Urology Annals

COMMENTARY
Year
: 2013  |  Volume : 5  |  Issue : 4  |  Page : 226--227

Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor


Nicholas G Cost 
 Department of Surgery, Division of Urology University of Colorado School of Medicine Aurora, Colorado 80045, United States

Correspondence Address:
Nicholas G Cost
Department of Surgery, Division of Urology, University of Colorado School of Medicine, 13123 E. 16th Ave., B 463, Aurora, CO 80045
United States




How to cite this article:
Cost NG. Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor.Urol Ann 2013;5:226-227


How to cite this URL:
Cost NG. Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor. Urol Ann [serial online] 2013 [cited 2021 Oct 21 ];5:226-227
Available from: https://www.urologyannals.com/text.asp?2013/5/4/226/120290


Full Text

In this report, the authors present a case of a young man with Stage Ib testicular non-seminomatous germ cell malignancy. The patient ultimately received adjuvant therapy in the form of a robotic-assisted laparoscopic retroperitoneal lymph node dissection (RPLND). The authors describe their surgical technique, the patient's short-term outcome and provide a limited discussion of some of the pertinent (and contentious) issues surrounding primary RPLND and specifically robotic-assisted RPLND.

In terms of the technical details outlined by the authors, I would provide a few comments. While they describe sparing all the lumbar vessels, it is my opinion that while this is technically feasible, I would caution against doing so at the expense of the full resection of all lymphatic tissue behind the great vessels. Additionally, full retraction of the liver is vitally important to fully expose the right renal vessels and dissect all the necessary hilar lymphatic tissue. While the authors mention using fixed external retraction by a surgical assistant, it must be understood that when the robotic surgeon is remotely located at the console, there can easily be clashing with any fixed rigid instrument at the bedside which, in this case, may lead to a liver injury. In terms of the port placement, while this is a matter of surgeon preference, I would encourage spending time pre-planning for port placement as the third robotic arm can be of great assistance in grasping and elevating the lymph node packet and allowing for two arms to work on meticulous dissection. These authors describe their placement as suboptimal and thus rendering the third arm useless. It is a good rule of surgical technique not to operate with "one arm tied behind your back."

While the authors certainly deserve congratulations for their fine surgical work, which appears to fulfill all the requirements demanded by a primary RPLND, I do think there are a few important points worth mentioning. First, there is no question that minimally-invasive RPLND is technically feasible as seen by the many reports in the literature (Article References 1-4). However, I must re-emphasize, that regardless of approach, primary RPLND is a therapeutic operation and thus not a staging procedure. The minimally-invasive operation must mimic the open approach and remove all lymphatic tissue in the described surgical template, not simply select suspicious nodes or easily accessible tissue in the template. [1] Second, as a primary RPLND it is important that the surgeon adhere to the template and appropriate nerve-sparing to achieve the high rates of preserved antegrade ejaculation seen in the open experience. [2],[3] Lastly, in terms of patient management after primary RPLND, it should again be mentioned that this is a therapeutic cancer operation, and thus N0 patients should be observed and N1 patients should be offered observation as a preferred option in accordance with National Comprehensive Cancer Network guidelines. [4] Even in N1 disease, we know that up to 75% of these patients are cured with a thorough primary RPLND alone. [5] In limited, short-term reports, it appears that these outcomes with observation can also be accomplished with minimally-invasive RPLND. [6] In summary, the surgery itself, the post-operative management, and the long-term outcomes of minimally-invasive RPLND should strive to replicate the experience with the open approach.

References

1Large MC, Sheinfeld J, Eggener SE. Retroperitoneal lymph node dissection: Reassessment of modified templates. BJU Int 2009;104:1369-75.
2Janetschek G, Hobisch A, Peschel R, Hittmair A, Bartsch G. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: Long-term outcome. J Urol 2000;163:1793-6.
3Steiner H, Zangerl F, Stöhr B, Granig T, Ho H, Bartsch G, et al. Results of bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection for testicular cancer. J Urol 2008;180:1348-52.
4NCCN. Clinical practice guidelines in oncology: Testicular cancer. Natl Compr Canc Netw 2012;1:2012.
5Rabbani F, Sheinfeld J, Farivar-Mohseni H, Leon A, Rentzepis MJ, Reuter VE, et al. Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: Pattern and prognostic factors for relapse. J Clin Oncol 2001;19:2020-5.
6Guzzo TJ, Gonzalgo ML, Allaf ME. Laparoscopic retroperitoneal lymph node dissection with therapeutic intent in men with clinical stage I nonseminomatous germ cell tumors. J Endourol 2010;24:1759-63.