Robotic Retroperitoneal Lymph Node Dissection Research Articles

Contemporary Perioperative Outcomes of Open Retroperitoneal Lymph Node Dissection for Testicular Cancer

Purpose: Retroperitoneal lymph node dissection (RPLND) is an essential component of multimodal treatment of testicular cancer. The latest data on the perioperative outcomes of RPLNDs performed using the open approach (O-RPLND) dates back over a decade. We report our contemporary institutional perioperative outcomes with O-RPLND. Materials and Methods: We retrospectively identified all patients who underwent O-RPLND between 2013 and 2022 across our institution. Clinical and demographic data were reviewed and recorded. Descriptive statistics and univariate analysis were performed with patients stratified according to primary RPLND and post-chemotherapy RPLND (PC-RPLND). Results: Our cohort included a total of 144 men. Seventy-seven percent of all cases were PC-RPLND. The PC-RPLND cohort showed higher preoperative clinical stages (81% vs 26% above cN1, P < .001; 41% vs 1% Stage 3, P < .001). PC-RPLND pathologies were more likely to be teratoma and necrosis or fibrosis (43% vs 6% and 39% vs 33%, P < .001). Estimated blood loss was significantly higher in the PC-RPLND group (291 vs 125 cc, P = .004). Operative time was longer for PC-RPLND (242 vs 196 minutes, P = .011). Length of stay and 30-day readmission rate were not significantly different between groups and averaged 4.3 days and 12%, respectively. Our most common complication was ileus (5%), followed by chyle leak (3%). Conclusions: While PC-RPLND becomes prominent for treating advanced testicular cancer, our recent data suggest positive perioperative results with O-RPLND. With long-term outcome data needed to appropriately select patients for robotic RPLND, O-RPLND in experienced hands continues to improve its outcome and remains the standard approach in the modern era.

Robotic retroperitoneal lymph node dissection for paratesticular rhabdomyosarcoma in adolescents: a case series

Robotic retroperitoneal lymph node dissection for paratesticular rhabdomyosarcoma in adolescents: a case series

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.

A Case of Robot-Assisted Repair of Lymphatic Fistula with Chylous Ascites Following Robotic Retroperitoneal Lymph Node Dissection

Clinical History: A 47-year-old patient, with a history of testicular tumor treated with chemotherapy and robotic retroperitoneal lymph node dissection, experienced recurrent postoperative chylous ascites despite conservative management. Therefore, decision was made to perform robot-assisted exploration to find the source of chyle leakage and to repair it. Physical Examination: Shifting dullness refers to a sign elicited on abdominal examination for ascites, see: https://en.wikipedia.org/wiki/Shifting_dullness. The patient had this sign on abdominal examination at the time of the intervention, as explained in the video. Diagnosis: Inguinal intranodal lymphography was performed, showing an effusion at the level of the third lumbar vertebral body that was embolized. Intervention: On robot-assisted abdominal exploration, intraperitoneal lymphatic effusion was noted from the left para-aortic region, close to the left renal artery. The lymphatic vessels of greater caliber were then closed with metal clips, until all the major sources of lymph effusion were under control. Next, a continuous suture running over the remaining para-aortic lymphatic tissue was applied. Once the suture was completed, methylene blue was then introduced through the nasogastric tube, with no effusion resulting from the lymphatic tissue at any level in the abdomen. A layer of hemostatic matrix was then added and a tubular drain was placed in the retroperitoneum, with its tip laying on the effusion site. The peritoneum was closed and after a final check of the hemostasis, the robotic trocars were removed and the port sites closed. Follow-Up Outcomes: The drain was removed after 72 hours. Since the intervention, the patient did not experience any further recurrence. In this first description, robotic approach was feasible and efficient in management of postoperative chylous ascites not responding to conservative treatment. The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors declare that they have not had any commercial associations during the past 3 years that might create a conflict of interest in connection with the video. This study is derived from the “IRCCS Azienda Ospedaliero-Universitaria di Bologna,” and there are no conflicts of interest or obligations resulting from it. Runtime of video: 4 mins 22 secs

