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Yuan Y, Zhang D, Ning Y, Luo H, Qiu X, Tan Y, Li Y, Yang X. Clinical efficacy and safety of robotic retroperitoneal lymph node dissection for testicular cancer: a systematic review and meta-analysis. Front Oncol 2023; 13:1257528. [PMID: 38169835 PMCID: PMC10758414 DOI: 10.3389/fonc.2023.1257528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
Background Retroperitoneal lymph node dissection (RPLND) is an effective treatment for testicular tumors. In recent years, with the development of robotics, many urological procedures performed via standard laparoscopy have been replaced by robots. Our objective was to compare the safety and efficacy of robotic retroperitoneal lymph node dissection (R-RPLND) versus Non-robotic retroperitoneal lymph node dissection (NR-RPLND) in testicular cancer. Methods Pubmed, Embase, Scopus, Cochrane Library, and Web of Science databases were searched for literature on robotic surgery for testicular germ cell tumors up to April 2023. The statistical and sensitivity analyses were performed using Review Manager 5.3. Meta-analysis was performed to calculate mean difference (MD), odds ratio(OR), and 95% confidence interval (CI) effect indicators. Results Eight studies with 3875 patients were finally included in this study, 453 with R-RPLND and 3422 with open retroperitoneal lymph node dissection (O-RPLND)/laparoscopic retroperitoneal lymph node dissection (L-RPLND). The results showed that R-RPLND had lower rates of intraoperative blood loss (MD = -436.39; 95% CI -707.60 to -165.19; P = 0.002), transfusion (OR = 0.06; 95% CI 0.01 to 0.26; P = 0.0001), total postoperative complication rates (OR = 0.39; 95% CI 0.21 to 0.70; P = 0.002), and length of stay (MD=-3.74; 95% CI -4.69 to -2.78; P<0.00001). In addition, there were no statistical differences between the two groups regarding perioperative and oncological outcomes regarding total operative time, the incidence of postoperative complications grade≥III, abnormal ejaculation rate, lymph node yield, and postoperative recurrence rate. Conclusions The R-RPLND and O-RPLND/L-RPLND provide safe and effective retroperitoneal lymph node dissection for testicular cancer. Patients with R-RPLND have less intraoperative bleeding, shorter hospitalization period, fewer postoperative complications, and faster recovery. It should be considered a viable alternative to O-RPLND/L-RPLND. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023411696.
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Affiliation(s)
- Yacheng Yuan
- Department of Urology, The 940 Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
| | - Dawei Zhang
- Department of Urology, Central Hospital of Gansu Province, Lanzhou, China
| | - Yiping Ning
- Department of Urology, The 940 Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
| | - Hengfeng Luo
- Department of Urology, The 940 Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
| | - Xiaolong Qiu
- Department of Urology, The 940 Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
| | - Yangyang Tan
- Department of Urology, The 940 Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
| | - Yuxiang Li
- Department of Urology, The 940 Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
| | - Xukai Yang
- Department of Urology, The 940 Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
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Vasudeo V, Khanna A, Pratihar SK, Jaipuria J, Chakraborty A, Rawal SK, Singh A. Robot-assisted retroperitoneal lymph node dissection for post-chemotherapy residual mass in testicular cancer: Long-term experience from a tertiary care centre. J Minim Access Surg 2023; 19:288-295. [PMID: 36629220 PMCID: PMC10246628 DOI: 10.4103/jmas.jmas_141_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/03/2022] [Accepted: 07/09/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives To present our intermediate to long-term oncological and functional outcomes of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in post-chemotherapy (PC) residual mass in testicular cancers. To the best of our knowledge, this is the largest single-centre experience of RA-RPLND for in such setting. Methods Prospectively maintained database of carcinoma testis patients undergoing RA-RPLND from February 2012 to September 2021 was reviewed. Patient demographics, tumour stage and risk groups and chemotherapy details were recorded. Intraoperative details and post-operative complications were also noted. Pathological outcomes included were lymph node yield and histopathology report. Further, follow-up was done for recurrence and antegrade ejaculation status. Results Total of 37 cases were done for PC residual masses. International germ cell cancer collaborative group good, intermediate and poor risk proportion was 18 (48.6%), 14 (37.8%) and 5 (13.5%), respectively. Bilateral full template dissection, unilateral modified template dissection and residual mass excision was performed in 59.5% (22/37), 35.1% (13/37) and 5.4% (2/37) patients, respectively. The median size of the excised residual mass was 3.45 cm interquartile range (IQR 2-6 cm), with the largest being 9 cm. The median lymph nodal yield was 19. The most common histology was necrosis (n = 24, 65%), followed by teratoma (n = 11, 30%) and viable malignancy (n = 2, 5%). Antegrade ejaculation was reported in 32 patients (86.4%). After a median follow-up of 41 (IQR 14-64) months, only one patient had a recurrence. Conclusions RA-PC-RPLND is thus a safe, feasible and oncologically effective option for selected patients. With increasing experience, larger masses can also be dealt with efficiently.
