Robotic RPLND: The future?

Inset: intra-operative image of post-chemotherapy residual mass. A) mass being dissected off the great vessels. B) Completed dissection

Open retroperitoneal lymph node dissection (O-RPLND) has long been the standard surgical approach for retroperitoneal metastases in testicular cancer, particularly in patients with clinical stage I and II non-seminomatous germ cell tumors (NSGCT) and those with residual masses post-chemotherapy. While O-RPLND provides excellent oncologic control and enables meticulous lymph node dissection, it is associated with significant morbidity, including prolonged hospital stays, postoperative ileus, and substantial postoperative pain. To mitigate these complications, minimally invasive approaches such as laparoscopic RPLND (L-RPLND) and robotic-assisted RPLND (R-RPLND) have been developed, aiming to achieve comparable oncologic outcomes with reduced perioperative morbidity.

L-RPLND, introduced in 1994, offers advantages such as reduced blood loss and shorter recovery times compared to open surgery. However, its adoption remains limited due to a steep learning curve, technical difficulties in dissecting lymph nodes near major vessels, and challenges in controlling vascular injuries. Moreover, standard laparoscopic instruments lack the dexterity and articulation of robotic systems, making complex dissections challenging.

Robotic-assisted RPLND, first reported in 2006, represents a significant advancement in minimally invasive surgery. The robotic platform enhances dexterity, provides three-dimensional visualization, and improves ergonomics, effectively addressing the limitations of conventional laparoscopy. These advantages have positioned R-RPLND as a promising alternative for managing clinical stage I and II NSGCT and post-chemotherapy residual masses. A recent systematic review and meta-analysis of 42 studies involving 4,224 patients demonstrated that R-RPLND is associated with a significantly lower transfusion rate (0.9% vs. 14.5%, p=0.0001) and fewer complication rate (7.8% vs. 18.5%, p=0.002) compared to O-RPLND. However, conversion rates to open surgery were 2.2% for primary R-RPLND and 8.9% for post-chemotherapy R-RPLND, highlighting the need for careful patient selection.

The bedside assistant's role is crucial to successful R-RPLND. They facilitate instrument exchanges, provide suction, retract tissues, and manage immediate intraoperative complications such as bleeding. Their expertise is essential for the smooth execution of the procedure and ensuring patient safety.

R-RPLND has emerged as a feasible and effective minimally invasive alternative to open surgery for selected patients with testicular cancer. It offers advantages such as reduced blood loss, shorter hospital stays, and lower complication rates. Comparative studies suggest that, when performed by experienced surgeons, R-RPLND can achieve oncologic outcomes similar to O-RPLND with decreased morbidity. However, successful outcomes require a skilled surgical team, including a proficient bedside assistant, to manage intraoperative challenges. Further prospective studies with long-term follow-up are needed to establish oncologic efficacy and refine patient selection criteria for R-RPLND.

Dr Sridhar P

AIIMS, New Delhi