Interview: Timothy Clinton

What has driven you to specialise in urologic oncology, in particular the management of advanced testicular and bladder malignancies? My interest in urology started in medical school at the University of Texas Health Science Center in San Antonio, USA. During that time, I learned so much about urology, but really found the surgical management of bladder cancer (radical cystectomy) and testicular cancer (retroperitoneal lymph node dissection) to be the most interesting. While they are two very different disease processes with very different survival rates, what I have always found most interesting is the vital role that appropriate surgical management plays within each disease. While surgery is one aspect of urologic oncology, what I appreciate most is the multidisciplinary approach, and caring for these complex patients as a team. You were recently acknowledged with an award for your contributions as a peer-reviewer for urology articles. Could you outline the areas you would like to read more research in in the near future? As a reviewer, I truly enjoy this as a means of keeping up with the constant amount of urologic research that is coming out. My personal interests match my clinical and research interests, mainly around translational research and clinical trials for bladder and testicular cancer. Whilst translational genomics research has long been centered around DNA and RNA sequencing, I am currently exploring more epigenetic changes and markers, and the emerging field of fragmentomics for cell-free DNA (cfDNA). Part of your research interests lie with defining the genomic determinants and biomarkers of urothelial carcinoma and germ cell tumours. Are there any recent notable advances you would like to share in this field? Recently there have been many clinical advances and large-scale genomic sequencing efforts in the management of urothelial carcinoma, but unlike lung cancer, the ability for personalised precision oncology in bladder cancer has not yet been achieved. Largely, the lack of adequate biomarkers continues to be a major deficit in achieving personalised treatment for these patients. From emerging data on circulating tumour DNA (ctDNA), and my own work in cfDNA, we are starting to see evidence for more plasma-based biomarkers. New urine ctDNA assays are emerging, and may be even better for localised bladder cancer decision-making. In germ cell tumors, the groups that have helped to identify and now utilise microRNA-371a-3p as a biomarker in prospective multi-institutional trials have truly moved this field forward, which has not seen much development for many years. I believe that this is just the start of a more personalised medicine approach for our patients with testicular cancer, and I look forward to the arrival of other biomarkers in development. You recently co-authored an article, ‘Genomic heterogeneity as a barrier to precision oncology in urothelial cancer’. What was the key message delivered here? This was a project that truly took a massive effort, led by my former lab mentor David Solit, with the help of many collaborators, including co-author Jessica Chen. Utilising the large-scale sequencing effort from Memorial Sloan Kettering Cancer Centre, New York, USA, we sought to determine the degree of heterogeneity in bladder cancer by comparing mutational frequencies across grade and stage. This led to using whole exome sequencing to look at mutational concordance between primary and metastatic tumors within individual patients. This demonstrated, through phylogenic analysis, that bladder cancer is characterised by early branched evolution. Additionally, discordant ARID1A alterations were found only in the metastatic lesions, which suggests its role in metastatic progression. Further validation of our matched pair analysis in 119 primary/metastatic pairs demonstrated that primary and metastatic sites have 23% discordance in actionable genomic alterations. Finally, evaluation of plasma cfDNA, compared to tumour samples in 123 patients, found that 17% of targetable alterations were exclusive to cfDNA only, and 23% were exclusive to tumour samples. To summarise, in patients with progression we recommend not only metastatic biopsies, but utilisation of plasma cfDNA for identification of targetable alterations. Having featured on a podcast recently discussing bacillus Calmette–Guérin (BCG) refractory non-muscle invasive bladder cancer, what were the key points from this session, and can we expect to see you contribute more research and discussion in this field soon? It was a real pleasure to talk with experts Aditya Bagrodia and Eugene Pietzak about BCG-unresponsive non-muscle invasive bladder cancer. We were able to highlight the different options available for these patients, and the counselling that we incorporate with our patients in this difficult clinical scenario. My personal research in this area is looking to evaluate novel therapeutics as alternative treatment options. We know that certain alterations are associated with BCG unresponsive disease and thus, if we can target these alterations, this may be a viable alternative to cystectomy in many patients. Robotic surgery has an increasing role in urology. How have you seen this change over the course of your career so far? Is there room for artificial intelligence (AI) in urologic oncology? At this point, robotic minimally invasive surgery is a mainstay in the treatment of nearly every urologic cancer surgery. As a younger attending doctor, I have been trained by true experts in open and robotic surgery, and have come to appreciate the benefits and need for both approaches for the benefit of my own patients. As a surgeon most interested in bladder cancer and testicular cancer, the use of robotic surgery is emerging in both of these spaces. I have found that in appropriately selected patients, the use of robotic cystectomy with intracorporeal diversion and robotic retroperitoneal lymph node dissection has truly been revolutionary in the recovery of such morbid operations. This truly provides a unique surgical approach for our cancer centre, and decreases pain, blood loss, and recovery. With that being said, there are plenty of patients where an open approach is still required, and additionally, robotic surgery does not negate a poor lymph node dissection or poor surgical excision. Thus, it is imperative for those of us performing such robotic surgeries to still uphold the same level of expertise as previously achieved in open surgery. The use of AI in urologic oncology will continue to grow, as we have seen already in pathology and radiology. It is only a matter of time until surgical approaches, and specifically robotic surgery, will start to include shades of AI. What advice would you give a younger self, looking to establish themself as a clinician and researcher? I would consider myself still a growing clinician and researcher, and at the start of my career. In general, when I counsel residents and medical students, I remind everyone that the patient remains our sole focus. There are no shortcuts in surgery, and it is imperative to understand not only the disease process and management, but the experience of seeing and learning, and ultimately mastering an operation. This learning never ends, and there are unique scenarios that will continue to challenge every clinician. As long as all of us starting our career remember thiss, I think we can all achieve success. Since your appointment at Brigham and Women’s Hospital, what has been your proudest achievement? Is there anything this hospital approaches well that you think other organisations could learn from? Brigham and Women’s Hospital and Dana–Farber Cancer Institute has a unique position as a premier cancer institute; thus, our greatest approach is the ability to provide complex and comprehensive multidisciplinary care to our patients. What I find most enjoyable is engaging not only my colleagues in urology, but those in medical and radiation oncology to determine the best treatment course. My proudest achievements have been the ability to bring new techniques to the treatment of our patients with bladder and testicular cancer.

