Robot assisted retroperitoneal lymph node dissection of post chemotherapy residual mass – a single center experience of 18 patients
Retroperitoneal lymph node dissection (RPLND) is a well-established treatment for post chemotherapy residual mass in non-seminomatous germ cell tumor (NSGCT) as it has diagnostic as well as therapeutic advantage. Although the open RPLND is gold standard, but due to high postoperative morbidity and poor cosmesis due to long midline abdominal incision laparoscopic retroperitoneal lymph node dissection (L-RPLND), robot assisted laparoscopic retroperitoneal lymph node dissection(RA-RPLND) has been described. The proposed advantages of RA-RPLND are good cosmesis, shorter hospital stay, less post-operative pain and reduced compilation rate. We describe our experience of robot assisted retroperitoneal lymph node dissection (RA-RPLND) and comparison to historic cohort of L- RPLND in terms of surgical, pathological and oncological outcome.
A total of 18 patients underwent RA - RPLND between September 2011 to September 2017 in our Institute. Study was started on January 2015 so data were collected retrospectively and prospectively regarding demography of patients, tumor characteristic, surgical, pathological and oncological outcomes. Short term and medium term outcomes were also recorded
Mean age of patients was 28 years and mean body mass index was 21.51 kg/m2. RA - RPLND was successfully completed in all 18 patients. Mean console time, estimated blood loss and length of hospital stay were 180.78 min, 207.89 ml and 4.31 days respectively. The mean yield of lymph node was 20. Matted lymph nodal mass was found in 4 patients and one patient had only single large retroperitoneal para-aortic mass of size 8.5x6x4.5 cm. In 10 patients modified RPLND was done and in 1 patient only large para-aortic post chemotherapy mass was excised. Out of 18 patients, 15 patients underwent nerve preserving RPLND. Only 12 patients of nerve preserving RPLND have antegrade ejaculation. Histopathological examination revealed necrosis in 14 patients whereas mature teratoma was noticed in 4 patients with one of these showing sarcomatoid differentiation too. After mean follow up period of 19.5 months, no retroperitoneal recurrence was reported. 6 patients developed chyle leak in immediate post-operative period, of these 2 patients were managed conservatively with dietary modification and octreotide, 2 patients underwent lymphangiogram and embolization and another 2 patients underwent exploratory laparotomy and ligation of cysterna chyli.
RA - RPLND is safe and feasible for post chemotherapy residual mass with acceptable complication rate. Ours is a largest reported series till date. In literature authors have mentioned series of 7-8 cases. Though larger studies are required to establish its diagnostic and therapeutic utility