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https://doi.org/10.1007/s00120-025-02678-3

Retroperitoneal lymphadenectomy in the treatment of testicular germ cell tumors-Is the robot-assisted technique superior to the open surgical approach?

Oct 1, 2025
Urologie (Heidelberg, Germany)
Markus Angerer +2 more

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Retroperitoneal lymph node dissection (RPLND) is an established treatment modality for nonseminomatous germ cell tumours (NSGCT) and selected seminomas. The advent of minimally invasive techniques, particularly robot-assisted RPLND (R-RPLND), involves the prospects of reducing procedure-related morbidity while maintaining oncologic efficacy. We performed anarrative review comparing contemporary data on R‑RPLND and open RPLND (O-RPLND) across different clinical settings (primary, clinical stagesI-II, and postchemotherapy). Guideline recommendations are reviewed regarding results from prospective and retrospective studies, as well as recent meta-analyses. R‑RPLND consistently demonstrated advantages in perioperative outcomes, including reduced blood loss, shorter length of hospital stay, and faster convalescence. High-grade complication rates (Clavien-Dindo ≥ III) were comparable or lower than with O‑RPLND. Oncologic outcomes, including recurrence-free survival, were noninferior across all stages. In the postchemotherapy setting, R‑RPLND was associated with lower morbidity, though surgical feasibility is highly dependent on tumour size, location, and prior abdominal surgery. R‑RPLND represents asafe and effective alternative to O‑RPLND in selected patients when performed in high-volume centres. Its perioperative advantages, coupled with equivalent short-term oncologic outcomes, render R‑RPLND an attractive option. However, high-quality randomised trials with long-term follow-up are required to confirm oncologic equivalence and to refine patient selection criteria.

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Research Article
10.1111/bju.16747

Matched-pair analysis of peri-operative and oncological outcomes of robot-assisted vs open retroperitoneal lymph node dissection.

Apr 22, 2025
BJU international
Pailin Pongratanakul + 6 more

To analyse a comparatively large cohort of patients who underwent robot-assisted retroperitoneal lymph node dissection (R-RPLND) in a single centre, assessing the peri-operative and oncological safety of this procedure compared to that in a matched-pair cohort of patients who underwent open retroperitoneal lymph node dissection (O-RPLND). We retrospectively identified 100 patients who underwent R-RPLND between October 2010 and January 2024. A matched-pair analysis of R-RPLNDs and O-RPLNDs was conducted based on the following criteria: surgical indication, histology, clinical stage (CS), and tumour size. The primary endpoint of this analysis was progression-free survival (PFS). Secondary endpoints were peri-operative parameters. Based on surgical indication, the R-RPLND cohort was divided into four groups: CS II seminoma (Group 1, 42 patients); marker-negative CS II non-seminoma (Group 2, 15 patients); CS I non-seminoma with high-risk factors (Group 3, seven patients), and post-chemotherapy patients (Group 4, 34 patients). Two patients were excluded due to uncommon testicular histology. With a mean follow-up of 32, 31, 32 and 28 months in the four groups, respectively, relapses occurred in 10/42 of Group 1, 3/15 of Group 2, and 1/7 of Group 3, while all patients remained relapse-free in Group 4. The matched-pair analysis revealed that histological retroperitoneal lymph node dissection specimens, relapse rates, and PFS were similar in the R-RPLND and O-RPLND groups. R-RPLND had advantages in terms of a shorter hospital stay as a surrogate for less morbidity. In selected patients and selected surgical indications, R-RPLND represents a minimally invasive alternative to O-RPLND in the management of patients with testicular germ cell tumours.