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]

Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors in the lateral decubitus position: oncological and functional outcomes.

Retroperitoneal lymph node dissection (RPLND) is recommended for residual masses following chemotherapy for non-seminomatous germ cell tumors (NSGCT). Recently, aberrant recurrence patterns were reported in patients who underwent robotic RPLND. We aimed to evaluate perioperative safety in addition to functional and early oncological outcomes of postchemotherapy robotic RPLND (pcR-RPLND) for NSGCT. A total of 25 patients with NSGCT who underwent a pcR-RPLND between January 2011 and June 2022 were evaluated retrospectively. Descriptive statistics were provided for demographics, clinical characteristics, intraoperative and postoperative parameters. Functional and oncological outcomes were recorded. The median patient age was 28.9years (IQR 21.5-32.4). The median retroperitoneal tumor size was 2.6cm (IQR 1.5-3.5). Intraoperative complications occurred in only one case and the open conversion rate was 12%. There were seven cases with postoperative complications (Clavien grade II: 5 and IIIa: 2). Patients were followed for a median of 33.2months (IQR 14.8-43.0). Antegrade ejaculation was preserved in 85.7% of the patients. Two patients (8%) relapsed and both had out-of-field recurrences at unusual sites (perinephric fat and omentum). Of those, one patient died (4%) of testicular cancer. pcR-RPLND is a feasible and technically reproducible procedure with favorable perioperative morbidity, low rate of complications, and acceptable postoperative ejaculatory function. Although the recurrence rate was low (8%), recurrences were observed at unusual sites. Further studies are required to investigate any association between the robotic approach and aberrant recurrence patterns.