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Affiliation(s)
- Vivek Vasudeo
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Ashish Khanna
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | | | - Jiten Jaipuria
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Arnab Chakraborty
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Sudhir Kumar Rawal
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Amitabh Singh
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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Garg H, Mansour AM, Psutka SP, Kim SP, Porter J, Gaspard CS, Dursun F, Pruthi DK, Wang H, Kaushik D. Robot-assisted retroperitoneal lymph node dissection: a systematic review of perioperative outcomes. BJU Int 2023. [PMID: 36754376 DOI: 10.1111/bju.15986] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To assess the safety and feasibility of robot-assisted retroperitoneal lymph node dissection (R-RPLND) and to compare the perioperative outcomes of R-RPLND with open RPLND (O-RPLND), as RPLND forms an integral part of the management of testis cancer and R-RPLND is a minimally invasive treatment option for this disease. MATERIALS AND 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 4222 patients (single-arm studies, n = 459; comparative studies, n = 3763). Of 459 patients in the single-arm studies, 271 underwent primary R-RPLND and 188 underwent post-chemotherapy R-RPLND. For primary R-RPLND, the operative time ranged from 175 to 540 min and the major complication rate was 4.1%. For post-chemotherapy R-RPLND, the operative time ranged from 134 to 550 min and the major complication rate was 8.5%. The conversion rate to open surgery was 2.2% in primary R-RPLND and 9.0% in post-chemotherapy R-RPLND. In comparison with O-RPLND, R-RPLND was associated with a lower transfusion rate (14.5% vs 0.9%, P < 0.001) and a lower complication rate (18.5% vs 7.8%, P = 0.002). CONCLUSION Robot-assisted RPLND has acceptable perioperative outcomes in both the primary and post-chemotherapy settings but a notable rate of conversion to open surgery in the post-chemotherapy setting. Compared with O-RPLND, R-RPLND is associated with a lower transfusion rate and fewer overall complications. Given the potential impact of selection bias, the optimal patient selection criteria for R-RPLND remain to be elucidated.