Preprint Article
10.69622/27890046.v1

Microrna and retroperitoneal lymph node dissection : advances in testicular cancer treatment

Jan 16, 2025
Anna Thor

BACKGROUND Testicular germ cell tumor (TGCT) is the most common malignancy in young men, with an excellent five-year survival rate over 95%. Metastatic TGCTs can be cured by either chemotherapy, radiation or retroperitoneal lymph node dissection (RPLND), either solitary or in combination. Current research focuses on refining treatments and minimizing side effects. Over the past decade, the novel biomarker microRNA 371a-3p has demonstrated promising performance with high sensitivity and specificity for germ cell tumors (GCT), however, excluding teratomas. RPLND is a complex surgical procedure associated with certain morbidity, requiring substantial surgical experience for optimal outcomes. A global trend is emerging toward surgery as primary treatment for select patients with limited disease burden. The collaboration within the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) enables populationbased studies on a relatively rare condition. AIMS Paper I, to evaluate miR-371a-3p levels in TGCT patients undergoing orchiectomy and in healthy blood donors using digital droplet PCR (ddPCR). Paper II, to assess miR-371a-3p levels in GCT patients undergoing RPLND using ddPCR and to evaluate the marker’s ability to predict viable cancer. Paper III, to report the outcomes for the first 62 patients in Sweden and Norway with low-stage, low-volume metastatic seminoma receiving RPLND as first-line treatment. Paper IV, to assess post-operative outcomes in a population-based cohort of metastatic GCT patients who underwent RPLND over a five-year period, in the context of centralization and wide-ranging adoption of robot-assisted procedures. METHODS Paper I is first part of the binational prospective multicenter study SWENOTECA-MIR. 180 TGCT patients and 50 healthy blood donors were analyzed for miR-371a-3p before and after orchiectomy, using ddPCR. The performance of ddPCR was compared to the quantitative PCR (qPCR) made by others to detect miR-371a-3p. Results were stratified by tumor subtype, tumor size, and clinical stage (CS), and levels of miR-371a-3p were statistically analyzed across the groups. Performance of the miR-371a-3p test was compared to conventional tumor markers. Paper II is the third part of the SWENOTECA-MIR study. 114 patients (86 nonseminomas, 28 seminomas) underwent open or robot-assisted RPLND from 2017 to 2022. miR-371a-3p levels were analyzed in pre- and post-operative samples using ddPCR. The cohort was categorized into primary and postchemotherapy RPLND groups and further subdivided into seminomas and nonseminomas. Statistical comparisons were made between pre- and postoperative miR-371a-3p levels, with optimism-corrected performance metrics assessed against conventional serum tumor biomarkers. Paper III describes the outcomes of a prospective population-based cohort. 