Open Retroperitoneal Lymph Node Dissection Research Articles

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

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

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.

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

Robotic retroperitoneal lymph node dissection: A systematic review and meta-analysis of perioperative outcomes.

420 Background: Retroperitoneal lymph node dissection (RPLND) forms an integral part of the management of testis cancer. Robotic RPLND (R-RPLND) is a minimally invasive treatment option for this disease. This systematic review assessed the safety and feasibility of R-RPLND and compared the perioperative outcomes of R-RPLND with open RPLND (O-RPLND). 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 4,224 patients (single-arm studies, n=461; comparative studies, n=3,763). Of 461 patients in the single-arm studies, 271 underwent primary R-RPLND and 190 underwent post-chemotherapy R-RPLND. For primary R-RPLND, the operative time ranged from 175-540 minutes and the major complication rate was 3.1%. For post-chemotherapy R-RPLND, the operative time ranged from 134-550 min and the major complication rate was 8.4%. The conversion rate to open surgery was 2.2% in primary R-RPLND and 8.9% 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=0.0001) and a lower complication rate (18.5% vs 7.8%, p=0.002; Table). Conclusions: R-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. [Table: see text]

Twenty Years' Experience in Retroperitoneal Lymph Node Dissection for Testicular Cancer in a Tertiary Referral Center.

Background and Objectives: The aim of this article is to present a single-surgeon, open retroperitoneal lymph node dissection (RPLND) series for testicular cancer in a high-volume center. Materials and Methods: We reviewed data from patients who underwent RPLND performed by an experienced surgeon at our institution between 2000 and 2019. We evaluated surgical and perioperative outcomes, complications, Recurrence-Free Survival (RFS), Overall Survival (OS), and Cancer-Specific Survival (CSS). Results: RPLND was performed in primary and secondary settings in 21 (32%) and 44 (68%) patients, respectively. Median operative time was 180 min. Median hospital stay was 6 days. Complications occurred in 23 (35%) patients, with 9 (14%) events reported as Clavien grade ≥ 3. Patients in the primary RPLND group were significantly younger, more likely to have NSGCT, had higher clinical N0 and M0, and had higher nerve-sparing RPLND (all p ≤ 0.04) compared to those in the secondary RPLND group. In the median follow-up of 120 (56-180) months, 10 (15%) patients experienced recurrence. Finally, 20-year OS, CSS, and RFS were 89%, 92%, and 85%, respectively, with no significant difference in survival rates between primary vs. secondary RPLND subgroups (p = 0.64, p = 0.7, and p = 0.31, respectively). Conclusions: Open RPLND performed by an experienced high-volume surgeon achieves excellent oncological and functional outcomes supporting the centralization of these complex procedures.

Phase 2 Single-arm Trial of Primary Retroperitoneal Lymph Node Dissection in Patients with Seminomatous Testicular Germ Cell Tumors with Clinical Stage IIA/B (PRIMETEST)

BackgroundPrimary retroperitoneal lymph node dissection (RPLND) for clinical stage (CS) IIA/B seminoma without adjuvant treatment is an experimental treatment to avoid radiotherapy- or chemotherapy-related toxicity from standard treatment. ObjectiveThe PRIMETEST trial aimed to prospectively evaluate the oncological efficacy and surgical safety of primary RPLND. Design, setting, and participantsPRIMETEST is a single-arm, single-center prospective phase 2 trial. Patients with seminoma, unilateral retroperitoneal lymph node metastases <5 cm, and human chorionic gonadotropin levels <5 mU/ml were included. Patients with CS IIA/B seminoma at initial diagnosis, and recurrence under active surveillance or following adjuvant carboplatin for CS I disease were eligible. Outcome measurements and statistical analysisUnilateral open or robot-assisted primary RPLND was performed. The primary endpoint of the study was progression-free survival (PFS) after 36 mo. The trial was considered positive if <30% of patients experienced a recurrence. Results and limitationsBetween 2016 and 2021, 33 patients were accrued (nine with primary CS IIA/B, 19 recurrences during active surveillance, and five recurrences following adjuvant carboplatin). Thirteen and 20 patients had CS IIA and IIB, respectively. Open and robot-assisted RPLND procedures were performed in 14 (42%) and 19 (58%) patients, respectively. After a median follow-up of 32 mo (interquartile range 23–46), ten recurrences were detected (30%, 95% confidence interval: 16–49%); thus, the primary endpoint was not met. Infield recurrences occurred in three of ten patients. The current analysis of risk factors could not identify the predictors of recurrence. Three of 33 patients (9%) presented with pN0. ConclusionsThe PRIMETEST trial did not meet its primary endpoint. Nevertheless, PFS of 70% after a median follow-up of 32 mo suggests this approach to be of interest for highly selected patients. Selection criteria, however, need to be defined and validated in a larger prospective cohort of patients. Until then, surgery alone for the treatment of patients with CS IIA/B seminoma cannot be recommended outside of a clinical trial setting. Patient summaryIn this study, we investigated primary surgery as an alternative to conventional treatment (chemotherapy or radiation therapy) in patients with metastatic seminoma. The primary objective of the study, to prevent at least 30% of patients from recurrence, was not met. However, certain patients may benefit from this approach and thereby avoid chemotherapy or radiation therapy. Predictive factors need to be analyzed to better select patients for this surgery-only approach.

