V2152: ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR TESTICULAR CARCINOMA
VideoIntroduction and Objectives
Retroperitoneal lymph node dissection (RPLND) is an accepted staging and treatment option for clinical stage 1 non-seminomatous germ cell tumor (NSGCT). Laparoscopic RPLND has been performed in an effort to decrease the morbidity of open RPLND. Robotic surgical techniques have recently been employed in urologic procedures with the noted advantages of 3-D vision and greater degrees of instrument freedom. To determine whether the advantages of robotic surgery could be applied to laparoscopic RPLND, we present our experience with robotic RPLND.
Robotic RPLND was performed using two approaches. Early in our experience a lateral approach using 4 robotic trocars and an assistant trocar was used. With more experience and the need to treat post chemotherapy patients, a supine approach with the patient in Trendelenberg position was utilized. The supine approach allows a full bilateral dissection in one setting. The fourth robotic arm is used throughout the procedure and is instrumental in providing exposure of the lymphatic tissue and retraction of the bowel and major vessels. Nerve sparing is performed within the template. The spermatic cord is dissected completely within the inguinal canal by repositioning the robot over the patient's legs.
Robotic RPLND was performed successfully in 16 patients with 11 performed from the lateral approach and 5 in the supine position. Mean operative time was 259 minutes and mean estimated blood loss was 75 cc. Mean hospital stay was 1.5 days with 10 of 16 patients leaving the hospital the day following surgery. Mean number of lymph nodes removed was 21. Four patients were found to have Stage IIa disease and one patient developed a lung recurrence at 4 months while the remaining three are disease free without post-operative chemotherapy at a mean follow up of 23 months. There was one ureteral transection, no open conversions and no transfusions. Two patients who underwent bilateral RPLND had ejaculatory dysfunction.
Robotic RPLND can be performed successfully and provides improved visualization and dexterity over conventional laparoscopic instrumentation. The supine approach facilitates bilateral dissection for post chemotherapy patients. Patients experience significantly reduced morbidity and nodal yield is comparable to open surgical techniques. Further study will be necessary to determine the long term oncologic outcomes of this approach.