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

Robotic retroperitoneal lymph node dissection is emerging as an attractive minimally invasive technique to remove residual and recurrent retroperitoneal masses in patients with germ cell malignancies. It has huge potential benefits for patients in terms of lower rates of blood loss, ileus, postoperative pain, and scarring, and faster return to full activity. Inadvertent injury to the great vessels, lumbar tributaries, and other vessels is not uncommon and requires a calm but strategic management response. A thorough knowledge of the standard anatomy, specific pathology, and anatomic variations will help robotic surgeons in managing intraoperative haemorrhage. We describe the anatomy of the retroperitoneal vessels, surgical case selection, and the technical and nontechnical skills essential for success in this complex and high-risk procedure. Patient summaryRobot-assisted surgical removal of lymph nodes from the area behind the abdominal cavity is a complex operation that has minimal bleeding if all goes well. However, as it involves operating on the major abdominal blood vessels, there is a risk of life-threatening bleeding that the operating team must be able to rapidly control. Effective teamwork and a range of advanced technical skills are required to respond to any serious bleeding.

PE44 - Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors: Single-center, retrospective study to evaluate oncological and functional outcomes

PE44 - Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors: Single-center, retrospective study to evaluate oncological and functional outcomes

Robotic-assisted retroperitoneal lymph node dissection for stage II testicular cancer

ObjectiveTo evaluate the perioperative as well as early oncological outcomes of patients undergoing robotic retroperitoneal lymph node dissection for treatment of testicular cancer. MethodsWe conducted a prospective consecutive case series of patients undergoing robotic assisted retroperitoneal lymph node dissection for metastatic testicular cancer between May 2018 and July 2021 at our institution. Data were collected on patient and tumour characteristics, intraoperative and postoperative parameters, and functional and oncological outcomes. Descriptive statistics are presented. ResultsNineteen patients were identified; 18 (94.7%) completed the procedure robotically and one was converted to open surgery; 78.9% of patients had stage ≥IIB and 12 (63.2%) patients had undergone prior chemotherapy. The median operative time was 300 (interquartile range [IQR] 240–315) min. Median blood loss was 100 (IQR 50–175) mL. Median length of stay was 2 (range 1–11) days. All robotically completed patients commenced diet and passed flatus on Day 1 and were discharged by Day 3. The median lymph node yield was 40.5 (IQR 38–51) nodes. All patients undergoing nerve-sparing procedures recovered antegrade ejaculatory function. One patient had a Clavien-Dindo III complication (chylous ascites requiring drainage). At a median follow-up of 22.3 (IQR 16.3–24.9) months, one patient developed retroperitoneal recurrence, which was successfully treated with second-line chemotherapy; no other patients have had recurrences. ConclusionRobotic retroperitoneal lymph node dissection is a safe and feasible alternative to open surgery in appropriately selected patients, offering low morbidity. Early oncological outcomes are promising. Larger cohorts and longer follow-ups are required to validate our institution's findings.