Retroperitoneal lymph-node dissection (RPLND) as upfront management in stage II germ-cell tumours: Evaluation of safety and efficacy.

Patients with stage II germ-cell tumours (GCT) usually undergo radiotherapy (seminoma only) or chemotherapy. Both strategies display a recognised risk of long-term side effects. We evaluated retroperitoneal lymph node dissection (RPLND) as exclusive treatment in stage II GCT. Between 2008 and 2019 included, 66 selected stage II GCT patients underwent primary open (O-) or laparoscopic (L-)RPLND. Type of procedure and extent of dissection, operative time, node rescue, hospital stay, complications (according to Clavien-Dindo), administration of chemotherapy, relapse and site of relapse were evaluated. Five patients had pure testicular seminoma. Nineteen (28.8%) had raised markers prior to RPLND; 48 (72.7%), 16 (24.2%) and two (3.0%) were stage IIA, IIB and IIC, respectively. O-RPLND and unilateral L-RPLND were 36 and 30 respectively. Six stage II A patients (12.5%) had negative nodes. Four patients underwent immediate adjuvant chemotherapy. One patient was lost at follow-up. After a median follow-up of 29 months, 48 (77.4%) of the 62 patients undergoing RPLND alone remained recurrence-free; one patient had an in-field recurrence following a bilateral dissection. According to procedure, number of rescued nodes (O-RPLND: 25. IQR 21-31; L-RPLND: 20, IQR 15-26; p: 0.001), hospital stay (L-RPLND: 3 days, IQR 3-4; O-RPLND: 6 days, IQR 5-8; p: .001) and grade ≥2 complications (L-RPLND 7%, O-RPLND 22%; p: 0.1) were the only significant differences. Primary RPLND is safe in stage II GCT, including seminoma, and may warrant a cure rate greater than 70%. When feasible, L-RPLND may be as effective as O-RPLND with better tolerability.

Oncologic outcomes of primary retroperitoneal lymph node dissection (RPLND) for stage II seminoma: Indiana University experience.

e17012 Background: Stage II seminoma is typically treated with radiotherapy or chemotherapy based on NCCN guidelines. Primary RPLND has demonstrated efficacy as first-line therapy for retroperitoneal (RP)-only disease. Our aim was to study recurrences of patients undergoing primary RPLND for Stage IIa or IIb seminoma to identify clinicopathologic factors affecting outcomes. Methods: Using our prospectively maintained database, we identified patients that had primary RPLND for seminoma from 2014-2021. All patients had at least 6 months of follow up. Patients were clinical stage IIa or IIb at the time of surgery and underwent open RPLND. We used Kaplan-Meier analysis for recurrence free survival (RFS) and compared clinicopathologic factors. Results: We identified 67 patients that underwent RPLND for RP only seminoma. Table shows the clinical characteristics of patients experiencing recurrences (median follow up - 22.4 months) and excludes 2 patients that had adjuvant chemotherapy. The 2-year RFS rate was 80.2%. Eleven patients (16.4%) experienced recurrences. Kaplan Meier analysis demonstrated improved survival in patients that had an RPLND after 12 months of surveillance (p = 0.02). Fifty-six patients were presumably cured with surgery alone at time of last follow-up. No patients died of testis cancer. One patient had a recurrence within the surgical field. Two patients had contralateral recurrences that may have been cured with bilateral RP template dissection. Seven patients that had a bilateral template dissection had disease on the contralateral side, of which 4 patients had visible nodes on pre-operative scans. In total, 9 out of 67 patients had disease on the contralateral side suggesting that bilateral RP template could confer higher cure rates. Recurrences were successfully treated with BEPx3 (9 pts), Redo RPLND then BEPx3 (1 pt), BEPx3 then High Dose chemotherapy (1 pt), and EPx4 (1 pt). Conclusions: Primary RPLND for low volume RP disease is effective with over 80% chance of surgical cure. Recurrences were cured almost exclusively with induction chemotherapy. Patients with delayed RP only recurrences had improved surgical success. Further investigation in larger trials may help standardize bilateral templates in seminoma and surveillance protocols in the post-operative setting. [Table: see text]