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Affiliation(s)
- Harshit Garg
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Ahmed M Mansour
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Simon P Kim
- Division of Urology, University of Colorado-Denver, Denver, CO, USA
| | - James Porter
- Department of Urology, Swedish Medical Center, Seattle, WA, USA
| | | | - Furkan Dursun
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Deepak K Pruthi
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Hanzhang Wang
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Dharam Kaushik
- Department of Urology, University of Texas Health, San Antonio, TX, USA
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Ghoreifi A, Mitra AP, McClintock G, Baky F, McDowell Z, Lavallée E, Saoud R, Cai J, Gill IS, Sfakianos J, Porter J, Bagrodia A, Ahmadi N, Eggener S, Ward JF, Djaladat H. Robotic post-chemotherapy retroperitoneal lymph node dissection for testicular cancer: A multicenter collaborative study. Urol Oncol 2023; 41:111.e7-111.e14. [PMID: 36437156 DOI: 10.1016/j.urolonc.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/06/2022] [Accepted: 11/03/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the perioperative and oncological/functional outcomes of robotic post-chemotherapy retroperitoneal lymph node dissection for testicular cancer. METHODS AND MATERIALS In this retrospective study, we included patients who underwent robotic post-chemotherapy retroperitoneal lymph node dissection at 7 academic centers between 2011 and 2021. Patients' characteristics, perioperative findings, as well as oncological and functional outcomes are reviewed. Relationships with the main outcome (90-day complications) were analyzed using multivariable logistic regression. RESULTS A total of 90 patients with a median (IQR) age of 30 (25-37) years were included. The main primary histologic type was non-seminomatous germ cell tumor (89%). Seven patients (8%) were electively converted to open. Median estimated blood loss, operative time, and length of hospital stay were 150 ml, 5.6 hours, and 2 days, respectively. Final pathology revealed teratoma in 49 (55%), necrosis/fibrosis in 29 (32%), and viable germ cell tumor in 12 (13%) patients. The 90-day complication rate was 16.7%, most of which were low-grade (Clavien-Dindo < III) and managed conservatively. On multivariable analysis, pure seminoma (odds ratio 17.4) and bilateral dissection template (odds ratio 4.2) were independently associated with 90-day complications. No 90-day hospital readmission was recorded. With a median (IQR) follow-up of 16 (4-32) months, 6 (6.7%) patients had disease recurrence and there was 1 cancer-related death. CONCLUSION With appropriate patient selection at centers with expertise in testicular cancer and minimally invasive surgery, robotic post-chemotherapy retroperitoneal lymph node dissection appears safe and effective, although longer follow-up is warranted.
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Affiliation(s)
- Alireza Ghoreifi
- Institute of Urology, University of Southern California, Los Angeles, CA
| | - Anirban P Mitra
- Department of Urology and Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - George McClintock
- Department of Urology, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Fady Baky
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Etienne Lavallée
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ragheed Saoud
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL
| | - Jie Cai
- Institute of Urology, University of Southern California, Los Angeles, CA
| | - Inderbir S Gill
- Institute of Urology, University of Southern California, Los Angeles, CA
| | - John Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Aditya Bagrodia
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA
| | - Nariman Ahmadi
- Department of Urology, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Scott Eggener
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL
| | - John F Ward
- Department of Urology, University of Texas MD Anderson Cancer Canter, Houston, TX
| | - Hooman Djaladat
- Institute of Urology, University of Southern California, Los Angeles, CA.
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Nason GJ, Hamilton RJ. Robotic RPLND for stage IIA/B nonseminoma: the Princess Margaret Experience. World J Urol 2022; 40:335-342. [PMID: 34988650 DOI: 10.1007/s00345-021-03899-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/17/2021] [Indexed: 01/11/2023] Open
Abstract
PURPOSE 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. METHODS A review and summary of the published data to date was performed regarding the role of robotic RPLND for stage IIA/B nonseminoma. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- G J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, 610 University Avenue - Suite - 3-130, Toronto, ON, M5G 2M9, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, 610 University Avenue - Suite - 3-130, Toronto, ON, M5G 2M9, Canada.