62 seminoma patients from Norway and Sweden were operated between 2019 and 2022. Patients with lymphadenopathy £ 3 cm, primary CS IIA/B or CS I with relapse, underwent uni- or bilateral template RPLND, either open or robotassisted. Outcome measures included surgical complications according to the Clavien-Dindo classification, and Kaplan-Meier survival estimates for 24-month progression-free survival (PFS) and overall survival (OS). Paper IV is a prospective, population-based, observational multicenter study including all GCT patients who underwent RPLND in Sweden from 2018 to 2022. The cohort comprised 217 patients, with 175 nonseminomas and 42 seminomas. Unilateral and bilateral primary (P) RPLND and post-chemotherapy (PC) RPLND were performed, either open or robot-assisted. Primary outcomes included intra- and post-operative complications, loss of antegrade ejaculation, and histopathological findings of viable cancer or teratoma. RESULTS In Paper I, ddPCR demonstrated high performance in detecting miR-371a-3p, with a sensitivity of 89% for the entire cohort. Sensitivities for CS I seminomas and CS I nonseminomas were 87% and 89%, respectively. Sensitivity for CS I–IV seminomas was 89%, and for CS I–IV nonseminomas, it was 90%. The specificity for the cohort was 100%, with a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 55%. In comparison, AFP demonstrated 52% sensitivity and b-HCG 51%, in nonseminomas. Linear regression indicated an association between tumor size and miR-371a-3p levels across the entire cohort (R² = 0.159, p < 0.001). Levels of miR-371a-3p decreased significantly following orchiectomy in nearly all patients, with the change being less evident in metastatic patients. In Paper II, all seminoma patients (n = 24) undergoing primary RPLND had normal conventional markers, with six having received adjuvant treatment prior to surgery. miR-371a-3p demonstrated a sensitivity of 74%, specificity of 100%, PPV of 100%, and NPV of 21% for detecting viable tumor. miR-371a-3p levels decreased significantly after surgery (p = 0.001). In the nonseminoma group (n = 18) undergoing primary RPLND, 22% had elevated conventional markers, and three patients had received prior adjuvant treatment. For primary nonseminoma patients, miR-371a-3p demonstrated a sensitivity of 34%, specificity of 88%, PPV of 67%, and NPV of 62%. No significant association was observed between stage or prior adjuvant treatment and miR-371a-3p outcome. In the postchemotherapy group (n = 72), miR-371a-3p sensitivity was 9%, and it dropped to 0% when seminoma patients (n = 4) were excluded. Teratomas and benign histology yielded essentially negative results. In Paper III, 33 patients (53%) had CS I with relapse during surveillance, six patients (10%) had CS I with relapse after adjuvant chemotherapy, and 23 patients (37%) had initial CS IIA/B disease. Post-operative analysis confirmed metastatic seminoma in 58 patients (94%), with a median largest diameter of 18 mm (IQR: 13–24). Robot-assisted RPLND was performed in 40 patients (65%). Clavien-Dindo III complications occurred in three patients (5%), and no grade ³ IV complications were observed. Eighteen patients (29%) received adjuvant chemotherapy after surgery. The median follow-up was 23 months (IQR: 16–30), with recurrence occurring in six patients (10%) after a median of 8 months (IQR: 4–14). PFS was 90% (95% CI: 0.86–1), and OS was 100% at 24 months. In Paper IV, the cohort experienced intra-operative complications in 8% of unilateral and 0% of bilateral P-RPLND procedures, with renal injury being the most common event. For PC-RPLND, the rates were 0% for unilateral and 8% for bilateral templates. Post-operative complications were more frequent with bilateral templates (P-RPLND: 40% vs. 26%, p = 0.3; PC-RPLND: 49% vs. 18%, p = 0.0), with Clavien-Dindo ≥ IIIb complications in 2% of P-RPLND cases and 3% of PC-RPLND cases. Loss of antegrade ejaculation was more common