V05-07 ROBOTIC-ASSISTED LAPAROSCOPIC LEFT RENAL VEIN TRANSPOSITION FOR TREATMENT OF NUTCRACKER SYNDROME

You have accessJournal of UrologyCME1 May 2022V05-07 ROBOTIC-ASSISTED LAPAROSCOPIC LEFT RENAL VEIN TRANSPOSITION FOR TREATMENT OF NUTCRACKER SYNDROME Robert Harrison, Tanner Corse, and Michael Stifelman Robert HarrisonRobert Harrison More articles by this author , Tanner CorseTanner Corse More articles by this author , and Michael StifelmanMichael Stifelman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002579.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nutcracker syndrome is an uncommon clinical condition in which the left renal vein is compressed between the superior mesenteric artery and aorta. Patients most commonly present with hematuria or left flank pain, and a wide range of treatment modalities are available to treat symptomatic nutcracker syndrome. One such intervention is left renal vein transposition, which has produced excellent results when performed with an open approach. Minimally-invasive techniques have revolutionized how many surgical procedures are performed, but despite the increasing popularity of robotics, the literature on robotic-assisted left renal vein transposition remains limited. In this study, we describe our robotic left renal vein transposition technique in a patient with nutcracker syndrome. METHODS: The patient was a 19-year-old male with a 12-month history of left flank pain, gross hematuria, and early satiety. The patient had a thin body habitus, with a body mass index of 17.7 kg/m2. Physical examination was unremarkable. His baseline serum creatinine was 0.8 mg/dL, and urinalysis showed moderate blood and no proteinuria. The patient initially attempted conservative treatment options, including weight gain and acetaminophen for flank pain, which were unsuccessful. Computed tomography of the abdomen revealed a compressed left renal vein. In the context of his clinical presentation, laboratory reports and, and imaging findings, a presumptive diagnosis of nutcracker syndrome was made. The patient was counseled regarding the various treatment options for this condition and elected to proceed with robotic-assisted left renal vein transposition. RESULTS: The patient tolerated the procedure well. Total operative time was 152 minutes, there were no complications, and the patient was discharged home on postoperative day one. At his six-week follow-up visit, the patient reported resolution of left flank pain and hematuria, and ultrasound revealed no abnormalities. CONCLUSIONS: Robotic-assisted left renal vein transposition is a safe and effective treatment for nutcracker syndrome. This approach to left renal vein transposition should be achievable for surgeons experienced with robotic retroperitoneal lymph node dissection and caval thrombectomy. Source of Funding: n/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e518 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Harrison More articles by this author Tanner Corse More articles by this author Michael Stifelman 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.

A0558 - Complications of primary open or robotic RetroPeritoneal Lymph Node Dissection (RPLND) in stage II A/B patients with seminoma – results from the prospective phase II PRIMETEST trial

A0558 - Complications of primary open or robotic RetroPeritoneal Lymph Node Dissection (RPLND) in stage II A/B patients with seminoma – results from the prospective phase II PRIMETEST trial

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.

Robotic versus Laparoscopic Retroperitoneal Lymph node Dissection for Clinical Stage I Non-seminomatous Germ Cell Tumor of Testis: A Comparative Analysis.

To compare the treatment outcomes of robotic retroperitoneal lymph node dissection (R-RPLND) versus laparoscopic RPLND (L-RPLND) for clinical stage I non-seminomatous germ cell testicular tumors (NSGCTs). We retrospectively reviewed the data of patients with stage I NSGCTs who underwent robotic or laparoscopic RPLND between 2008 and 2017. Perioperative data and oncologic outcomes were reviewed and compared between the two groups. Progression-free survival was analyzed using Kaplan-Meier survival curves and compared between two groups. A total of 31 and 28 patients underwent R-RPLND and L-RPLND respectively. The preoperative characteristics of the patients were comparable in the two groups. Patients in R-RPLND group had significantly shorter median operative time (140 vs. 175 minutes, P < .001), a shorter median duration to surgical drain removal (2 vs. 4 days, P = .002) and a shorter median postoperative hospital stay (5 vs. 6 days, P = .001). There were no statistical differences in intra- and post-operative complication rate between the groups and the oncologic outcomes were similar in the two groups. In expert hands, R-RPLND and L-RPLND were comparable in oncological parameter and morbidity rate; R-RPLND showed superiority in operation duration, median days to surgical drain removal and postoperative hospital stay for stage I NSGCTs. Multicenter and randomized studies with good power of study and sufficient follow-up duration are required to validate our result.