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Lloyd P, Hong A, Furrer MA, Lee EWY, Dev HS, Coret MH, Adshead JM, Baldwin P, Knight R, Shamash J, Alifrangis C, Stoneham S, Mazhar D, Wong H, Warren A, Tran B, Lawrentschuk N, Neal DE, Thomas BC. A comparative study of peri-operative outcomes for 100 consecutive post-chemotherapy and primary robot-assisted and open retroperitoneal lymph node dissections. World J Urol 2022; 40:119-126. [PMID: 34599350 DOI: 10.1007/s00345-021-03832-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/30/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To describe and compare differences in peri-operative outcomes of robot-assisted (RA-RPLND) and open (O-RPLND) retroperitoneal lymph node dissection performed by a single surgeon where chemotherapy is the standard initial treatment for Stage 2 or greater non-seminomatous germ cell tumour. METHODS Review of a prospective database of all RA-RPLNDs (28 patients) and O-RPLNDs (72 patients) performed by a single surgeon from 2014 to 2020. Peri-operative outcomes were compared for patients having RA-RPLND to all O-RPLNDs and a matched cohort of patients having O-RPLND (20 patients). Further comparison was performed between all patients in the RA-RPLND group (21 patients) and matched O-RPLND group (18 patients) who had previous chemotherapy. RA-RPLND was performed for patients suitable for a unilateral template dissection. O-RPLND was performed prior to the introduction of RA-RPLND and for patients not suitable for RA-RPLND after its introduction. RESULTS RA-RPLND showed improved peri-operative outcomes compared to the matched cohort of O-RPLND-median blood loss (50 versus 400 ml, p < 0.00001), operative duration (150 versus 195 min, p = 0.023) length-of-stay (1 versus 5 days, p < 0.00001) and anejaculation (0 versus 4, p = 0.0249). There was no statistical difference in complication rates. RA-RPLND had lower median lymph node yields although not significant (9 versus 13, p = 0.070). These improved peri-operative outcomes were also seen in the post-chemotherapy RA-RPLND versus O-RPLND analysis. There were no tumour recurrences seen in either group with median follow-up of 36 months and 60 months, respectively. CONCLUSIONS Post-chemotherapy RA-RPLND may have decreased blood loss, operative duration, hospital length-of-stay and anejaculation rates in selected cases and should, therefore, be considered in selected patients. Differences in oncological outcomes require longer term follow-up.
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Affiliation(s)
- Paul Lloyd
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Anne Hong
- Department of Urology, Royal Melbourne Hospital, Melbourne, Australia
| | - Marc A Furrer
- Department of Urology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Urology, University Hospital of Bern, Bern, Switzerland.,The Australian Medical Robotics Academy, Melbourne, Australia
| | - Elaine W Y Lee
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Harveer S Dev
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Maurice H Coret
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | | | - Peter Baldwin
- Department of Gynae-Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - Richard Knight
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | | | | | - Sara Stoneham
- Department of Oncology, University College London Hospital, London, UK
| | - Danish Mazhar
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Han Wong
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Anne Warren
- Department of Pathology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Nathan Lawrentschuk
- Department of Urology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - David E Neal
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Benjamin C Thomas
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK. .,Department of Urology, Royal Melbourne Hospital, Melbourne, Australia. .,The Australian Medical Robotics Academy, Melbourne, Australia. .,Department of Surgery, University of Melbourne, Melbourne, Australia.
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Indications, feasibility and outcome of robotic retroperitoneal lymph node dissection for metastatic testicular germ cell tumours. Sci Rep 2021; 11:10700. [PMID: 34021196 PMCID: PMC8140155 DOI: 10.1038/s41598-021-89823-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/30/2021] [Indexed: 12/26/2022] Open
Abstract
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.
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Robotic retroperitoneal lymph node dissection for primary and post-chemotherapy testis cancer. J Robot Surg 2021; 16:369-375. [PMID: 33982173 DOI: 10.1007/s11701-021-01252-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
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.
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Yang H, Obiora D, Tomaszewski JJ. Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer. Transl Androl Urol 2021; 10:2188-2194. [PMID: 34159101 PMCID: PMC8185654 DOI: 10.21037/tau.2020.03.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.
