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Robotic Retroperitoneal Lymph-Node Dissection for Testicular Cancer: Initial Experience - Beyond the Abstract

Retroperitoneal Lymph-Node Dissection (RPLND) is an important part of the workup and management of testicular cancer. In the United Kingdom, RPLND is usually offered to patients who have failed chemotherapy or who have teratoma identified from their orchidectomy.1 Traditionally, RPLND has been performed using open surgery (O-RPLND). This is a major operation with significant associated morbidity.2 In recent years, across the world of surgery, robotic surgery has become increasingly popular due to benefits such as lower blood loss and shorter recovery times whilst upholding equivalent oncological outcomes to open surgery and being ergonomically more favourable for the surgeon.3 The first Robotic RPLND (RA-RPLND) was described by Davol in 2006.4 RA-RPLND can be much more challenging, depending on whether it is used as the primary management of retroperitoneal lymph nodes or if it has been performed post-chemotherapy (PC RA-RPLND). In the United States, primary RPLND is performed much more frequently than in the UK and Europe, as recommended in the AUA guidelines.5 Whilst some case series report favourable data from primary RPLNDs,4,6 there are limited data reported from post-chemotherapy patients.7 This is likely due to the lower number of PC RA-RPLNDs performed worldwide, and the increased complexity it poses secondary to post-chemotherapy desmoplastic reaction in the retroperitoneum and compromise to the patient's renal, pulmonary, and haematologic status.

We retrospectively reviewed our electronic theatre records to identify all patients undergoing Robotic Retroperitoneal Lymph-Node Dissection from April 2021 to July 2024. All surgeries were performed by one robotic surgeon with vast experience in robotic prostatectomy, robotic cystectomy, and open RPLND.

A total of 24 patients underwent an RA-RPLND in our Trust. The mean age was 36 (range 18–68). Most patients 92% (n = 22), underwent their operation post-chemotherapy. The indication for RA-RPLND surgery was residual post-chemotherapy mass in 79% (n = 19), late relapse in 13% (n = 3), and primary RPLND in 8% (n = 2). The mean pre-chemotherapy lymph-node (LN) size was 29mm (5-86mm). On CT imaging prior to RA-RPLND, 50% (n = 12) had a mass < 2cm, 46% (n = 11) had a mass 2- < 5cm, and one patient had a mass 5-10cm in size. The mean pre- RA-RPLND CT LN size was 26mm (12-96mm). An average LN yield of 10 was achieved (range 1–35), and the average size of the LN packet was 72mm (range 35–120mm). Five patients with a mass > 10cm were completed robotically. In the post-chemotherapy category, 68% (n = 13) of this cohort had a specimen containing teratoma, the remaining 32% (n = 6) had no evidence of tumour in the specimen.
The mean console time was 170min (range 60–320). The mean blood loss was 195ml (range 30–2500). One patient required conversion to open secondary to bleeding from the left renal artery and had a blood transfusion. One patient was re-admitted within 90days of surgery with a chyle leak, which was managed conservatively. There were no peri-operative deaths. The average length of stay is 1.5days (range 1–6). There has been a total of 406 months of follow-up, with a mean of 17.66 months (range 1–38 months).

Traditionally in open surgery, it is well known that post-chemotherapy RPLND is more challenging and has more complications than primary RPNLD. In the post-chemotherapy setting, O-RPLND has shown operating times ranging (180–240min), blood loss (300–500ml), transfusion (3–26%), CD > 3a complications (9–12%), as well as adjuvant nephrectomy (5–22%).8-12 Primary O-RPLND has been shown to have fewer intraoperative and post-operative complications, with shorter operating times, less blood loss, and less blood transfusion requirements.13 Both primary and PC RA-RPLND have shown benefits for patients such as quicker recovery and less blood loss when compared to open surgery. RA-RPLND also provides superior vision, dexterity, and access to nodes posterior to the major vessels for the surgeon.14 Primary RA-RPLND has been shown to have less complications compared to PC RA-RPLND with conversion to open (2.2% vs 9%), major complication (4.1% vs 8.5%), and length of stay (1.9 vs 3days).14 These outcomes are considerably better than those mentioned from open surgery and are comparable to our own data presented in this article, largely consisting of post chemotherapy patients (92%). Our conversion to open rate was 4%, with no major complications, and our mean length of stay was 1.5 days. Our mean RPLND LN size (26mm) and LN yield n=10) is similar to other primary papers by Bergdahl et al., Lloyd et al., a systematic review by Tselos et al., and meta-analysis by Ge et al.7,15-17

A number of papers have shown superior patient outcomes for PC R-RPLND compared to their PC O-RPLND cohorts.7,18 In the UK, most RPLNDs are performed in the post-chemotherapy setting in line with the EAU guidelines, and Open RPLND is performed much more commonly than RA-RPLND. To the best of our knowledge, we are one of only two centres routinely performing RA-RPLND.

Despite the additional operative challenges in post-chemotherapy patients, our study demonstrates that RA-RPLND is both feasible and safe, with outcomes comparable to those of international centres performing this procedure. We achieved favourable results, including low complication rates, minimal blood loss, and a reduced length of hospital stay. Whilst RA-RPLND is associated with longer operative times compared to O-RPLND, this minimally invasive technique offers significant advantages, such as reduced peri-operative morbidity and a quicker recovery. A robotic approach offers an enhanced view, and the superior surgical precision and dexterity allow access to lymph nodes in difficult anatomical locations whilst maintaining lymph-node yields comparable to O-RPLND.

To conclude, as one of the first UK institutions to report on RA-RPLND, we are optimistic about the potential for this approach to redefine the surgical management for these patients, particularly in centres equipped with robotic expertise. Although further research and long-term follow-up are required, our results support the wider adoption of RA-RPLND in specialised centres, especially in the UK, where this technique remains underutilised. Expanding the use of robotic technology for RPLND could significantly enhance patient outcomes and improve the standard of care for testicular cancer patients.

Written by: Daniel Peter McNicholas, F. Kattakayam, T. Thompson, J. Hemmant, R. Weston, V. Hanchanale

Royal Liverpool University Hospital, Prescot Street, Liverpool, Merseyside, England.

References:

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  2. Williams SB, McDermott DW, Winston D, Bahnson E, Berry AM, Steele GS, Richie JP (2010) Morbidity of open retroperitoneal lymph node dissection for testicular cancer: contemporary perioperative data. BJU Int 105(7):918–921. https:// doi. org/ 10. 1111/j. 1464- 410X. 2009. 08888.x. (Epub 2009 Aug 28 PMID: 19747353)
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