Attention: Restrictions on use of AUA, AUAER, and UCF content in third party applications, including artificial intelligence technologies, such as large language models and generative AI.
You are prohibited from using or uploading content you accessed through this website into external applications, bots, software, or websites, including those using artificial intelligence technologies and infrastructure, including deep learning, machine learning and large language models and generative AI.
ROBOTICS Why Robotic Surgery Is Significant for Testicular Cancer
By: Rogerio Huang, MD, Swedish Medical Center, Seattle, Washington; James Porter, MD, Swedish Medical Center, Seattle, Washington | Posted on: 19 Apr 2024
Testicular cancer is the most common malignancy in young American men, with an estimated 9190 new cases and 470 deaths in 2023.1 Retroperitoneal lymph node dissection (RPLND) is a management option for early-stage nonseminomatous germ cell tumors and postchemotherapy residual masses.2 An open RPLND has historically been the standard approach. However, it is associated with significant pain and morbidity. For this reason, many patients opt for surveillance or chemotherapy. Surveillance is the preferred management strategy in stage IA nonseminomatous germ cell tumors, but its effectiveness can be reduced by noncompliance in this young and highly mobile population.3 Although chemotherapy is highly curative, it is accompanied by numerous long-term risks including cardiovascular disease, pulmonary complications, nephrotoxicity, infertility, and secondary malignancies.4 A high-quality RPLND can cure up to 80% of patients who harbor small volume pN1 disease, thereby avoiding the toxicity of chemotherapy.5,6
Laparoscopic RPLND brought about reduced morbidity, but the steep learning curve and technical complexity meant very few patients could reap the benefits.7 With the advent of robotics, minimally invasive surgery in urology became widely adopted due to breakthroughs in optics, dexterity, precision, and ergonomics. Application of the robotic platform to RPLND yielded major advantages including better control of lumbar vessels and safer dissection of lymph nodes posterior to the great vessels. Since the first robotic RPLND in 2006,8 innovations in technology and technique have made this surgery more pragmatic. The da Vinci Xi robot enabled both retroperitoneal and spermatic cord dissection to be performed without the need to redock. And the development of the supine approach with a linear port configuration (Figure) allowed a full template bilateral lymphadenectomy to be performed without the need to reposition the patient or place additional ports as is the case with flank positioning.9
Despite these advances, there remain concerns about the effectiveness and safety of the robotic approach. Outcomes data have largely been derived from single institution case series. A recent systematic review summarized the past 15 years of publications on robotic RPLND.10 When compared to open, robotic RPLND had similar operative times, lower blood loss, fewer transfusions, and half the overall complications. Ureteral, splenic, bowel, and pancreatic injuries were reported, though all were successfully managed robotically. The open conversion rate for a primary robotic RPLND was 2.2% and 9% in a postchemotherapy setting. The median hospital stay for a robotic RPLND was 2 days compared to 4 to 6 days for an open RPLND.11,12 Lymph node yields were no different between the 2 approaches.12-14 Oncologic outcomes rivaled open RPLND data with a disease recurrence rate of 6.7%.12-14 Thus, a growing body of literature suggests a robotic RPLND in experienced hands can replicate the oncologic outcomes of open surgery while mitigating morbidity and shortening convalescence. With continued refinement of the technique, patients will have more choice in the management of their testicular cancer.
- American Cancer Society. Cancer facts & figures 2023. 2022. Accessed January 18, 2024. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2023/2023-cancer-facts-and-figures.pdf
- Stephenson A, Bass EB, Bixler BR, et al. Diagnosis and treatment of early-stage testicular cancer: AUA guideline amendment 2023. J Urol. 2023;211(1):20-25.
- Ernst DS, Brasher P, Venner PM, et al. Compliance and outcome of patients with stage 1 non-seminomatous germ cell tumors (NSGCT) managed with surveillance programs in seven Canadian centres. Can J Urol. 2005;12(2):2575-2580.
- Fung C, Dinh P Jr, Ardeshir-Rouhani-Fard S, Schaffer K, Fossa SD, Travis LB. Toxicities associated with cisplatin-based chemotherapy and radiotherapy in long-term testicular cancer survivors. Adv Urol. 2018;2018:1-20.
- Rabbani F, Sheinfeld J, Farivar-Mohseni H, et al. Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse. J Clin Oncol. 2001;19(7):2020-2025.
- Richie JP, Kantoff PW. Is adjuvant chemotherapy necessary for patients with stage B1 testicular cancer?. J Clin Oncol. 1991;9(8):1393-1396.
- Steiner H, Peschel R, Janetschek G, et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Urology. 2004;63(3):550-555.
- Davol P, Sumfest J, Rukstalis D. Robotic-assisted laparoscopic retroperitoneal lymph node dissection. Urology. 2006;67(1):199.e7-199.e8.
- Stepanian S, Patel M, Porter J. Robot-assisted laparoscopic retroperitoneal lymph node dissection for testicular cancer: evolution of the technique. Eur Urol. 2016;70(4):661-667.
- Garg H, Mansour AM, Psutka SP, et al. Robot-assisted retroperitoneal lymph node dissection: a systematic review of perioperative outcomes. BJU Int. 2023;132(1):9-30.
- Bhanvadia R, Ashbrook C, Bagrodia A, Lotan Y, Margulis V, Woldu S. Population-based analysis of cost and peri-operative outcomes between open and robotic primary retroperitoneal lymph node dissection for germ cell tumors. World J Urol. 2021;39(6):1977-1984.
- Brown CT, Sebastião YV, Zann A, McLeod DJ, DaJusta D. Utilization of robotics for retroperitoneal lymph-node dissection in pediatric and non-pediatric hospitals. J Robotic Surg. 2020;14(6):865-870.
- Lloyd P, Hong A, Furrer MA, et al. A comparative study of peri-operative outcomes for 100 consecutive post-chemotherapy and primary robot-assisted and open retroperitoneal lymph node dissections. World J Urol. 2022;40(1):119-126.
- Grenabo Bergdahl A, Månsson M, Holmberg G, Fovaeus M. Robotic retroperitoneal lymph node dissection for testicular cancer at a national referral centre. BJUI Compass. 2022;3(5):363-370.
advertisement
advertisement