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Affiliation(s)
- Hailiu Yang
- Division of Urology, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Daisy Obiora
- Division of Urology, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Jeffrey J Tomaszewski
- Division of Urology, Department of Surgery, MD Anderson Cancer Center at Cooper, Cooper Medical School of Rowan University, Camden, NJ, USA
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Robot-assisted retroperitoneal lymphadenectomy: The state of art. Asian J Urol 2020; 8:27-37. [PMID: 33569270 PMCID: PMC7859427 DOI: 10.1016/j.ajur.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 08/03/2020] [Accepted: 08/20/2020] [Indexed: 12/03/2022] Open
Abstract
Objective To perform a narrative review about the role of robot-assisted retroperitoneal lymphadenectomy (R-RPLND) in the management of testicular cancer. Methods A PubMed search for all relevant publications regarding the R-RPLND series up until August 2019 was performed. The largest series were identified, and weighted means calculated for outcomes using the number of patients included in each study as the weighting factor. Results Fifty-six articles of R-RPLND were identified and eight series with more than 10 patients in each were included. The weighted mean age was 31.12 years; primary and post chemotherapy R-RPLND were performed in 50.59% and 49.41% of patients. The clinical stage was I, II and III in 47.20%, 39.57% and 13.23% of patients. A modified R-RPLND template was used in 78.02% of patients, while 21.98% underwent bilateral full template. The weighted mean node yield, operative time and estimated blood loss were, respectively, 22.15 nodes, 277.35 min and 131.94 mL. The weighted mean length of hospital stay was 2 days and antegrade ejaculation was preserved in 92.12% of patients. Major post-operative complications (Clavien III or IV) occurred in 5.34%. Positive pathological nodes were detected in 24.54%, while the recurrence free survival was 95.77% with a follow-up of 21.81 months. Conclusion R-RPLND has proven to be a reproducible and safe approach in experienced centers; short-term oncologic outcomes are similar to the open approach with less morbidity and shorter convalescence related to its minimal invasiveness. However, longer follow-up and new trials comparing head-to-head both techniques are expected.
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Blok JM, van der Poel HG, Kerst JM, Bex A, Brouwer OR, Bosch JLHR, Horenblas S, Meijer RP. Clinical outcome of robot-assisted residual mass resection in metastatic nonseminomatous germ cell tumor. World J Urol 2020; 39:1969-1976. [PMID: 32955662 PMCID: PMC8217018 DOI: 10.1007/s00345-020-03437-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate the outcome of robot-assisted residual mass resection (RA-RMR) in nonseminomatous germ cell tumor (NSGCT) patients with residual tumor following chemotherapy. PATIENTS AND METHODS Retrospective medical chart analysis of all patients with NSGCT undergoing RA-RMR at two tertiary referral centers between January 2007 and April 2019. Patients were considered for RA-RMR in case of a residual tumor between 10 and 50 mm at cross-sectional computed tomography (CT) imaging located ventrally or laterally from the aorta or vena cava, with normalized tumor markers following completion of chemotherapy, and no history of retroperitoneal surgery. RESULTS A total of 45 patients were included in the analysis. The Royal Marsden stage before chemotherapy was IIA in 13 (28.9%), IIB in 16 (35.6%), IIC in 3 (6.7%) and IV in 13 patients (28.9%). The median residual tumor size was 1.9 cm (interquartile range [IQR] 1.4-2.8; range 1.0-5.0). Five procedures (11.1%) were converted to an open procedure due to a vascular injury (n = 2), technical difficulty (n = 2) or tumor debris leakage (n = 1). A postoperative adverse event occurred in two patients (4.4%). Histopathology showed teratoma, necrosis and viable cancer in 29 (64.4%), 14 (31.1%), and two patients (4.4%), respectively. After a median follow-up of 41 months (IQR 22-70), one patient (2.2%) relapsed in the retroperitoneum. The one- and 2-year recurrence-free survival rate was 98%. CONCLUSION RA-RMR is an appropriate treatment option in selected patients, potentially providing excellent cure rates with minimal morbidity. Long-term outcome data are needed to further support this strategy and determine inclusion and exclusion criteria.
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Affiliation(s)
- Joost M Blok
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands.
