AUA 2018: Outcomes and Factors Associated with Receipt of Open vs Minimally Invasive RPLND for Testis Cancer

San Francisco, CA (UroToday.com) Retroperitoneal lymph node dissection (RPLND) for testis cancer remains one of the most complex operations performed in urologic oncology practice. Over the past decade or so, several centers have described their use of laparoscopic RPLND, typically in the setting of primary RPLND or low volume retroperitoneal disease. With increasing surgeon comfort with the da Vinci robotic platform, several reports have emerged in the past couple of years describing robotic RPLND, which is a more favorable minimally invasive approach considering the length and technical dissection associated with these procedures.
A review manuscript compiled by several oncologic minimally invasive experts concluded that a RPLND is challenging regardless of approach, however, in the appropriate hands robotic RPLND may offer similar oncologic outcomes to the traditional open procedure, with the recovery benefits of a minimally invasive approach [1]. Outcomes of minimally invasive RPLND compared to open RPLND are limited. As such,  Alexandra Tabakin, MD and colleagues presented their findings comparing these two approaches using a population-level dataset.

For this study, the authors used the National Cancer Database from 2010-2014 to identify 29,399 men with primary testis cancer. Men were excluded for benign histology and CIS, a prior cancer diagnosis, non-germ cell histology, those not undergoing RPLND and those where a surgical approach was not identifiable, resulting in 1,018 men who comprised the final cohort. Those with seminoma (19.5%) vs non-seminoma (NSGCT) (80.5%) were further stratified according to whether they had a primary RPLND or a post-chemotherapy RPLND. Primary RPLND was defined as an RPLND performed for clinical stage (CS) IA-IIB without prior chemotherapy and PC-RPLND classified as RPLND performed for CS IIA-IIIC after chemotherapy. Further stratification was undertaken with respect to an open vs minimally invasive approach. 

RPLND for testis cancer AUA2018

Covariates included patient demographics, insurance status, comorbidities, hospital characteristics, socioeconomic status, and postoperative outcomes. The Fisher’s exact test was used to compare outcomes between groups.

Secondary to minimally invasive RPLND being seldom performed in the primary or post-chemotherapy setting for seminoma, the authors did not report on this cohort. Among 819 men with NSGCT receiving an RPLND, 94.1% received an open procedure vs 5.9% that underwent a minimally invasive RPLND. In the post-chemotherapy, 97% received an open RPLND and 3% received a minimally invasive RPLND. There was a statistical trend towards men undergoing a primary minimally invasive RPLND being more commonly performed at academic centers vs primary open RPLND (71.4% vs 54%, p=0.086), otherwise there were no notable demographic or institutional differences between the groups. Interestingly, the 30-day readmission rates did not differ in men undergoing primary RPLND by either approach (6.1% for open RPLND vs 7.1% for minimally invasive RPLND, p=0.739). However, 30-day readmission rates after minimally invasive post-chemotherapy RPLND were significantly higher when compared to open post-chemotherapy RPLND (66.7% vs 8.3%, p=0.026).

The strength of the study is the population-based approach allowing a large enough sample size to compare different RPLND approaches in the primary and post-chemotherapy settings. There are several limitations with this study, including exclusion of 3,555 patients who did not have an RPLND/surgical approach identified, and 22,399 patients excluded secondary to unavailable stage. This certainly introduces potential bias and decreases generalizability. Second, this is purely a descriptive study without any multivariable analyses performed (ie. to assess predictors of minimally invasive RPLND). Dr. Tabakin concluded that though the proportion of men who received minimally invasive RPLND was significantly lower than those who underwent open RPLND, a higher 30-day readmission rate for those undergoing a minimally invasive RPLND was observed. Although reasons for these findings are conjecture, perhaps there was pressure to discharge these patients early than surgically/medically fit.

References:
1. Abdul-Muhsin HM, L’esperance JO, Fischer K, et al. Robot-assisted retroperitoneal lymph node dissection in testicular cancer. J Surg Oncol 2015;112(7):736-740.

Presented by: Alexandra Tabakin, BA, MD, Rutgers RWJMS, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
Co-Authors: Sinae Kim, Charles F. Polotti, Zorimar Rivera-Núñez, Joshua Sterling, Parth K. Modi, Nicholas J. Farber, Kushan D. Radadia, Rahul Parikh, Sharad Goyal, Robert E. Weiss, Isaac Y. Kim, Sammy E. Elsamra, Eric A. Singer, Thomas L. Jang, New Brunswick, NJ

Written by:  Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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