Robotic RPLND is as good as open RPLND
Alejandro R Rodríguez, M.D. Chief of Urology and Urology Oncology
Director of Robotic and Minimally Invasive Surgery
Samaritan Medical Center
Watertown, New York
Financial and Other Disclosures
No Financial relationship
Disclosure code : N
Introduction Testicular Cancer
In USA for 2018: 9,310 new cases 400 deaths
NIH-NCI –Seer.cancer.gov.2018
RPLND for Clinical Stage I NSGCTs
In the USA, it is the most commonly used option for stage I patients who elect adjuvant therapy.
In Europe, a risk-adapted approach has been proposed by the EAU guidelines:
Low risk = Surveillance
High risk (LVI present) = 2 cycles of BEP
RPLND for Clinical Stage I NSGCTs
For men with high-risk pathologic features
For those who are unable to comply with a surveillance schedule
RPLND for Clinical Stage I NSGCTs
Advantages over surveillance or adjuvant chemotherapy:
Accurate pathologic staging
Low short and long-term morbidity
Minimizes de risk of relapse due to Chemo-resistant GCT and Teratoma
Simplified FU regimen, limited to tumor markers and chest imaging.
RPLND for NSGCTs
RPLND is the standard approach to the surgical management of NSGCTs in both the primary and post-chemotherapy setting
A template dissection or a nerve-sparing approach to minimize the risk of ejaculatory disorders should be considered in patients undergoing primary RPLND for stage I non seminoma.
Post Chemotherapy Setting:
A full bilateral template RPLND should be performed in all patients undergoing RPLND with boundaries being:
Superiorly: Renal hilar vessels
Laterally: Ureters
Inferiorly: Common iliac arteries
Robotic Bilateral RPLND Supine Position
Following Surgical Principles of Open RPLND
Beveridge TS, et al J Urol 2016
Following Surgical Principles of Open RPLND
Beveridge TS, et al J Urol 2016
Is Robotic RPLND as good as Open RPLND?
Robotic RPLND Prevents
Large Incision:
Pain Ileus Poor Cosmesis
Increased: EBL Transfusion Rate Hospitalization
Subramanian VS et al. Urol Oncol 2010
Type of Complication P-RPLND PC-RPLND P value Intraoperative: 5% 12% NS Postoperative: 24% 32% NS Late: 7 % 7% NS Grade III-V 3% 8% NS Ileus 63% 45% NS
1982-2007: 204 patients and 208 RPLND
Subramanian VS et al. Urol Oncol 2010
Type of Complications P-RPLND PC-RPLND P value Blood loss 450 cc 1000cc <0.001 Transfusion rate 6% 42% <0.001 Incisional Hernia: 4 patients in each cohort (Total of 8 patients) Hospitalization: Median of 6 days in both cohorts.
1982-2007: 204 patients and 208 RPLND
Williams SB et al. BJU Int. 2009;105: 918
2001-2008: 190 patients P- RPLND: 7% complications
Ileus: 3 Chylous Ascitis: 2
PC- RPLND: 11 % complications Ileus: 2 Chylous Ascitis: 2 Aortic Lesion (10 units of blood): 1
Williams SB et al. BJU Int. 2009;105: 918
Robotic RPLND
1st reported in 2006.1
Has the advantages of the laparoscopic approach in addition to: 3-D imaging Articulating instruments
Several small single-institutional case series have been reported. 2,3
1. Davol P, et al. Urology 2006; 67: 199. 2. Williams SB et al. Eur Urol 2011; 60: 1299-302. 3. Cheney SM et al. BJU Int 2015; 115: 114-20
Robotic RPLND
Abdul-Muhsin HM, et al. J Surg Onc 2015;112: 736-740
2011 – 2015 : 47 Robotic P-RPLND Clinical stage I-IIA NSGCT
42 (89%) CS I 5 (11%) CS IIA
Operative time: 235 min EBL: 50 cc (50-100 cc) Length of stay: 1 day
Complications:
Intraoperative : 2 (4%) Early post operative: 4 (9%) Antegrade ejaculation: 100%
Pearce SM et al Eur Urol 2017; 71: 476-482
Node count : 26 (18-32) 8 (17%) positive nodes
pN1 = 7 pN2 = 1
5 (62%) received adjuvant chemotherapy One recurrence was out of the template in the pelvis after
adjuvant chemo (resected teratoma)
Median FU: 16 months 2 year recurrrence free survival was 97%
Pearce SM et al Eur Urol 2017; 71: 476-482
2011-2015: 12 PC- Robotic RPLND 9 (75%) NSGCT 3 (25%) seminoma tumors
Clinical Stage was: CS II A in 1 (8.03%) CS II B in 2 (16.7%) CS II C in 3 (25%) CS III in 6 (50%)
Mean Operative Time: 312 min Mean EBL: 475 cc Mean Hospital Stay: 3.2 days
Kamel MH et al J Endourol 2016;30 (5): 510-519
Mean LN count: 12 Teratoma in 5 (45.5%) Benign/necrosis in 5 (45.5%) Viable Germ cells in 1 (9%)
Median FU - 31 months: no recurrences
Kamel MH et al J Endourol 2016;30 (5): 510-519
Conclusions
With strict adherence to open oncology principles, Robotic RPLND can be performed
safely with the same oncologic control as open RPLND and a marked reduction in
patient morbidity.