Introduction:

Following orchiectomy, men with non-seminomatous germ cell tumors of the testis must choose their next course of treatment from among active surveillance, platinum-based chemotherapy, and primary retroperitoneal lymph node dissection (RPLND). With the intention of reducing the morbidities of therapy, several surgeons have given new attention to robotic RPLND (R-RPLND).  It is the intent of R-RPLND to replicate the open technique and its outcomes although limited data exist regarding long-term or comparative efficacy.  Therefore, a more thorough analysis of a single surgeon’s experience over an extended period of time is warranted to assess the safety and feasibility of R-RPLND in the pre-chemotherapy setting.

Methods:

A retrospective analysis was performed of all primary R-RPLND cases performed by a single surgeon, who performs both open and R-RPLND at high volume at an academic institution, between August 2013 and August 2019. Data on patient demographics, operative techniques, perioperative outcomes, and tumor characteristics were obtained.

Results:

Twenty-eight men were identified who underwent primary R-RPLND. The baseline characteristics and subsequent outcomes of these primary R-RPLND patients are reported in Table 1. The median age at RPLND was 30 years (interquartile range (IQR): 26-37 years), and the majority of patients (N=21, 75%) had clinical stage I disease. Most patients (N=13, 46%) underwent a bilateral template surgery. Of note, two cases involving clinical stage II disease were converted electively from robotic to open procedures at the discretion of the surgeon—one for body habitus, the second for more advanced disease than predicted by preoperative imaging. R-RPLND patients experienced no intraoperative complications and required no red blood cell transfusions. The median follow-up time after R-RPLND was 8 months (IQR: 4-29 months). Median node count was 31 (IQR: 19-43). 16 (57%) patients had node-positive disease; among these, pN1=6 (38%), pN2=8 (50%), and pN3=2 (12%). Embryonal carcinoma was the most common pathology. Of the 28 primary R-RPLND patients, 4 (14%) received adjuvant chemotherapy following surgery (pN1= 1; pN2= 2; pN3 = 1), 1 (4%) developed disease recurrence at 10 months after RPLND, and none required additional oncologic surgery. Postoperative complications included chylous ascites in 3 (11%) patients, nausea and abdominal pain in 2 (7%) patients, and retroperitoneal hematoma in 1 (4%) patient. Length of stay following R-RPLND was 2 days (IQR: 2-2.5 days). Ejaculatory function was retained in 12 (67%) of 18 patients who provided feedback on their ejaculation status.

Conclusion:

With relatively short-term data, primary R-RPLND is safe and efficacious procedure for carefully selected men with stage I and II non-seminomatous germ cell tumors of the testis.  Long-term data is needed to evaluate comparative oncologic efficacy with open surgery and a notably high rate of chylous ascites.

Funding: N/A