BERKELEY, CA (UroToday.com) - We have recently published an article on our experience with robotic-assisted laparoscopic retroperitoneal lymph node dissection (RPLND) in adolescents with testicular cancer.1
This is timely issue given the increasing adoption of robotic-assistance in technically complex surgical cases. While laparoscopic RPLND has been previously described and studied in adults with testicular cancer, descriptions of robotic-assisted laparoscopic RPLND are rare. Additionally, there are no reports of its use in a pediatric or adolescent population. Thus, we used this opportunity to describe the manner in which we approach these cases. While the debate about the role of minimally-invasive RPLND will continue until a randomized trial is conducted, there are clearly benefits to its use that are driving its continued implementation. Much of the debate surrounding laparoscopic RPLND is its use in cases of testicular germ cell malignancy where the RPLND is done as a “staging” procedure and not with therapeutic intent as should be the goal in this setting.2, 3 However, most surgeons currently performing robotic-assisted or laparoscopic RPLND for testicular germ cell cancer are doing so with curative intent and are offering post-operative observation for those with N1 disease as would be offered for those treated with open primary RPLND. Therefore, we agree with critics who point out that minimally-invasive RPLND can never be truly compared to the experience of open RPLND until the standards are the same with the goal being surgical cure.
Aside from these oncologic issues, the potential benefits from minimally-invasive RPLND are well described: decreased complications, improved visualization, cosmesis, decreased hospital stay by approximately 7 days, and a reduced convalescence which translates to higher post-operative quality of life.4-6 We feel that these benefits are especially important in this younger pediatric and adolescent population. Additionally, we should mention that minimally-invasive RPLND should have an even more prominent role in adolescents since a large percentage of these cases are being done as true “staging” procedures in the setting of para-testicular rhabdomyosarcoma. All of these patients will receive post-RPLND chemotherapy as dictated by the relevant Children’s Oncology Group (COG) or Société Internationale d’Oncologie Pédiatrique / International Society of Paediatric Oncology (SIOP) study protocol.
Obviously, the controversy surrounding minimally-invasive RPLND for testicular germ cell cancer will continue to rage; however, given the growing experience demonstrating its efficacy we feel that it should be offered, along with full disclosure, as an option in appropriately selected patients. Also, we advocate minimally-invasive RPLND as the procedure of choice for adolescents with para-testicular rhabdomyosarcoma given its benefits and its role in the overall treatment of this disease. Regardless of the indication, we feel that robotic-assisted laparoscopic RPLND can be successfully employed to completely remove all of the necessary lymph node tissue described in even the most aggressive templates. We have described our technique, including our preferred port placements and instruments of choice in order to help with the increased utilization of this technology in appropriate instances. Our goal is to highlight the benefits of such an approach while describing the lessons learned from our experience.
- Cost, N. G., Dajusta, D. G., Granberg, C. F. et al.: Robot-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection in an Adolescent Population. J Endourol, 2012
- Kenney, P. A., Karam, J. A.: Editorial comment. J Urol , 187: 492, 2012
- Hyams, E. S., Pierorazio, P., Proteek, O. et al.: Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumor: a large single institution experience. J Urol , 187: 487, 2012
- Abdel-Aziz, K. F., Anderson, J. K., Svatek, R. et al.: Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors. J Endourol, 20: 627, 2006
- Tomaszewski, J. J., Sweeney, D. D., Kavoussi, L. R. et al.: Laparoscopic retroperitoneal lymph node dissection for high-risk pediatric patients with paratesticular rhabdomyosarcoma. J Endourol , 24: 31
- Albqami, N., Janetschek, G.: Laparoscopic retroperitoneal lymph-node dissection in the management of clinical stage I and II testicular cancer. J Endourol , 19: 683, 2005
Nicholas G. Cost,* Daniel G. DaJusta, Candace F. Granberg, Raven M. Cooksey, Carrie E. Laborde, Jonathan E. Wickiser, and Patricio C. Gargollo as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Nicholas G. Cost, MD
Cincinnati Children’s Hospital Medical Center
Division of Pediatric Urology
3333 Burnet Avenue, MLC 5037
Cincinnati, OH 45229
Office: (513) 803-0773, Fax: (513) 636-6753