Robotics and Laparoscopy
A comparative analysis of robotic vs laparoscopic retroperitoneal lymph node dissection for testicular cancer Kelly T. Harris, Michael A. Gorin, Mark W. Ball, Phillip M. Pierorazio and Mohamad E. Allaf The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Objective To compare the safety and perioperative outcomes of robotic retroperitoneal lymph node dissection (R-RPLND) vs laparoscopic RPLND (L-RPLND).
and perioperative outcomes including operative time, estimated blood loss, lymph node yield, complicate rate, and ejaculatory status were similar between groups (all P > 0.1).
Patients and Methods
Conclusions
Our Institutional Review Board-approved retrospective testicular cancer registry was queried for patients who underwent a primary unilateral R-RPLND or L-RPLND by a single surgeon for a stage I testicular non-seminomatous germ cell tumour. Groups were compared for differences in baseline and outcome variables.
Results
As an early checkpoint, R-RPLND appears comparable to LRPLND in terms of safety and perioperative outcomes. It remains unclear if R-RPLND offers any tangible benefits over standard laparoscopy.
Keywords robotic surgery, testicular cancer, retroperitoneal lymph node dissection, RPLND
Between July 2006 and July 2014, 16 R-RPLND and 21 L-RPLND cases were performed by a single surgeon. Intra-
Introduction According to current guidelines, primary retroperitoneal lymph node dissection (RPLND) remains a recommended treatment option for select men with stage I or II non-seminomatous germ cell tumours (NSGCT) [1]. Given that most men diagnosed with testicular cancer are young and otherwise healthy, RPLND is an ideal option for patients who wish to avoid long-term surveillance or chemotherapy. Traditionally performed via an open approach, the first primary laparoscopic RPLND (L-RPLND) was described by Rukstalis et al. [2] in 1992. The laparoscopic technique has since been shown to yield faster recovery times, less blood loss, and reduced complication rates [3,4]. Furthermore, L-RPLND was found to have comparable oncological outcomes and improved morbidity when compared with open RPLND [5]. In recent years, robotic surgery has largely replaced standard laparoscopy for many urological procedures, including radical prostatectomy and partial nephrectomy. Proponents of robotic surgery cite that this technology helps bridge the
BJU Int 2015; 116: 920–923 wileyonlinelibrary.com
three-dimensional benefits of open surgery with the minimally invasive benefits of laparoscopy. In addition, robotics offers superior freedom of movement compared with laparoscopic surgery [6]. However, the cost of the robotic system is one of the main drawbacks to its use. The first use of the robot during RPLND (R-RPLND) was described in 2006 by Davol et al. [7]. Since the time of this original report, promising results in the primary setting for stage I disease as well as in the post-chemotherapy setting for stage II disease have been reported [8–10]. To date, there has been no comparative analysis of R-RPLND and L-RPLND to ascertain if the robotic approach offers any advantages to laparoscopy. The aim of the present study was to compare the safety and perioperative outcomes of R-RPLND vs L-RPLND.
Patients and Methods Our Institutional Review Board-approved retrospective testicular cancer registry was queried for patients who underwent a primary unilateral R-RPLND or L-RPLND by a
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13121 Published by John Wiley & Sons Ltd. www.bjui.org
R-RPLND vs L-RPLND for testicular cancer
single surgeon (M.A.E.) for a stage I NSGCT between July 2006 and July 2014. Of note, patients presenting during the study period with a stage I NSGCT were offered the choice of management with active surveillance, chemotherapy or minimally invasive RPLND. The study cohort includes only those patients who elected for RPLND. Before 2011, all minimally invasive RPLNDs were performed laparoscopically. After this year, robotic technology became readily available at our institution and cases were preferentially performed with this approach. Surgical Technique Our laparoscopic technique for RPLND has previously been reported [11]. For robotic cases, the patient is placed in the modified flank position. After insufflation, a four-port configuration is used with two assistant ports. The ipsilateral colon is reflected, the gonadal vein identified, ligated proximally and dissected to the inguinal ring. A modified template dissection is used, bounded by the renal vessels cranially, the ureter laterally, and the iliac bifurcation caudally. For right-sided procedures, the paracaval, interaortocaval and pre-aortic lymph nodes (LNs) superior to the inferior mesenteric artery are sequentially dissected. For left-sided procedures, the para-aortic, pre-aortic cranial to the inferior mesenteric artery, interaortocaval and pre-caval lymph LNs are dissected. Lymphatics are meticulously dissected and clips are used liberally to prevent postoperative lymphatic leak. Postoperative Surveillance Postoperative surveillance was conducted according to the National Comprehensive Cancer Network (NCCN) guidelines based on the clinical stage and postoperative pathological staging [1].
vs 28.9 (26.1–32.8) kg/m2 (P = 0.10). In the L-RPLND group, there was a significantly more pT2 cases (52.4% vs 12.5%; P = 0.02). As detailed in Table 2, RPLND operative times, estimated blood loss, intraoperative complications, LN yield, and frequency of LN positivity were similar between groups. RPLND specimens included only embryonal and teratomatous features, with no differences in pathological subtypes between groups. Additionally, the follow-up duration was comparable, at a median (IQR) of 2.8 (0.2–31.0) vs 13.5 (5.8–20.1) months (P = 0.18). There was also similar rates of postoperative complications and ejaculatory status outcomes.
