After a little friendly ad hominem banter, Dr. Eggener established his position in a historical context, showing programs from Society of Urologic Oncology (SUO) meetings past where minimally invasive surgery (MIS) nephrectomy, prostatectomy, and cystectomy were debated, even showing a scheduled debate about laparoscopic RPLND from 2002. Clearly minimally invasive surgery for prostatectomy and nephrectomy have gained wide acceptance, and MIS cystectomy has now been shown to be oncologically equivalent to open cystectomy in at least two large-scale clinical trials. Even RPLND already has an official place in the guidelines as being an option in expert hands.
These all faced similar concerns about unusual metastatic patterns perhaps suggesting oncologic inferiority at various times. In response to these case reports, pointed out a large series of re-operative RPLNDs reported at high-volume centers, demonstrating that recurrence after RPLND is not a problem unique to the robotic technique.
He then highlighted five separate series including over 250 patients total showing low rates of recurrence, with in-field recurrences being even rarer.1-5 For example, one such series from MD Anderson of 30 post-chemotherapy robotic RPLNDs, including 4 patients with >5cm masses, noted only 3 recurrences with no recurrences being either in-field or unusual for germ cell tumor.
Dr. Eggener further noted that, given the overall excellent outcomes in patients with testicular cancer, there is a growing emphasis on survivorship in this population. So, while cosmesis and postoperative recovery clearly rank far below oncologic efficacy in terms of medical priorities, it is not unreasonable that these be used as deciding factors in choosing MIS over open surgery given the lack of evidence of oncologic difference seen in other series. Certainly, the 10- 20% of all RPLNDs done that he has anecdotally had reported by his colleagues at high volume centers so far does not seem like overly-exuberant utilization.
Dr. Daneshmand then took the stage. He began by pointing out that the vast majority of urologists who perform RPLND will perform fewer than 3 in a year,6 and thus any standard of care that depends on true surgical expertise in those performing this procedure is doomed to fail.
He then highlighted the reality that, unlike in prostatectomy, nephrectomy, and cystectomy, robotic RPLND has not gained wide acceptance in the ~20 years that it has been available. This fact alone suggests that there is something about RPLND that have made urologists shy away from attempting it robotically while they enthusiastically adopted the platform for other procedures.
Dr. Daneshmand pointed out that a large number of patients with negative markers and no suspicion for metastatic disease were included in the series presented by Dr. Eggener and others. These patients are the easiest surgical cases, but surgery will never be necessary for the majority of them, and thus guidelines allow for upfront RPLND only for patients who decline surveillance or are at risk for non-compliance.
Finally, Dr. Daneshmand concluded by advocating for his own published extraperitoneal RPLND technique. With this technique, he claims he is able to achieve similar or even superior exposure to traditional open RPLND with a smaller incision and lower risk of perioperative ileus.7,8
With such limited data, it seems unlikely that this debate will be resolved any time soon. However, as happened with prostatectomy, it may be that the competition of robotics encourages innovations in open surgery, such as the one presented by Dr. Daneshmand, that further lower perioperative morbidity.
Presented By: Scott E. Eggener MD, Bruce and Beth White Family Professor of Surgery and Radiology & Vice Chair, Section of Urology, University of Chicago Medical Center
Siamak Daneshmand, MD, Director of Urologic Oncology, University of Southern California-Keck School of Medicine
Written by: Marshall Strother, MD, Society for Urologic Oncology Fellow, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia PA @mcstroth at the 2020 Society of Urologic Oncology Annual Meeting – December 2-5, 2020 – Washington, DC
References:
- Rocco NR, Stroup SP, Abdul-Muhsin HM, et al. Primary robotic RLPND for nonseminomatous germ cell testicular cancer: a two-center analysis of intermediate oncologic and safety outcomes. World J Urol. 2020;38(4):859-867.
- Hiester A, Nini A, Arsov C, Buddensieck C, Albers P. Robotic assisted retroperitoneal lymph node dissection for small volume metastatic testicular cancer. Journal of Urology. 2020;204(6):1242-1248.
- Taylor J, Becher E, Wysock JS, Lenis AT, Litwin MS, Jipp J, Langenstroer P, Johnson S, Bjurlin MA, Tan HJ, Lane BR, Huang WC. Primary Robot-assisted Retroperitoneal Lymph Node Dissection for Men with Nonseminomatous Germ Cell Tumor: Experience from a Multi-institutional Cohort. Eur Urol Focus. 2020 Jul 15:S2405-4569(20)30172-3. doi: 10.1016/j.euf.2020.06.014. Epub ahead of print. PMID: 32682794.
- Li R, Duplisea JJ, Petros FG, González GMN, Tu SM, Karam JA, Huynh TT, Ward JF. Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer. Eur Urol Oncol. 2019 Mar 29:S2588-9311(19)30015-X. doi: 10.1016/j.euo.2019.01.014. Epub ahead of print. PMID: 31412007.
- Steiner H, Leonhartsberger N, Stoehr B, Peschel R, Pichler R. Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients. Eur Urol. 2013 Jun;63(6):1013-7. doi: 10.1016/j.eururo.2012.09.036. Epub 2012 Sep 24. PMID: 23021090.
- Flum AS, Bachrach L, Jovanovic BD, Helenowski IB, Flury SC, Meeks JJ. Patterns of performance of retroperitoneal lymph node dissections by American urologists: most retroperitoneal lymph node dissections in the United States are performed by low-volume surgeons. Urology. 2014 Dec;84(6):1325-8. doi: 10.1016/j.urology.2014.07.054. Epub 2014 Oct 11. PMID: 25306483.
- Syan-Bhanvadia S, Bazargani ST, Clifford TG, Cai J, Miranda G, Daneshmand S. Midline Extraperitoneal Approach to Retroperitoneal Lymph Node Dissection in Testicular Cancer: Minimizing Surgical Morbidity. Eur Urol. 2017 Nov;72(5):814-820. doi: 10.1016/j.eururo.2017.02.024. Epub 2017 Mar 18. PMID: 28325537.
- Kim P, Syan-Bhanvadia S, Djaladat H, et al. Midline extraperitoneal approach for retroperitoneal lymph node dissection for testicular germ cell tumor. Urology. 2012;80(4):941-945.