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Lin J, Hu Z, Huang S, Shen B, Wang S, Yu J, Wang P, Jin X. Comparison of laparoscopic, robotic, and open retroperitoneal lymph node dissection for non-seminomatous germ cell tumor: a single-center retrospective cohort study. World J Urol 2023; 41:1877-1883. [PMID: 37332060 PMCID: PMC10352171 DOI: 10.1007/s00345-023-04459-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/25/2023] [Indexed: 06/20/2023] Open
Abstract
PURPOSE To compare the perioperative outcomes of L-RPLND, R-RPLND and O-RPLND, and determine which one can be the mainstream option. METHODS We retrospectively reviewed medical records of 47 patients undergoing primary RPLND by three different surgical techniques for stage I-II NSGCT between July 2011 and April 2022 at our center. Standard open and laparoscopic RPLND was performed with usual equipment, and robotic RPLND was operated with da Vinci Si system. RESULTS Forty-seven patients underwent RPLND during 2011-2022, and 26 (55.3%) of them received L-RPLND, 14 (29.8%) were operated with robot, while 7 (14.9%) were performed O-RPLND. The median follow-up was 48.0 months, 48.0 months, and 60.0 months, respectively. The oncological outcomes were comparable among all groups. In L-RPLND group, there were 8 (30.8%) cases of low grade (Clavien I-II) complications, and 3 (11.5%) cases of high-grade (Clavien III-IV) complications. In R-RPLND group, one (7.1%) low-grade complication and four (28.6%) high-grade complications were observed. In O-RPLND group, there were 2 (28.5%) cases of low-grade complications and one case (14.2%) of high-grade one. The operation duration of L-RPLND was the shortest. In O-RPLND group, the number of positive lymph nodes were higher than other two groups. Patients undergoing open surgery had lower (p < 0.05) red blood cell count, hemoglobin level, and higher (p < 0.05) estimated blood loss, white blood cell count than those receiving either laparoscopic or robotic surgery. CONCLUSION All three surgical techniques are comparable in safety, oncological, andrological, and reproductive outcomes under the circumstance of not using primary chemotherapy. L-RPLND might be the most cost-effective option.
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Affiliation(s)
- Juntao Lin
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Zhenghui Hu
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Shihan Huang
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Bohua Shen
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Shuo Wang
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Jianjun Yu
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Ping Wang
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China.
| | - Xiaodong Jin
- Department of Urology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, People's Republic of China.
- Department of Urology, Zhejiang Provincial Hospital of Chinese Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, People's Republic of China.
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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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Yan H, Luo M, Wang L, Qiu Z, Mo Z, Xiang Z, Zhang Y, Chen G, Zhong Z, Wang X, Gao F, Zhang F. Clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the palliative treatment of retroperitoneal metastatic lymph nodes. Cancer Imaging 2020; 20:25. [PMID: 32252826 PMCID: PMC7137200 DOI: 10.1186/s40644-020-00299-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to the unique anatomical location of retroperitoneal metastatic lymph nodes, current treatment options are limited. This study was designed to explore the clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the treatment of retroperitoneal metastatic lymph nodes. METHODS We retrospectively evaluated 92 patients received 125I brachytherapy for retroperitoneal metastatic lymph nodes. A layered Cox proportional hazards model was established to filter out the independent factors affecting local tumor progression-free survival (LTPFS). RESULTS The median LTPFS was 8 months. Metastatic lymph node with uniform density (p-0.009), clear boundaries (p-0.011), regular morphology (P < 0.001), and < 3 organs at risk of metastasis (p-0.020) were associated with better LTPFS. Necrotic lymph nodes (p < 0.001), fusion (p-0.003), and invasion of vessels visible on images (p < 0.001) were associated with poor LTPFS. Puncture path through abdominal wall or paravertebral approach were also associated with better LTPFS than a hepatic approach (P < 0.05). A maximum diameter ≤ 3 cm (P-0.031) or 3-5 cm (P-0.018) were also associated with significantly better LTPFS than a maximum diameter ≥ 5 cm. The Cox proportional hazards model suggested that lymph nodes invaded the large vessels visible on images, maximum diameter and puncture path were independent risk factors for LTPFS. CONCLUSION CT-guided 125I brachytherapy is an optional palliative treatment modality for retroperitoneal metastatic lymph nodes, which can provide high local control without severe complications. Better preoperative planning, intraoperative implementation, better choice of puncture path, and selection of appropriate tumor size are important factors that can improve the clinical efficacy of 125I brachytherapy for retroperitoneal metastatic lymph nodes.
