Primary Robot-Assisted Retroperitoneal Lymph Node Dissection for Men with Nonseminomatous Germ Cell Tumor: Experience from a Multi-Institutional Cohort - Beyond the Abstract

Retroperitoneal lymph node dissection (RPLND) is an important primary treatment option for men with high-risk clinical stage I and select clinical stage II non-seminomatous germ cell tumor (NSGCT) following radical orchiectomy. Over the past few decades, rates of RPLND have declined as surveillance and single-cycle chemotherapy have gained strong support as safe and effective options. Recently, robot-assisted RPLND has emerged as a promising alternative to the open approach, in a few early studies.

In this study, we present complication rates and interim oncologic outcomes from a multi-institutional cohort of patients undergoing robot-assisted RPLND for clinical stage I and select clinical stage II NSGCT. Our hypothesis was that primary robot-assisted RPLND is technically feasible and yields perioperative and short-term oncologic outcomes similar to historical open RPLND controls. Additionally, we explore the potential reduction in overall chemotherapy with upfront RPLND in patients with low-stage disease.

Our cohort included 47 patients with clinical stage I-IIB NSGCT for whom primary robotic RPLND was performed at five institutions experienced in robotic RPLND. Operative characteristics, complication rates, and oncologic outcomes were collected retrospectively.

Eight (16.4%) patients were clinical stage II. Median operative time was 288 minutes with 100 mL estimated blood loss. Median lymph node yield was 32. Median length of stay was one day. There was one (2%) intraoperative complication, and nine (18.4%) postoperative complications, the majority of which were Clavien grade 1 or 2.

Viable germ cell tumor was found in 32.6% of patients and teratoma alone in 10.2% of patients. Adjuvant chemotherapy was administered to nine patients (18.4%) - seven clinical stage I and two clinical stage II patients. At a median follow-up of 15 months, there was one retroperitoneal recurrence, and three extra-retroperitoneal or “out of field” recurrences. The retroperitoneal recurrence was in a para-aortic lymph node following a modified template right-sided RPLND. The three “out-of-field” recurrences occurred in the following patients:

  1. A patient with clinical stage IB who developed pulmonary recurrence three months following robot-assisted RPLND for teratoma
  2. A patient with clinical stage IB who developed enlarging mesenteric lymph nodes following RPLND for pathologic stage IIA NSGCT, and
  3. A clinical stage IIB patient who developed a rib recurrence seven months after a bilateral template RPLND for pathologic stage IIB NSGCT
In an exploratory analysis, we estimated the possible decreased chemotherapy burden assuming 30% of patients on surveillance would have recurred and stage II patients would have likely received four cycles of upfront chemotherapy. This theoretical analysis found chemotherapy would have been reduced by 72% and 87.5% for stage I and stage II patients, respectively. Furthermore, four patients with clinical stage II had pure teratoma in the RPLND pathology and were spared upfront chemotherapy through surgical staging, providing further evidence that RPLND is both diagnostic and therapeutic.

Our study is currently one of the largest series in the literature on primary robot-assisted RPLND demonstrating that in experienced centers robot-assisted RPLND can be performed safely with comparable oncologic results to the open approach. This minimally-invasive approach is particularly attractive for men who may not be candidates for surveillance. In addition, overall chemotherapy rates may be reduced with the increased use of RPLND which has been declining over recent years. Robot-assisted RPLND allows for increased utilization of RPLND which remains an important diagnostic and therapeutic option for patients with NSGCT. Surgical staging with robot-assisted RPLND has the potential to continue to improve overall outcomes for the treatment of NSGCT.

Written by: Jacob Taylor, MD, MPH, Resident Urologist, Dora Jerucevic, MD, Resident Urologist, and William Huang, MD, Co-Director NYU Langone Health Robotics Program, NYU Langone Health, New York, New York

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