PD51-02 ONCOLOGIC OUTCOMES OF PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR STAGE II SEMINOMA: INDIANA UNIVERSITY EXPERIENCE

You have accessJournal of UrologyCME1 May 2022PD51-02 ONCOLOGIC OUTCOMES OF PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR STAGE II SEMINOMA: INDIANA UNIVERSITY EXPERIENCE Isamu Tachibana, Andre Alabd, Sean Kern, Mohammad Mahmoud, Timothy Masterson, Nabil Adra, Richard Foster, Lawrence Einhorn, and Clint Cary Isamu TachibanaIsamu Tachibana More articles by this author , Andre AlabdAndre Alabd More articles by this author , Sean KernSean Kern More articles by this author , Mohammad MahmoudMohammad Mahmoud More articles by this author , Timothy MastersonTimothy Masterson More articles by this author , Nabil AdraNabil Adra More articles by this author , Richard FosterRichard Foster More articles by this author , Lawrence EinhornLawrence Einhorn More articles by this author , and Clint CaryClint Cary More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002622.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Stage II seminoma is typically treated with radiotherapy or chemotherapy based on NCCN guidelines. Primary Retroperitoneal Lymph Node Dissection (RPLND) has demonstrated efficacy in a Phase II trial as first-line therapy for retroperitoneal disease. We sought to study recurrence rates of patients who underwent primary RPLND for Stage IIa or IIb seminoma and to determine if pathologic nodal stage affected outcomes. METHODS: Using our prospectively maintained database at Indiana University, we identified patients that underwent primary RPLND for seminoma from 2014-2020. Patients were all clinically stage IIa or IIb at the time of surgery and underwent an open RPLND. We used Kaplan-Meier analysis for recurrence free survival (RFS) based on pathologic nodal stage (N0, N1, N2, N3). RESULTS: We identified 54 patients at Indiana University that underwent RPLND for RP only seminoma. Table 1 illustrates the clinical characteristics of patients included in our study with median follow up time of 25.6 months. There were 22 that underwent bilateral template dissection and 32 that underwent a unilateral template dissection. Kaplan Meier analysis (Figure 1) did not demonstrate any significant difference among pathologic nodal stages with RFS. The 2-year RFS was 82.8%. Forty-five patients were presumably cured with surgery alone at the time of their last follow-up. Nine (16.7%) recurrences were noted in total – 2 infield RP recurrences, 2 out of field RP recurrences, 3 contralateral recurrences. Two of these recurrences were multifocal with concurrent recurrences outside of the RP (chest and pelvis). Two patients had chest only recurrence. No patients died of testis cancer and all patients are disease free. Salvage regimens for recurrences are listed in Table 1 as well. CONCLUSIONS: Primary RPLND for clinically low volume RP disease is effective with over 80% chance of cure with surgery alone. Recurrences were cured almost exclusively with induction chemotherapy. Pathologic nodal stage did not affect recurrence free survival. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e842 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Isamu Tachibana More articles by this author Andre Alabd More articles by this author Sean Kern More articles by this author Mohammad Mahmoud More articles by this author Timothy Masterson More articles by this author Nabil Adra More articles by this author Richard Foster More articles by this author Lawrence Einhorn More articles by this author Clint Cary More articles by this author Expand All Advertisement PDF DownloadLoading ...

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

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 &lt; 5 cm (stage IIA and IIB) with human chorionic gonadotropin (HCG) &lt; 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.

