V1033: Robot-assisted retroperitoneal lymph node dissection: modified nerve-sparing left sided template

Video

Introduction and Objectives
Due to the inherent difficulty with dissection, laparoscopic retroperitoneal lymph node dissection (RPLND) is not considered standard treatment for patients with nonseminomatous germ cell tumors. The relatively short learning curve of robotic surgery is providing a comparative advantage over laparoscopic techniques. We report our technique for robot-assisted RPLND in a patient with clinical stage I non-seminomatous testicular cancer. To our knowledge this is the first video description of a left-sided template.

Methods
Our patient was a 25-year-old man who underwent a left orchiectomy for a mixed non-seminatous germ cell tumor (90% embryonal) with lymphovascular invasion (Stage 1B). Tumour markers were slightly elevated on admission. Staging CT scans were negative for nodal metastatic disease. The patient underwent a left-sided modified nerve-sparing template RPLND. The technique demonstrated is a transperitoneal 5-port approach with dissection contained to the left ureter laterally, great vessels medially, renal vein superiorly and bifurcation of common iliacs inferiorly. Hem-O-lok clips (Weck, Teleflex Medical, NC, USA) and robotic Harmonic™ device (Ethicon Endosurgery, OH, USA) were used for ligation of lymphatic channels. All lymphatic tissue was placed in an endoscopic bag and extracted via the periumbilical camera port.

Results
Operative time was 205 minutes. Estimated operative blood loss was 110mL and the patient’s post-operative hemoglobin dropped by 0.5 g/dL. The patient was discharged from the hospital postoperative day 1. The final specimen demonstrated pre-aortic, para-aortic and inter-aortocaval nodes with metastatic embryonal carcinoma in 6 of 28 lymph nodes and no evidence of extranodal extension. The patient thereafter underwent 3 cycles of Bleomycin, Etoposide and Cisplatin chemotherapy. Follow-up surveillance scans to date (12 months) do not demonstrate evidence of disease recurrence.

Conclusions
Robot-assisted repair of RPLND results in good lymph node yield, short hospital stay and low morbidity. New instrumentation such as the robotic Harmonic™ device is especially useful in this procedure for ligation of lymphatic channels. Analysis of larger case series is required before this technique can be compared to open RPLND.

Funding: none