after bilateral templates (P-RPLND: 60% vs. 31%, p = 0.07; PC-RPLND: 53% vs. 38%, p = 0.09). Viable cancer was found in 95% of seminomas and 52% of nonseminomas for primary procedures, while nonseminoma PC-RPLND showed 11% viable cancer, 50% teratoma, and 39% benign nodes. Robot-assisted procedures were not associated with higher rates of intra-operative or post-operative complications, nor increased loss of antegrade ejaculation. Patients who underwent robotic procedures had shorter hospital stays, and conversions to open surgery occurred in 10%. CONCLUSIONS Paper I: miR-371a-3p using ddPCR showed 89% sensitivity and 100% specificity in TGCTs, outperforming conventional biomarkers. It decreased postorchiectomy, with less reduction seen in metastatic patients. Paper II: miR-371a-3p had superior performance over conventional markers in seminomas undergoing primary RPLND (74% sensitivity, 100% specificity) but was less effective in nonseminomas and post-chemotherapy patients. Paper III: Primary RPLND appears to be a safe and effective treatment for selected metastatic seminomas, offering low complication and relapse rates, and potentially reducing long-term risks compared to conventional chemotherapy and radiotherapy. Paper IV: Centralized RPLND procedures are associated with low complication rates, with robotic surgery further improving certain outcomes. In PC-RPLND, rates of teratoma and viable cancer increased, with fewer benign findings. Careful patient selection and outcome monitoring are crucial. List of scientific papers I. Serum miR371 in testicular germ cell cancer before and after orchiectomy, assessed by digital-droplet PCR in a prospective study Myklebust MP, Thor A, Rosenlund B, Gjengstø P, Karlsdottir A, Brydøy M, Bercea B S, Olsen C, Johnson I, Berg M I, Langberg C W, Andreassen K E, Kjellman A, Haugnes H, Dahl O Scientific Reports, 2021 Aug 2: 11:15582. <a href="https://doi.org/10.1038/s41598-021-94812-2" rel="noreferrer" target="_blank">https://doi.org/10.1038/s41598-021-94812-2</a> II. miR-371a-3p Predicting Viable Tumor in Patients Undergoing Retroperitoneal Lymph Node Dissection for Metastatic Testicular Cancer: the SWENOTECA-MIR study Thor A, Myklebust MP, Grenabo Bergdahl A, Lundgren P-O, Skokic V, Almås B, Haugnes H, Tandstad T, Akre O, Cohn-Cedermark G, Dahl O, Kjellman A Journal of Urology, 2024 Nov; 212(5):720-730. <a href="https://doi.org/10.1097/JU.0000000000004164" target="_blank">https://doi.org/10.1097/JU.0000000000004164</a> III. Primary Retroperitoneal Lymph Node Dissection as Treatment for Low-volume Metastatic Seminoma in a Population-based Cohort: the Swedish Norwegian Testicular Cancer Group Experience Thor A, Negaard H, Grenabo Bergdahl A, Almås B, Melsen Larsen S, Lundgren P-O, Gerdtsson A, Halvorsen D, Johannsdottir B, Jansson A K, Hellström M, Wahlqvist R, Langberg C W, Hedlund A, Akre O, Glimelius I, Ståhl O, Haugnes H, Cohn-Cedermark G, Kjellman A/ Tandstad T European Urology Open Science, 2024 Jun 11:65:13-19. <a href="https://doi.org/10.1016/j.euros.2024.05.006" rel="noreferrer noopener" target="_blank">https://doi.org/10.1016/j.euros.2024.05.006</a> IV. Complications and clinical outcomes of retroperitoneal lymph node dissection in a centralized population-based cohort: insights from the SWENOTECA group Thor A, Grenabo Bergdahl A, Abniki A, Almås B, Melsen Larsen S, Gerdtsson A, Habberstad A, Halvorsen D, Lundgren P-O, Akre O, Cohn-Cedermark G, Kjellman A. 2024 [Manuscript]

