3 with an overall positivity rate of 26% and complication rate of 8%.…”