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Affiliation(s)
- Huzheng Yan
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Ma Luo
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Lifei Wang
- The Department of Radiology, The Third People’s Hospital of Shenzhen, Shenzhen, China
| | - Zhenkang Qiu
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Zhiqiang Mo
- Department of Interventional Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, 510060 China
| | - Zhanwang Xiang
- The Third affiliated hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanling Zhang
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Guanyu Chen
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Zhihui Zhong
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Xiuchen Wang
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Fei Gao
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
| | - Fujun Zhang
- Sun Yat-sen University Cancer Center, 651 Dongfeng Road, East, Guangzhou, 510060 China
- State Key Laboratory of Oncology in South China, 651 Dongfeng Road, East, Guangzhou, 510060 China
- Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road, East, Guangzhou, 510060 China
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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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Robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy for metastatic mixed testicular germ cell cancer: a case report. J Med Case Rep 2019; 13:272. [PMID: 31451109 PMCID: PMC6710881 DOI: 10.1186/s13256-019-2200-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The robot-assisted laparoscopic management of post-chemotherapy retroperitoneal metastasis and inferior vena cava tumor thrombus secondary to testicular cancer is a challenging task for urologists. CASE PRESENTATION A pathological examination of a 36-year-old Caucasian man who had undergone a right radical orchiectomy showed mixed testicular germ cell cancer (70% embryonal cancer and 30% seminoma); he had undergone four prior courses of cisplatin, etoposide, and bleomycin chemotherapy and was found to have residual retroperitoneal enlarged lymph nodes close to the right renal hilum and a 9.8 cm inferior vena cava tumor thrombus (pT1, N2, M1, S2). Pre-surgical three-dimensional image reconstruction was performed based on contrast computed tomography data. The inferior vena cava tumor thrombus was found in the vena cava at the level of the celiac trunk and the inferior mesenteric artery. Our patient accepted treatment with robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and cava reconstruction on September 12, 2018. During the procedure, a drop-in robotic ultrasound probe was used to define the thrombus. Vena cavoscopy using a flexible ureteroscope found that the tumor thrombus adhered to the cava wall in all directions. The tumor thrombus was dissected free from the inferior vena cava lumen, and vena cava reconstruction was achieved using the da Vinci™ Si HD surgical system. The operative time was 550 minutes. The intraoperative estimated blood loss was 2300 ml. Intraoperative blood transfusions consisted of 10 units of red blood cells (Clavien-Dindo grade II). No Clavien-Dindo grade III or above perioperative complications occurred. The length of hospital stay was 7 days. Pathology revealed no viable cancer cells in any of the residual lymph node tissues or in the vena cava tumor thrombus. CONCLUSION This is the first case of robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and reconstruction for metastatic mixed testicular germ cell cancer published to date. This complicated surgical procedure was facilitated by the innovative usage of three-dimensional image reconstruction for defining the vena cava tumor thrombus, a robotic ultrasound probe for intraoperatively defining the vena cava tumor thrombus, and vena cavoscopy using a flexible ureteroscope.
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Ghodoussipour S, Daneshmand S. Postchemotherapy Resection of Residual Mass in Nonseminomatous Germ Cell Tumor. Urol Clin North Am 2019; 46:389-398. [PMID: 31277733 DOI: 10.1016/j.ucl.2019.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The introduction of cisplatin-based chemotherapy has revolutionized the care of patients with disseminated testicular germ cell tumors. Although a majority are cured with chemotherapy alone, surgical resection continues to play a role because one-third will have residual mass after chemotherapy. In this article, we review the current indications for postchemotherapy resection in nonseminomatous germ cell tumors, including masses greater than 1 cm, resection after salvage chemotherapy, with elevated markers, after late relapse, and for growing teratoma syndrome. We also highlight technical considerations of this often-challenging surgery, including the need for adjunctive procedures, extraretroperitoneal resections, and modern techniques to minimize morbidity.
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Affiliation(s)
- Saum Ghodoussipour
- Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90033, USA
| | - Siamak Daneshmand
- Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90033, USA.
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Robot-assisted post-chemotherapy retroperitoneal lymph node dissection in germ cell tumor: is the single-docking with lateral approach relevant? World J Urol 2018; 36:655-661. [PMID: 29353314 DOI: 10.1007/s00345-018-2177-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Surgical treatment of post-chemotherapy residual mass of germ cell tumor (GCT) may be performed in various techniques. We assess the feasibility, safety, and efficacy of single-docking with lateral approach robot-assisted retroperitoneal lymph node dissection (R-RPLND) in residual mass of GCT in our center. MATERIALS AND METHODS A retrospective review of patients undergoing R-RPLND for residual mass of CGT was performed between January 2014 and April 2017. Patients with residual mass < 3 cm for seminoma or < 1 cm for non-seminoma were eligible. All surgeries were performed with single-docking RPNLD technique in lateral decubitus. We assessed preoperative characteristics (age, testicular pathology, template, chemotherapy regimen, lesion size, and clinical stage), peroperative (operative time, estimated blood loss, intraoperative complication, node count, pathology, and number of positive node), and postoperative outcomes (postoperative complications, hospital length of stay, recurrence-free survival at 2 year, and ejaculation dysfunction). RESULTS Eleven patients underwent R-RPLND with a median size of the residual mass of 20 mm. Median operative time was 153 min with 120 ml of estimated blood loss, without intraoperative complication. Median nodes count was 7 [1; 24]. Two patients had post-chemotherapy necrotic nodes and one no tumorous node. One patient had postoperative Clavien I complication (chyloperitoneum). We report 72.7% of antegrade ejaculation at 1 month from the surgery. Median clinical recurrence-free survival was 100% after 2 years from the surgery (n = 6). CONCLUSION Lateral approach with single-docking R-RPLND for residual mass of GCT is feasible and safe, with satisfying functional and oncologic outcomes.
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