PD53-05 EJACULATION AFTER ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION STRATIFIED BY INDICATION, SURGICAL TEMPLATE, AND NERVE SPARING

You have accessJournal of UrologyPenile & Testicular Cancer: Penile & Testicular Cancer II (PD53)1 Sep 2021PD53-05 EJACULATION AFTER ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION STRATIFIED BY INDICATION, SURGICAL TEMPLATE, AND NERVE SPARING Christian Fankhauser, Luca Afferi, Sean P. Stroup, Nicholas R. Rocco, San Diego, CA, Kathleen Olson, Aditya Bagrodia, Fady Baky, Walter Cazzaniga, David Nicol, Erik Mayer, Ekrem Islamoglu, Stephane de Vergie, Ragheed Saoud, Scott E. Eggener, Lee Hugar, Wade Sexton, Deliu-Victor Matei, Thomas Hermanns, Robert Hamilton, Andreas Hiester, Peter Albers, Noel W. Clarke, and Agostino Mattei Christian FankhauserChristian Fankhauser More articles by this author , Luca AfferiLuca Afferi More articles by this author , Sean P. StroupSean P. Stroup More articles by this author , Nicholas R. RoccoNicholas R. Rocco More articles by this author , San Diego, CASan Diego, CA More articles by this author , Kathleen OlsonKathleen Olson More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , Fady BakyFady Baky More articles by this author , Walter CazzanigaWalter Cazzaniga More articles by this author , David NicolDavid Nicol More articles by this author , Erik MayerErik Mayer More articles by this author , Ekrem IslamogluEkrem Islamoglu More articles by this author , Stephane de VergieStephane de Vergie More articles by this author , Ragheed SaoudRagheed Saoud More articles by this author , Scott E. EggenerScott E. Eggener More articles by this author , Lee HugarLee Hugar More articles by this author , Wade SextonWade Sexton More articles by this author , Deliu-Victor MateiDeliu-Victor Matei More articles by this author , Thomas HermannsThomas Hermanns More articles by this author , Robert HamiltonRobert Hamilton More articles by this author , Andreas HiesterAndreas Hiester More articles by this author , Peter AlbersPeter Albers More articles by this author , Noel W. ClarkeNoel W. Clarke More articles by this author , and Agostino MatteiAgostino Mattei More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002080.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Open retroperitoneal lymph node dissection (RPLND) is the standard of care in men with germ cell tumours and post-chemotherapy retroperitoneal residual disease. More recently, primary RPLND has re-emerged as a potential treatment option in stage 2 disease and as an adjuvant option in stage 1. The most frequent side-effect of RPLND is retrograde ejaculation but nerve-sparing, template resection and robotic surgery have been introduced to reduce this complication. The aim of this study was to describe ejaculatory function after robotic RPLND stratified by indication, surgical templates, and nerve sparing. METHODS: International, multicentre, retrospective cohort study describing patient characteristics, surgical template, nerve sparing and ejaculatory function after robotic RPLND. Ejaculation status was retrieved from medical charts. Logistic regression was performed to identify predictors for sustained post-operative ejaculatory function. RESULTS: Of 359 men undergoing robotic RPLND in 8 countries at 14 institutions, sufficiently detailed information regarding surgical templates, nerve sparing, and ejaculatory function was available in 255 (71%). Indications included primary RPLND in 185 including 4 with recurrence after one cycle of adjuvant chemotherapy for stage 1 disease and post-chemotherapy RPLND in 70. The median retroperitoneal mass size was 30mm (IQR 19-45). Median operative time was 282 minutes (IQR 212-349). Bilateral and modified templates were used in 119 and 136 respectively. Eight different modified templates were described. Nerve sparing was performed in 195 patients (76%). In multivariable regression, nerve-sparing and template resection improved ejaculatory function significantly (template vs bilateral resection [Odds ratio (OR) 19.4, 95% confidence interval (CI) 6.5-75.6], nerve sparing vs non-nerve sparing [OR 5.9, 95% CI 2.3-16.1]). There was a higher chance to maintain ejaculatory function in men undergoing primary compared to post-chemotherapy RPLND, although this difference failed to reach statistical significance (OR 1.8, 95% CI 0.8-4.0). In the overall cohort, ejaculation after RPLND was reported in 218 (85%) whereas in the subgroup of 75 men treated with primary RPLND, nerve sparing, and template resection, normal ejaculation was reported in 72 (96%). CONCLUSIONS: In this retrospective, international robotic RPLND cohort, template resection and nerve sparing improved post-operative ejaculatory function. From a functional perspective, the high proportion of men with normal ejaculation after primary RPLND with nerve sparing approaches supports further studies of surgery in men with stage 1 or 2 disease. However, long-term oncological follow-up is also required before RPLND can be recommended in early-stage testis cancer. Further studies should clearly define surgical templates and assess patient reported ejaculatory function prospectively. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e917-e918 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Fankhauser More articles by this author Luca Afferi More articles by this author Sean P. Stroup More articles by this author Nicholas R. Rocco More articles by this author San Diego, CA More articles by this author Kathleen Olson More articles by this author Aditya Bagrodia More articles by this author Fady Baky More articles by this author Walter Cazzaniga More articles by this author David Nicol More articles by this author Erik Mayer More articles by this author Ekrem Islamoglu More articles by this author Stephane de Vergie More articles by this author Ragheed Saoud More articles by this author Scott E. Eggener More articles by this author Lee Hugar More articles by this author Wade Sexton More articles by this author Deliu-Victor Matei More articles by this author Thomas Hermanns More articles by this author Robert Hamilton More articles by this author Andreas Hiester More articles by this author Peter Albers More articles by this author Noel W. Clarke More articles by this author Agostino Mattei 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 ...