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

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

MP40-03 POPULATION-BASED ANALYSIS OF COST AND PERI-OPERATIVE OUTCOMES BETWEEN OPEN AND ROBOTIC PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR GERM CELL TUMORS

You have accessJournal of UrologyPenile & Testicular Cancer I (MP40)1 Sep 2021MP40-03 POPULATION-BASED ANALYSIS OF COST AND PERI-OPERATIVE OUTCOMES BETWEEN OPEN AND ROBOTIC PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR GERM CELL TUMORS Caleb Ashbrook, Raj Bhanvadia, Aditya Bagrodia, Yair Lotan, Vitaly Margulis, and Solomon Woldu Caleb AshbrookCaleb Ashbrook More articles by this author , Raj BhanvadiaRaj Bhanvadia More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , Yair LotanYair Lotan More articles by this author , Vitaly MargulisVitaly Margulis More articles by this author , and Solomon WolduSolomon Woldu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002055.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While open retroperitoneal lymph node dissection (O-RPLND) has been the gold standard of treatment for germ cell tumors (GCT), robotic RPLND (R-RPLND) is gaining popularity as experience with robotic surgery increases. We therefore sought to compare perioperative outcomes and perform the first cost analysis between O-RPLND and R-RPLND using the Nationwide Inpatient Sample (NIS). METHODS: The NIS was queried for primary RPLND and GCT between 2013-2016. We compared cost, length of stay (LOS), and complications between O-RPLND and R-RPLND. Smoothed linear regression plots compared mean hospitalization cost by LOS and surgical approach to identify point of cost equivalence between the R-RPLND and O-RPLND. A multivariate linear regression model was generated to analyze predictors of cost adjusting for relevant factors. RESULTS: Our query identified 44 R-RPLND cases and 319 O-RPLND cases. R-RPLND was associated with a lower complication rate (0% vs 16.6%, p<0.01) and shorter LOS [Median(IQR): 1.5(1-3) vs 4(3-6) days, p<0.01]. On multivariate regression analysis, the robotic approach contributed $4,457 of additional cost, while each day of hospitalization contributed an additional $2,431; suggesting that a savings of approximately two days of hospitalization is required to offset the costs associated with robotic utilization. On smoothed linear regression analysis, the point of cost equivalence between a R-RPLND staying a mean of 2 days was between 4-5 days for O-RPLND, supporting the multivariate 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. CONCLUSIONS: While the open approach remains the gold standard for RPLND for GCT, our findings suggest primary R-RPLND may represent a cost-equivalent option with decreased LOS in carefully selected cases. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e714-e715 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Caleb Ashbrook More articles by this author Raj Bhanvadia More articles by this author Aditya Bagrodia More articles by this author Yair Lotan More articles by this author Vitaly Margulis More articles by this author Solomon Woldu More articles by this author Expand All Advertisement Loading ...

V08-03 FULL-TEMPLATE PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION WITH DAVINCI SINGLE PORT ROBOT

You have accessJournal of UrologyNOTES/LESS (V08)1 Sep 2021V08-03 FULL-TEMPLATE PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION WITH DAVINCI SINGLE PORT ROBOT John Sheng, Chrystal Chang, Gregory Lovallo, and Mutahar Ahmed John ShengJohn Sheng More articles by this author , Chrystal ChangChrystal Chang More articles by this author , Gregory LovalloGregory Lovallo More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002041.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retroperitoneal lymph node dissection (RPLND) can be employed as primary treatment for stage I non-seminomatous germ cell tumor (NSGCT) as well as for treatment of post-chemotherapy masses. Open RPLND has long been the standard approach but is associated with significant morbidity. Laparoscopic RPLND was developed to mitigate the morbidity associated with the open procedure, but is technically challenging requiring significant experience with laparoscopic dissection and suturing. Robotic RPLND has gained traction in recent years as an alternative, with better instrument dexterity and visualization compared to laparoscopic RPLND. The DaVinci single port robot, released by Intuitive in 2018, further advances minimally invasive surgery through one 25mm port. Here, we demonstrate the feasibility of using the single port robot technology to perform a full template RPLND for testis cancer through a single small incision. METHODS: 21 year old male with no significant past medical history underwent a left radical orchiectomy for a testicular mass. The final pathology showed mixed germ cell tumor with lymphovascular invasion. His CT scan showed subcentimeter lymphadenopathy in the retroperitoneum. Given his options of surveillance, chemotherapy or primary retroperitoneal lymph node dissection (RPLND), the patient elected to undergo primary RPLND with the single port robot. RESULTS: Patient underwent single port robotic assisted laparoscopic bilateral retroperitoneal lymph node issection. A single 25mm incision was made infraumbilically for the robotic instruments. No assistant port was used, making this a true single port procedure. The remotely operated suction irrigation system (ROSI) was used not only for suction but for dissection as well. The operative time for this case was 202 minutes. Estimated blood loss was 50cc. The patient was discharged within 18 hours of surgery with no need for post op narcotic use. CONCLUSIONS: The single port, in our experience, appears to show excellent mobility, visibility and control and allows us to perform this complex procedure in an even more minimally invasive way. Performing a robotic RPLND with the single port may allow for better cosmesis and less post operative pain which are important to many patients in this younger demographic affected by testis cancer. While there is a learning curve with the SP robot, we show that it is possible to be done safely and effectively. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e601-e602 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Sheng More articles by this author Chrystal Chang More articles by this author Gregory Lovallo More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement Loading ...

