Robot-assisted retroperitoneal lymphadenectomy: The state of art

Abstract

Objective: To perform a narrative review about the role of robot-assisted retroperitoneal lymphadenectomy (R-RPLND) in the management of testicular cancer.

Methods: A PubMed search for all relevant publications regarding the R-RPLND series up until August 2019 was performed. The largest series were identified, and weighted means calculated for outcomes using the number of patients included in each study as the weighting factor.

Results: Fifty-six articles of R-RPLND were identified and eight series with more than 10 patients in each were included. The weighted mean age was 31.12 years; primary and post chemotherapy R-RPLND were performed in 50.59% and 49.41% of patients. The clinical stage was I, II and III in 47.20%, 39.57% and 13.23% of patients. A modified R-RPLND template was used in 78.02% of patients, while 21.98% underwent bilateral full template. The weighted mean node yield, operative time and estimated blood loss were, respectively, 22.15 nodes, 277.35 min and 131.94 mL. The weighted mean length of hospital stay was 2 days and antegrade ejaculation was preserved in 92.12% of patients. Major post-operative complications (Clavien III or IV) occurred in 5.34%. Positive pathological nodes were detected in 24.54%, while the recurrence free survival was 95.77% with a follow-up of 21.81 months.

Conclusion: R-RPLND has proven to be a reproducible and safe approach in experienced centers; short-term oncologic outcomes are similar to the open approach with less morbidity and shorter convalescence related to its minimal invasiveness. However, longer follow-up and new trials comparing head-to-head both techniques are expected.

Keywords: Lymphadenectomy; Robotic surgical procedures; Testicular neoplasms.

Figure 1

PRISMA 2009 Flow Diagram. R-RPLND, robot-assisted retroperitoneal lymphadenectomy; L-RPLND, laparoscopic retroperitoneal lymph node dissection; PRISMA, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. From: Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6 (7): e1000097. https://doi.org/10.1371/journal.pmed1000097. For more information, visit http://www.prisma-statement.org/.

Figure 2

Supine position and docking and flank position and docking. (A) Trocar placement; (B) Patient positioning; (C) Robot docking; (D) Supine; (E) Flank decubitus; (F) The doctors were performing R-RPLND. R-RPLND, robot-assisted retroperitoneal lymphadenectomy.

Figure 3

Trans-operative relevant moments of RPLND in supine position. (A) Peritoneum suspension in abdominal wall to begin dissection and access the retroperitoneum; (B) Beginning of paracaval template, above the ureter cross the right iliac artery; (C) Precaval, preaortic, interaortocaval and retrocaval template with identification and sparing of postganglionic sympathetic nerve fibers (crossing between the IVC and AO); (D) Interaortocaval and retrocaval dissection reaching the right superior boundaries of the template (right renal hilum); (E) Preaortic and paraortic superior boundaries reaching the left renal hilum; (F) Final template showing the retroperitoneum vessels. AO, aorta; IVC, inferior vena cava; RPLND, retroperitoneal lymph node dissection.

Figure 4

Schematic templates and boundaries for retroperitoneal lymphadenectomy. 1. Boundaries of paracaval template (superior: Right renal hilum including dissection of renal arteries; lateral: Right ureter; medial: Interaortocaval template; inferior: Right ureter crossing the right iliac vessels. 2. Boundaries of interaortocaval, precaval, retrocaval, preaortic and retroaortic templates (superior: Renal vessels; lateral: Paracaval and paraortic templates; inferior: Aorta bifurcation. 3. Boundaries of paraaortic template (superior: Left renal hilum including dissection of renal arteries; lateral: Left ureter; inferior: Left ureter crossing the left iliac vessels [laterally]).