Preprint Article
10.69622/27890046

Microrna and retroperitoneal lymph node dissection : advances in testicular cancer treatment

Jan 16, 2025
Anna Thor

Discussion
1
10.1111/bju.12863

Retroperitoneal lymph node dissection (RPLND) - open surgery's next challenger is ready to enter the ring.

Dec 15, 2014
BJU international
Tim Dudderidge

The da Vinci surgical system delivers the benefits of laparoscopic surgery with an easier and more precise human–tissue interface than conventional laparoscopic instruments. Nearly all major uro-oncological procedures are being performed robotically. In this issue of BJUI, Cheney et al. 1 present their technique and initial experience of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for patients with primary and post-chemotherapy non-seminoma germ cell tumours. Quality indicators for RA-RPLND include adequate clearance of the desired surgical field, satisfactory lymph node yield, acceptable perioperative morbidity and length of stay, as well as longer-term functional and oncological outcomes. So how well does RA-RPLND stand up to scrutiny? The technique employed by Cheney et al., placing the robot at the head of the patient, is unfamiliar to most urologists I suspect. It appears to offer excellent access to the retroperitoneum, but still requires a re-docking when performing full bilateral dissections. Whether this technique is superior to the lateral approach that I and others have used for modified dissections requires further study 2, 3. The lymph node yield was lower than that previously reported for open RPLND and while Cheney et al. 1 observe this may be due to the use of a modified template where appropriate, the absence of any in-field recurrences at a median of 22 months is perhaps the more reliable sign that there is oncological equivalence. Concerns that a true template dissection cannot be completed with a robot-assisted laparoscopic approach are probably unjustified in my opinion. The description of surgical technique by Cheney et al., including suture ligation and division of lumbar vessels, confirms that if a surgeon is minded to do so, a complete bilateral or modified template clearance can be completed. The absence of significant complications in this series is impressive; however, there were three out of 18 conversions to open surgery. The mean length of stay of 2.4 days is close to the 3–4 days stay I would expect after an uncomplicated open RPLND in a young fit man. However, 1–2 night stays were seen in their later cases as they gained experience. Perhaps more importantly in a group of working age men, return to full physical activity within 3 weeks is possible 2. As highlighted by Cheney et al. 1, minimally invasive primary RPLND has been previously reported both by laparoscopic and robotic approaches. Their larger series provides an important demonstration that the robotic approach facilitates the more complex undertaking of post-chemotherapy RPLND. Furthermore they show that except for operative time, all other outcomes were similar in primary and post-chemotherapy cases. As an enthusiast for minimally invasive therapies, I of course welcome these results and think that along with other published and presented series, they provide sufficient evidence to consider a more formal evaluation of this approach. However, how feasible is the wider introduction of RA-RPLND? Despite having experience of robotics and working in a team performing around 30 RPLNDs a year, I was only able to identify five cases during a 1-year period suitable for a robotic approach. With experience this could have been a higher proportion, but it is fair to conclude that suitable cases in typical cancer centres would be limited in number. This is particularly so for the UK and other European countries, where primary RPLND is not used. Cheney et al. 1 had similarly low numbers each year and recruited their cohort of 18 cases over 5 years. An international multicentre registry is arguably the best way to gather more information on the safety and completeness of template dissection RPLND. Existing registries, e.g. the BAUS complex operations database, have already provided valuable insights into the results of RPLND in the UK 4 and could be combined with other international RA-RPLND databases already being compiled (Erik Castle MD personal communication). Partnership of testicular cancer surgeons without robotic experience with experienced robotic surgeons may also facilitate the development of additional centres for development of this procedure. They will also aid optimal patient selection and help avoid incomplete template dissections, which may compromise the excellent cancer control we are now used to. There are clear potential advantages with a minimally invasive approach to RPLND, not least of which are the avoidance of a laparotomy scar, the reduction of complications and an earlier return to normal activity. Cheney et al. 1 have shown that their technique is feasible, safe and effective in the medium term and their results justify wider consideration of the procedure for further study and improvement. I have no conflict of interest submitting this paper.

Supplementary Content
8
10.1097/js9.0000000000000520

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

May 24, 2023
International Journal of Surgery (London, England)
Si Ge + 7 more

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.

Research Article
16
10.1016/s0022-5347(01)64228-9

SEXUAL FUNCTIONING AFTER MULTIMODALITY TREATMENT FOR DISSEMINATED NONSEMINOMATOUS TESTICULAR GERM CELL TUMOR

Oct 1, 1997
Journal of Urology
J.P Van Basten + 8 more

SEXUAL FUNCTIONING AFTER MULTIMODALITY TREATMENT FOR DISSEMINATED NONSEMINOMATOUS TESTICULAR GERM CELL TUMOR

Research Article
46
10.1016/j.juro.2007.03.123

Short-Term Morbidity of Primary Retroperitoneal Lymph Node Dissection in a Contemporary Group of Patients

Jun 11, 2007
Journal of Urology
Stephen D.W Beck + 4 more

Short-Term Morbidity of Primary Retroperitoneal Lymph Node Dissection in a Contemporary Group of Patients

Research Article
3
10.1200/jco.2009.27.15_suppl.5084

Open versus laparoscopic retroperitoneal lymph node dissection (RPLND) in clinical stage I nonseminomatous germ-cell tumors (NSGCTs): Two contemporary series from a single institution