Laparoscopic retroperitoneal lymph node dissection versus open retroperitoneal lymph node dissection for testicular cancer: A comparison of clinical and perioperative outcomes

ObjectiveThis study was performed to evaluate the clinical and perioperative outcomes of laparoscopic retroperitoneal lymph node dissection (L-RPLND) and open retroperitoneal lymph node dissection (O-RPLND) performed by one surgeon at a single center. MethodsWe evaluated 30 patients with stage IIA germ cell tumors who underwent retroperitoneal lymph node dissection (15 underwent L-RPLND and 15 underwent O-RPLND) at our institution between April 1, 2010 and March 31, 2018. The clinical parameters were compared between patients who underwent L-RPLND using the retroperitoneal approach and those who underwent O-RPLND using the transperitoneal approach. There were no significant differences in the background characteristics of the two groups except for the median follow-up duration (46 months for L-RPLND and 71 months for O-RPLND, p=0.02). ResultsL-RPLND was associated with a shorter mean operative time (mean 222 min for L-RPLND vs. 453 min for O-RPLND, p<0.001). There was significantly less blood loss during surgery in the L-RPLND group compared to the O-RPLND group (mean 165 mL for L-RPLND vs. 403 mL for O-RPLND, p<0.001). Parameters related to postoperative recovery were significantly better for the L-RPLND group than for the O-RPLND group. There were no differences in the histopathological characteristics between the two groups. No patients in either group exhibited disease recurrence. ConclusionPatients who underwent L-RPLND had more rapid recovery, and shorter hospital stay compared to those who underwent O-RPLND; complications were comparable between the two groups. L-RPLND is an efficient procedure with the benefits of minimally invasive surgery.

Post-chemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection for Mixed Malignant Germ Cell Testicular Tumors.

Retroperitoneal lymph node dissection (RPLND) is performed to treat residual disease following chemotherapy for stage II and III testicular cancer. Significant morbidity can be associated with open RPLND. As such, laparoscopic techniques have been demonstrated to be safe and effective in select cases. Outcomes following post-chemotherapy laparoscopic RPLND for mixed malignant germ cell testicular tumors (MMGCT) are limited in the literature. We performed a retrospective chart review for patients who underwent laparoscopic RPLND at our institution for MMGCT from May 2006 to October 2016. Patient clinical data and perioperative and oncologic outcomes were recorded. Twenty-three patients underwent post-chemotherapy laparoscopic RPLND. Thirty-five percent (8/23) underwent bilateral template dissection, whereas 65% (15/23) underwent a modified unilateral template dissection. Robotic assistance was utilized in 22% (5/23) of cases. Bilateral template was inferior to unilateral template RPLND in operative time, estimated blood loss, open conversion rate, length of hospital stay, and complication rate. The mean follow-up was 35.1 months and 43.3 months for the bilateral and unilateral template groups, respectively. The mean lymph node yield and recurrence rate were similar between the 2 cohorts. One recurrence of mature teratoma was noted 67 months after unilateral laparoscopic RPLND. In select patients, laparoscopic RPLND for stage II and III MMGCT is safe and effective in the post-chemotherapy setting. Bilateral template laparoscopic RPLND was associated with inferior perioperative outcomes, but similar oncologic outcomes compared with unilateral template. Patients requiring bilateral template RPLND should be considered for an open approach.