V26 - Post chemotherapy robotic retroperitoneal lymph node dissection with IVC repair

V26 - Post chemotherapy robotic retroperitoneal lymph node dissection with IVC repair

Indications, feasibility and outcome of robotic retroperitoneal lymph node dissection for metastatic testicular germ cell tumours

Data on robotic retroperitoneal lymph node dissection (R-RPLND) for metastatic testicular germ cell tumours (mTGCTs) are scarce and the use of R-RPLND itself is still under debate. The aim of our study was to evaluate the indications, feasibility and outcomes of R-RPLND, with special emphasis on differences between primary R-RPLND (pR-RPLND) and post-chemotherapeutic R-RPLND (pcR-RPLND) in mTGCTs. We retrospectively analysed the data of patients who underwent R-RPLND for mTGCT between November 2013 and September 2019 in two centres in Germany. Indications, operative technique, intra- and postoperative complications and oncologic outcome were analysed. Twenty-three mTGCT patients underwent R-RPLND (7 pR-RPLND, 16 pcR-RPLND). For pR-RPLND versus pcR-RPLND, median time of surgery was 243 min [interquartile range (IQR) 123–303] versus 359 min (IQR 202–440, p = 0.154) and median blood loss 100 mL (IQR 50–200) versus 275 mL (IQR 100–775, p = 0.018). Intra- and postoperative complications were more frequent in pcR-RPLND (pcR-RPLND: intra/post: 44%/44%; pR-RPLND: intra/post: 0%/29%). However, these were only statistically significant in the case of intraoperative complications (intra: p = 0.036, post: p = 0.579). Intraoperative complications (n = 7), conversions (n = 4) and transfusions (n = 4) occurred in pcR-RPLND patients only. After a median follow-up of 16.3 months (IQR 7.5–35.0) there were no recurrences or deaths. R-RPLND displays a valuable, minimally invasive treatment option in mTGCT. However, R-RPLND is challenging and pcR-RPLND especially bears a considerable risk of complications. This operation should be limited to patients with an easily accessible residual tumour mass and to surgeons experienced in robotic surgery and TGCT treatment.

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

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