Introduction
Retroperitoneal lymph lode dissection (RPLND) forms an integral part of the multidisciplinary management of testicular cancer. , Cisplatin-based chemotherapy regimens have revolutionized the treatment of testicular cancer, and consequently the role of surgery has changed. However, their combined role has resulted in overall survival rates over 90%.
Robot-assisted RPLND is increasingly being used in selective cases for stage 2 disease in both the primary and the postchemotherapy setting and has been described previously. ,
Unilateral/bilateral template
- 1.
Dissection, clipping and dividing of lumbar veins to maximize mobilization of the inferior vena cava
- 2.
Careful dissection along the major vessels to maintain anatomical overview
Unilateral template
- 1.
Adequate mobilization of colon and duodenum to ensure optimal exposure
- 2.
Minimal or no diathermy when performing Kocher’s maneuver to prevent duodenal injury
- 3.
Early identification and retraction of the ureter to prevent ureteric injury
Bilateral template
- 1.
Pushing the small bowel as much as possible into the left and right upper quadrants to identify ureter and common iliac artery
- 2.
Usage of retraction (“hammock”) sutures to maximize exposure to the inferior vena cava and aorta to the level of the left renal vein
Indications and contraindications for robot-assisted retroperitoneal lymph node dissection
There are some geographical variations in the indications for RPLND between North America and Europe, particularly for primary RPLND in nonseminomatous germ cell tumor. In North America, primary RPLND is offered in high-risk stage 1 nonseminomatous germ cell tumor and stage 2A and 2B nonseminomatous germ cell tumor. Primary RPLND is increasingly being recommended for stage 2A disease in Europe. Universally, RPLND is recommended for residual masses greater than 1 cm after chemotherapy where tumor markers have normalized or in the event of retroperitoneal relapse with normal markers. RPLND is also being utilized in the trial setting for stage 2 seminoma prior to any chemotherapy.
There are no absolute indications for a robot-assisted approach specifically. Table 29.1 lists factors that should be considered in determining whether robot-assisted RPLND may be feasible. As most robot-assisted approaches only allow dissection from a limited number of directions, the size of the mass should be small enough to enable adequate exposure of the mass. A threshold of 5 cm could be used as a guideline from this perspective. The relationship of the disease to the great vessels is perhaps the most important consideration with circumferential adherence/contact being a contra-indication. Predominance of disease that is posterior, especially retroaortic or retrocaval, will be more difficult to dissect, and any vascular injury will be more difficult to repair. Masses that have shrunk significantly after chemotherapy tend to be more fibrotic and hence can be more challenging to dissect than larger cystic masses with a well-defined border. Dissection is also more difficult in patients who have had multiple lines of chemotherapy. ,
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Table 29.2 lists relative and absolute contraindications to robot-assisted RPLND. For robot-assisted RPLND, there must be surgical expertise available to perform an open RPLND in the event of conversion and also vascular surgical expertise for vascular control and repair. Table 29.3 lists advantages and disadvantages of the robot-assisted approach as compared to the open approach.
| Relative Contraindication | Absolute Contraindication |
|---|---|
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| Advantages | Disadvantages |
|---|---|
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Preoperative assessment
All cases considered for RPLND should be discussed in a multidisciplinary setting. If surgery is recommended, surgical planning should begin with extensive review of the patient’s most recent cross-sectional imaging and any previous imaging, particularly prechemotherapy imaging. A decision regarding unilateral or bilateral template dissection should be made based on institutional policy as there remains significant conjecture regarding suitability of unilateral templates, particularly in the postchemotherapy setting.
The relationship of the disease to the renal vessels and ureters should be assessed. Preoperative ureteric stenting may be helpful if the ureters appear densely adherent to the retroperitoneal disease. Assessment of the proximity of retroperitoneal disease to the duodenum and great vessels should be made to determine if specialty assistance from a vascular surgeon or general surgeon may be required.
Routine blood tests should be performed preoperatively to assess the patient’s baseline renal function and also to assess whether hematological parameters have returned to the normal range after previous chemotherapy. If bleomycin was given as part of the chemotherapy regimen, respiratory assessment should be made to determine if additional measures are required peri-operatively such as preoperative steroids and anesthetic management of intraoperative ventilation. Blood grouping should be done to ensure there is adequate facility for urgent transfusion in the event of unexpected hemorrhage.
Theater and port setup
See Table 29.4 for special equipment required and for operating room setup, Fig. 29.1 for unilateral template, and Fig. 29.2 for bilateral template.
| Robotic Instruments | Sutures | Additional Equipment |
|---|---|---|
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For the borders of the templates, see Fig. 29.4 A (left unilateral template), Fig. 29.5 A (right unilateral template), and Fig. 29.6 A (bilateral template).
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