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.

V03-10 EN-BLOC ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS GERM CELL TUMOR

You have accessJournal of UrologyUTUC & Testis Cancer (V03)1 Apr 2020V03-10 EN-BLOC ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS GERM CELL TUMOR James Porter* and Elliot Blau James Porter*James Porter* More articles by this author and Elliot BlauElliot Blau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000849.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Open retroperitoneal lymph node dissection (RPLND) has been the gold standard in both the primary and post-chemotherapy treatment of non-seminomatous germ cell tumors (NSGCT). Of recent interest has been the safety and feasibility of utilizing a robotic-assisted (RA), minimally invasive approach. Proposed advantages to RA-RPLND include decreased morbidity and pain, shorter length of stay (LOS), improved cosmesis and similar oncologic outcomes to the open approach. There have been concerns raised as to the completeness of minimally invasive RPLND with incomplete removal of some lymphatic tissue behind the great vessels. To ensure a thorough dissection, we have developed a technique based on the en bloc removal of all lymphatic tissue within the bilateral template. In this video abstract we demonstrate our approach and technique for bilateral template RPLND utilizing an en-bloc method for extirpation of the specimen. METHODS: Our patient is a 32-year-old male with a history of mixed germ cell tumor of the right testis. He presented with elevated tumor markers and mildly enlarged lymph nodes and was initially stage IIa. He underwent BEP chemotherapy x3, with normalization of serum markers. On follow-up surveillance imaging there was evidence of retroperitoneal recurrence with a growing mass in the paraaortic region. Patient was taken for bilateral robotic RPLND. The robotic approach was performed in the supine position with the patient in Trendelenberg. Four robotic ports were placed in a linear configuration 4cm below the umbilicus and 7cm apart. A 12mm assistant port was placed in the right lower quadrant. Internal suspension sutures were used to provide exposure to the retroperitoneum. Complete en bloc removal of retroperitoneal lymph nodes was performed from the renal vessels to the bifurcation of the iliac arteries bilaterally. RESULTS: Robotic operative time was 6.5 hours. Estimated blood loss was 100cc. There were no complications. The patient was discharged to home post-operative day 1 on a low-fat diet. The specimen was removed en bloc. Pathology revealed 31 lymph nodes; 5 of these with evidence of fibrosis, 1 with viable mature teratoma measuring 4.9 cm. CONCLUSIONS: We present a technique for en bloc removal of retroperitoneal lymph nodes in a patient with a post chemotherapy mass using a supine robotic approach. The en bloc technique ensures complete removal of all lymphatics within the bilateral template including the retrocaval and retroaortic tissues. This method promotes control of lymphatic channels and avoids division of lymph nodes within the template. Robotic RPLND should be attempted in select patients by surgeons with significant experience in oncology and robotic surgery. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e282-e282 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Porter* More articles by this author Elliot Blau More articles by this author Expand All Advertisement PDF downloadLoading ...

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.

1019 - Identifying factors which prolong length of stay following open retroperitoneal lymph node dissection

1019 - Identifying factors which prolong length of stay following open retroperitoneal lymph node dissection

MP26-14 ROBOT ASSISTED RETROPERITONEAL LYMPH NODE DISSECTION OF POST CHEMOTHERAPY RESIDUAL MASS – A SINGLE CENTER EXPERIENCE OF 18 PATIENTS