May 20, 2009
Journal of Clinical Oncology
Nicola Nicolai + 9 more

5084 Background: Primary RPLND is our choice for clinical stage I (CSI) NSGCTs. Open RPLND (O-RPLND) has been our standard policy since 1985, while laparoscopic RPLND (L-RPLND) has been introduced since the late-1990s. Methods: Between June 2003-March 2008, 150 consecutive CSI NSGCT patients (pts) have been submitted to O-RPLND (n = 91) or L-RPLND (n = 59). Pts with high risk disease (vascular invasion/embryonal carcinoma > 90% in the primary tumor) were more frequently offered O-RPLND, while pts with low risk disease (none of the 2 above) were usually considered for L-RPLND. We reviewed our data focusing on: complications, operating time (OT), hospital stay (HS), number of removed nodes, occurrence of nodal metastases as well as of metastasis during follow-up and global need of chemotherapy (CT). Results: O-RPLND (91). 59/91 (64.8%) were high-risk patients. Median OT was 140 min (IQR 110–150). Five (5.5%) complications occurred: 4 lymphorrea and 1 hemorrhage. Median HS was 6 days (IQR 5–7). Nodal metastases were found in 24 (26.4%) pts. Median number of removed nodes was 20 (IQR 14–25). L-RPLND (59). 54/59 (91.2%) were low-risk patients. Median OT was 210 min (IQR 180–240). Ten (16.9%) complications occurred: 5 required conversions to open procedure due to intraoperative bleeding (4) or technical impossibility to conclude the procedure (1). Median HS was 4 days (IQR 4–5). Nodal metastases were found in 5 (8.5%) pts: 2 of them received immediate adjuvant CT. Median number of removed nodes was 14 (IQR 11–20). OT and HS were significantly better in O-RPLND and L-RPLND series, respectively (p.0001 at Mann Whitney test). After a median follow-up of 15.1 months (1–52), distant metastases were observed in 10 (0.7%) pts: 7/91 (7.7%) following O-RPLND and 1/59 (1.7%) following L-RPLND. CT was administered to 7 (7.7%) pts following O-RPLND and to 3 (5.1%) pts following L-RPLND. Conclusions: In this large case-series, no excess of recurrences but a higher rate of complications were recorded in L-RPLND pts. O-RPLND had a significant better OT while HS was shorter in L-RPLND series. Both procedures are still being applied: pts are currently offered one of the 2 modalities after counseling. No significant financial relationships to disclose.

Research Article
13
10.1200/jco.2022.40.6_suppl.420

The PRIMETEST trial: Prospective phase II trial of primary retroperitoneal lymph node dissection (RPLND) in stage II A/B patients with seminoma.

Feb 20, 2022
Journal of Clinical Oncology
Peter Albers + 5 more

420 Background: Primary retroperitoneal lymph node dissection (RPLND) in patients (pts) with stage II A/B seminoma without adjuvant local or systemic treatment is an experimental treatment to avoid radio- or chemotherapy–related toxicity. The prospective PRIMETEST trial (NCT 2015053664) evaluates recurrence-free (RFS) and overall survival (OS) as well as surgical safety of patients with clinical stage II A/B seminoma undergoing RPLND without adjuvant treatment. Interim results had been presented at ASCO GU 2019. Methods: Primary endpoint of the study is PFS after a median follow-up of 36 months. We performed unilateral open or robotic RPLND in pts with unilateral retroperitoneal lymphnode metastases < 5 cm (stage IIA and IIB) with human chorionic gonadotropin (HCG) < 5 mU/ml. Pts were included with either stage IIA/B at initial diagnosis, at time of recurrence under active surveillance, or after adjuvant carboplatin in clinical stage I. The phase II trial was designed to exclude the upper limit of a 95% confidence interval at 30% recurrences. Results: Trial accrual was completed in a single center from May 2016 to June 2021 with 33 consecutive pts. 13 and 20 pts presented with stage IIA and IIB, respectively. 9 pts had initial stage II, 19 pts presented with recurrence during active surveillance, 5 pts had adjuvant carboplatin. At time of RPLND median HCG was 0.1 mU/ml (range 0 – 2.2 mU/ml). Open and robotic RPLND was performed in 14 (42 %) and 19 (58 %) pts, respectively. One patient had to be converted from robotic to open surgery. Median size of metastasis on histological report was 28 mm (range 11 – 69 mm) with a median OR time of 169 min (range 101 – 351 min). Median estimated blood loss was 50 ml (range 0 – 400 ml). Higher grade complications (Clavien Dindo ≥ III) occurred in 3/ 33 pts (9 %; 2 x pulmonary embolism, 1 x ureteral stricture requiring ileal ureter substitute). Of 33 pts, 2 pts withdrew their consent during follow-up. As of September 1, 2021, the median follow-up is 26 months (range 2 – 56 months). Up to now we observed 10 recurrences (31 %). RFS is 69 % with a median time from RPLND to relapse of 6 months (range 3 – 36 months). The recurrences included infield recurrences in 3/ 10 cases. 5 and 5 recurrences were observed in stage II A and B pts, respectively. Analysis of predictive factors showed vascular invasion present in 5/ 10 recurrences. Half of pts with relapse were treated with robotic RPLND and open RPLND, respectively. All pts with relapse underwent standard chemotherapy and are currently without evidence of disease. Conclusions: Open and minimally invasive surgical resection of small volume, unilateral seminoma metastasis is feasible with acceptable toxicity. Current recurrence-free survival rates suggest this approach as an option to avoid standard treatment (chemotherapy, radiotherapy) in selected patients. Clinical trial information: NCT2015053664.

