V8-03: Robot-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Non-Seminomatous Germ Cell Tumors in the Post-Chemotherapy Setting
In patients who have completed a primary regimen of chemotherapy for a non-seminomatous germ cell tumor (NSGCT), retroperitoneal lymph node dissection (RPLND) is the recommended treatment modality for a residual retroperitoneal mass ≥ 1 cm in the setting of normal tumor markers. Currently, an open RPLND (O-RPLND) is the gold-standard approach, however, it is associated with a significant amount of perioperative morbidity. Recent experience has demonstrated the utility of the robot-assisted laparoscopic approach in the primary setting for NSGCT, however, data is lacking in the post-chemotherapy setting.
We conducted a multicenter, retrospective review of 163 men with NSGCT who underwent either a robot assisted RPLND (RA-RPLND) or O-RPLND. Of these, 48 were in the post-chemotherapy (PC) setting [14 O-RPLND (PC) and 34 RA-RPLND (PC)]. The robotic approach used has been described previously. Special surgical considerations in this select group of patients include the following: full bilateral templates are performed, nerve sparing approaches can be considered based off of disease burden, any tumor thrombus is treated as active disease, and the extent of disease may obviate the need for a more extensive resection. Pertinent comparisons were made between each approach.
Patient demographics and operative times were similar between groups. RA-RPLND (PC) showed statistically better outcomes when compared to O-RPLND (PC) in regard to intraoperative blood loss (335.4 vs 1069.2 mL, p = <0.001), post-operative pain (44.9 vs 972.9 mg of morphine equivalents, p = <0.001), and duration of post-operative hospitalization (2.7 vs 8.0 days, p = <0.001). There was no difference noted in the mean number of nodes obtained (26.8 vs 24.9, p = 0.574). Although there was a significant difference noted in the duration of follow up (29.1 vs 64.1 months, p = <0.001), only two recurrences have been documented. Although both were in the PC-RA-RPLND group, neither were in-field recurrences. </p>
RA-RPLND (PC) for NSGCT appears to be less morbid and better tolerated than the traditional open approach all while allowing for intricate dissection of adherent planes, complete removal of concerning tissue, and complex vascular reconstruction. Our current data suggests a similar oncologic outcome however more research is needed.