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2018MP26-14 ROBOT ASSISTED RETROPERITONEAL LYMPH NODE DISSECTION OF POST CHEMOTHERAPY RESIDUAL MASS – A SINGLE CENTER EXPERIENCE OF 18 PATIENTS AMITABH SINGH, Jiten Jaipuria, Saroj Baidya, Raghubir Bhardwaj, JALAJ JAIN, and Sudhir Rawal AMITABH SINGHAMITABH SINGH More articles by this author , Jiten JaipuriaJiten Jaipuria More articles by this author , Saroj BaidyaSaroj Baidya More articles by this author , Raghubir BhardwajRaghubir Bhardwaj More articles by this author , JALAJ JAINJALAJ JAIN More articles by this author , and Sudhir RawalSudhir Rawal More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.872AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Retroperitoneal lymph node dissection (RPLND) is a well-established treatment for post chemotherapy residual mass in non-seminomatous germ cell tumor (NSGCT) as it has diagnostic as well as therapeutic advantage. Although the open RPLND is gold standard, but due to high postoperative morbidity and poor cosmesis due to long midline abdominal incision laparoscopic retroperitoneal lymph node dissection (L-RPLND), robot assisted laparoscopic retroperitoneal lymph node dissection(RA-RPLND) has been described. The proposed advantages of RA-RPLND are good cosmesis, shorter hospital stay, less post-operative pain and reduced compilation rate. We describe our experience of robot assisted retroperitoneal lymph node dissection (RA-RPLND) and comparison to historic cohort of L- RPLND in terms of surgical, pathological and oncological outcome. METHODS A total of 18 patients underwent RA - RPLND between September 2011 to September 2017 in our Institute. Study was started on January 2015 so data were collected retrospectively and prospectively regarding demography of patients, tumor characteristic, surgical, pathological and oncological outcomes. Short term and medium term outcomes were also recorded RESULTS Mean age of patients was 28 years and mean body mass index was 21.51 kg/m2. RA - RPLND was successfully completed in all 18 patients. Mean console time, estimated blood loss and length of hospital stay were 180.78 min, 207.89 ml and 4.31 days respectively. The mean yield of lymph node was 20. Matted lymph nodal mass was found in 4 patients and one patient had only single large retroperitoneal para-aortic mass of size 8.5x6x4.5 cm. In 10 patients modified RPLND was done and in 1 patient only large para-aortic post chemotherapy mass was excised. Out of 18 patients, 15 patients underwent nerve preserving RPLND. Only 12 patients of nerve preserving RPLND have antegrade ejaculation. Histopathological examination revealed necrosis in 14 patients whereas mature teratoma was noticed in 4 patients with one of these showing sarcomatoid differentiation too. After mean follow up period of 19.5 months, no retroperitoneal recurrence was reported. 6 patients developed chyle leak in immediate post-operative period, of these 2 patients were managed conservatively with dietary modification and octreotide, 2 patients underwent lymphangiogram and embolization and another 2 patients underwent exploratory laparotomy and ligation of cysterna chyli. CONCLUSIONS RA - RPLND is safe and feasible for post chemotherapy residual mass with acceptable complication rate. Ours is a largest reported series till date. In literature authors have mentioned series of 7-8 cases. Though larger studies are required to establish its diagnostic and therapeutic utility © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e342 Advertisement Copyright & Permissions© 2018MetricsAuthor Information AMITABH SINGH More articles by this author Jiten Jaipuria More articles by this author Saroj Baidya More articles by this author Raghubir Bhardwaj More articles by this author JALAJ JAIN More articles by this author Sudhir Rawal More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Lymph Node Yield in Primary Retroperitoneal Lymph Node Dissection for Nonseminoma Germ Cell Tumors

The number of lymph nodes removed at surgery for various malignancies has diagnostic and prognostic value. However, there are limited data on the significance of the number of nodes removed at retroperitoneal lymph node dissection performed for testicular nonseminoma germ cell tumors. From 1979 to 2012 primary open retroperitoneal lymph node dissection was performed by a single experienced surgeon for clinical stage I/II testicular nonseminoma germ cell tumor in 157 patients. Node count was available in 111 cases (71%). Factors associated with total node count and nodes with viable cancer were assessed by linear regression. The association between node count and time to relapse was assessed by multivariate Cox proportional hazards models controlled for adjuvant chemotherapy. The median total lymph node count was 28 (IQR 19-38). Patient age, cancer laterality, body mass index, clinical stage, time from orchiectomy to retroperitoneal lymph node dissection, pathologist and lymph node dissection year were not associated with total lymph node count. A viable germ cell tumor was found in 70 patients (63%). Total node yield was not associated with nodal cancer metastasis. After lymph node dissection 17 patients (16%) received adjuvant chemotherapy. At a median 57-month followup 18 cases (17%) relapsed after primary retroperitoneal lymph node dissection. Increasing total node count was associated with a decreased risk of relapse on univariate and multivariate analysis (HR 0.96, 95% CI 0.92-0.99, p = 0.03 and HR 0.94, 95% CI 0.89-0.99, p = 0.017, respectively). No analyzed clinical or pathological variable was associated with the node yield of primary retroperitoneal lymph node dissection. However, there may be a relationship between the total node yield at retroperitoneal lymph node dissection and the risk of relapse.