Research Article
3
10.1177/0391560310077017s10

Long-Term Results of Laparoscopic Retroperitoneal Lymph Node Dissection (RPLND) in Low-Stage Nonseminomatous Germ-Cell Testicular Tumors (NSGCTT) Performed by a Senior Surgeon: 1999–2003

Oct 1, 2010
Urologia Journal
G Pizzocaro + 5 more

Laparoscopic RPLND for low-stages NSGCTT is controversial: it is performed and recommended by excellent laparoscopic surgeons, but it is not widely used. The aim of this paper is to evaluate the results achieved by a senior surgeon, expert in open RPLND, who was introduced to laparoscopic surgery by excellent laparoscopists (LN, CU, GJ). of the 48 operated patients, 36 had primary RPLND for clinical stage I disease (22 TIN0, 7 TxN0, 5 T2-3 N0 and 2 TIS1 N0) and 12 had post-chemotherapy surgery for IIA and IIB retroperitoneal nodes with normalized AFP and HCG. L-RPLND was performed with 4 ports and the en bloc removal of unilateral retroperitoneal nodes with the spermatic vessels. No post-operative adjuvant chemotherapy was planned for patients with documented nodal metastases as for open RPLND since 1985. Average operative time was 3.30' for the 36 clinical stage I patients and 4 hours for post-chemotherapy surgery. Blood loss was minimal in all cases, because of early conversion to open surgery in all patients with no immediate hemostasis at L-RPLND. Metastases were found in 6 (17%) out of the 36 clinical stage I patients: none in the 22 pTI, 1 in the 7 Tx, 3 in the 5 pT2-3 and in 2 of the 2 pT1S1 patients. Residual teratoma was found in 6 of the 12 patients who received neo-adjuvant chemotherapy for clinical stage IIA or IIB disease. The other 6 had fibrosis-necrosis. Further metastases developed in 2 of the 30 patients with negative nodes: 1 in the lung in a pT1, and 1 in a pT2 patient with increasing markers. Surprisingly, the first two pT2-3 patients with positive nodes developed liver metastases in a few months after L-RPLND. Consequently, all following patients with active metastases at L-RPLND received 2 courses of adjuvant PEB. All 4 patients who relapsed were cured, are alive and disease-free. L-RPLND is a very demanding operation, which appears to be more a staging procedure than a curative operation. It is ideal for pT1 clinical stage I and for post-chemotherapy stages IIA& B with residual teratoma and normalized markers, but wait & see in good risk and open RPLND in high risk patients are very competing. Only few reports compared laparoscopic versus open RPLND, but not in a randomized study.

Research Article
12
10.1007/s00345-020-03403-9

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

Aug 14, 2020
World Journal of Urology
Raj Bhanvadia + 5 more

To compare perioperative outcomes and perform the first cost analysis between open retroperitoneal lymph node dissection (O-RPLND) and Robotic-RPLND (R-RPLND) using anational all-payer inpatient care database. 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 plotsidentified point of cost equivalence between R-RPLND and O-RPLND.A multivariable linear regression model was generated to analyze predictors of cost. 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 transfusionswere 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 determinedpoint of cost equivalence between an R-RPLND staying a mean of 2days was 4-5days 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. 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.

Research Article
19
10.1111/bju.15986

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

Mar 9, 2023
BJU international
Harshit Garg + 9 more

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. 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. 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). 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.