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - J Martijn Kerst
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - Oscar R Brouwer
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - J L H Ruud Bosch
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - Richard P Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Ray S, Pierorazio PM, Allaf ME. Primary and post-chemotherapy robotic retroperitoneal lymph node dissection for testicular cancer: a review. Transl Androl Urol 2020; 9:949-958. [PMID: 32420211 PMCID: PMC7214990 DOI: 10.21037/tau.2020.02.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Shagnik Ray
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Phillip M Pierorazio
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohamad E Allaf
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Mittakanti HR, Porter JR. Robot-assisted laparoscopic retroperitoneal lymph node dissection: a minimally invasive surgical approach for testicular cancer. Transl Androl Urol 2020; 9:S66-S73. [PMID: 32055487 DOI: 10.21037/tau.2019.12.36] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Klaassen Z, Hamilton RJ. The Role of Robotic Retroperitoneal Lymph Node Dissection for Testis Cancer. Urol Clin North Am 2019; 46:409-417. [PMID: 31277735 DOI: 10.1016/j.ucl.2019.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Retroperitoneal lymph node dissection (RPLND) is complex; however, recent advances in technology have allowed adoption of the robotic platform for highly select cases. Initial case series have shown improved cosmesis, less blood loss, and decreased length of stay compared with open RPLND. Our preference for performing robotic RPLND is via a transperitoneal approach with the patient in the supine position, thus facilitating a bilateral template dissection identical to that used in all our open procedures. Robotic RPLND should mimic the open approach with regard to oncologic principles and should only be performed by clinicians well versed in open RPLND.
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Affiliation(s)
- Zachary Klaassen
- Division of Urology, Medical College of Georgia, Augusta University, 1120 15th Street, BA-8414, Augusta, GA 30912, USA; Georgia Cancer Center, Augusta, GA, USA
| | - Robert J Hamilton
- Division of Urology, University Health Network, 610 University Avenue - Suite 3-130, Toronto, Ontario M5G 2M9, Canada; Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
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16
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Therapeutic supine robotic retroperitoneal lymph node dissection for post-chemotherapy residual masses in testicular cancer: technique and outcome analysis of initial experience. J Robot Surg 2019; 13:747-756. [PMID: 30656537 DOI: 10.1007/s11701-018-00903-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022]
Abstract
Retroperitoneal lymph node dissection (RPLND) is a therapeutic standard of care for post-chemotherapy residual masses in testicular cancer. While a robotic approach to this procedure has the potential of decreasing the morbidity associated with this major endeavour, it is often criticised for its inability to provide a bilateral complete template resection without redocking and repositioning the patient. Herein, we present the technique and initial outcomes of a supine approach to Robotic RPLND (R-RPLND) using the da Vinci Xi® system, which obviates the need for repositioning or redocking for a bilateral full template resection. Three patients (age 21-36) with nonseminomatous germ cell tumours of the testis underwent R-RPLND for post-chemotherapy residual retroperitoneal masses with normalised tumor markers. Salient steps of the procedure were as follows: port placement in supine Trendelenburg position, docking of the da Vinci Xi® system from one side, exposure of retroperitoneum, dissection of paracaval, retrocaval, interaortocaval, paraaortic and bilateral common iliac templates, and excision of gonadal vein. Mean console time and estimated blood loss were 257 (190-305) minutes and 333 (300-400) ml, respectively. Mean lymph node yield was 52 (29-94). One patient had a common iliac vein injury which was managed robotically without further consequence. No drains were placed in all three. There were no postoperative complications and all of them were advanced to a normal diet within 24 h and discharged on the second postoperative day. Histopathology reports were suggestive of necrosis and mature teratoma without any viable tumour. There have been no recurrences in these patients at a mean follow-up of 14 (1-22) months. R-RPLND in the supine position is practical, safe and feasible in the post-chemotherapy setting of testicular cancer. It eliminates the need for repositioning the patient or redocking the robot to achieve a complete resection with adequate lymph node yields, while preserving the benefits of a minimally invasive surgical approach.
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