Discussion For patients with stage I or II NSGCTs, long-term survival with initial observation, RPLND or chemotherapy approaches 100% [12]. Therefore, the decision about the initial mode of treatment for stage I disease is largely based on patient preference. For many, the choice to pursue treatment with RPLND is premised on the desire to avoid chemotherapy, as well as the extensive follow-up of surveillance. When L-RPLND was first introduced in 1992 [2], the main criticism was concern for lower overall LN yield and its impact on oncological outcomes. However, over time the technique has improved, so that retro-aortic and retro-caval LNs are now routinely removed laparoscopically. Recent studies have shown L-RPLND to have comparable oncological outcomes with superior morbidity when compared with the open approach [5]. In the last decade, robot-assisted technology has emerged in the field of urology as an alternative to traditional Table 1 Characteristics of the study cohort.
Statistical Analysis Variable
Demographic, pathological, intraoperative and perioperative data were compared between the R-RPLND and L-RPLND groups. Continuous variables were compared with the Mann– Whitney U-test and categorical variables with Fisher’s exact test. Statistical analysis was performing using Stata Version 13 (College Station, TX, USA). A two-sided P < 0.05 was considered to indicate statistical significance.
Results During the study period, 16 R-RPLND and 21 L-RPLND cases were performed by a single surgeon (M.E.A.) at our institution for stage I NSCGT. The preoperative characteristics of the groups are shown in Table 1. The median age was similar between groups. There was a trend towards higher body mass index in the R-RPLND cohort, with a median (interquartile range, IQR) of 25.7 (22.5–31.5)
Number of cases Median (IQR) Age, years BMI, kg/m2 N (%) Race White Other Primary laterality Left Right pT Stage pT1 pT2 Orchidectomy pathology Choriocarcinoma Embryonal Seminoma Teratoma Yolk sac
L-RPLND
R-RPLND
21
16
28.8 (23.4–32.9) 25.7 (22.5–31.5)
29.8 (24.7–37.6) 28.9 (26.1–32.8)
P
0.61 0.10
20 (95.2) 1 (4.8)
15 (93.7) 1 (6.3)
0.69
8 (38.1) 13 (61.9)
8 (50.0) 8 (50.0)
0.52
10 (47.6) 11 (52.4)
14 (87.5) 2 (12.5)
0.02
2 13 4 12 10
0.18 0.63 1.00 1.00 0.33
19 6 15 9
0 (90.5) (28.6) (71.4) (42.9)
(12.5) (81.3) (25.0) (75.0) (62.5)
© 2015 The Authors BJU International © 2015 BJU International
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Harris et al.
Table 2 Comparison of intraoperative, pathological and perioperative outcomes of R-RPLND vs L-RPLND. Variable RPLND template, n (%) Left Right Median (IQR) operative time, min Median (IQR) estimated blood loss, mL Intraoperative complication, n (%) Conversion, n (%) Median (IQR) LN yield pN Stage, n (%) pN0 pN1 pN2 RPLND pathology, n (%) Choriocarcinoma Embryonal Seminoma Teratoma Yolk sac Postoperative complication, n (%) Clavien Grade, n (%) I–II III–IV Antegrade ejaculation, n (%) Yes No Unknown Median (IQR) follow-up, months
L-RPLND (N = 21)
R-RPLND (N = 16)
P
8 13 294 125 0 1 22
8 8 270.5 75 1 1 30
0.52
(38.1) (61.9) (259–370) (50–150) (4.8) (18–30)
17 (81.0) 3 (14.3) 1 (4.8)
14 (87.5) 2 (12.5) 0
0 3 (14.3) 0 1 (4.8) 0 2 (9.5)
0 1 (6.3) 0 1 (6.3) 0 1 (6.3)
1 (4.8) 1 (4.8)
0 1 (6.3)
16 2 3 2.8
(76.2) (9.5) (14.3) (0.2–31.0)
laparoscopic surgery. The robot provides greater degrees of freedom of movement and better three-dimensional visualisation, while maintaining the benefits of a minimally invasive approach. The major controversy over the use of robotics lies in the increased cost associated with this technology [13,14]. These costs include the purchase and maintenance of the robot itself, as well as the price of disposable limited-life instruments and robotic drape. Thus, unless there is a demonstrable advantage to using the robot, the cost-benefit ratio generally steers towards laparoscopy or an open approach. However, due to the relatively recent advent of robotic surgery there currently is no comparative data as to whether R-RPLND offers any advantages over laparoscopy. For both prostatectomy and nephrectomy, advocates of robotic technology refer not only to the superior perioperative outcomes, but also to the ease of intracorporeal suturing and improved control around vessels and nerve plexuses. These technical advantages of robotics are critical for RPLND, particularly with respect to the number of LNs resected, success of a nerve-sparing technique as evidenced by antegrade ejaculation, and protection of the great vessels. Not only may the robotic approach be more technically advantageous for RPLND, there is evidence in other urological procedures, specifically partial nephrectomy, that use of robotics leads to increased use of the procedure [15]. It is worth noting that while proponents of R-RPLND cite improved control around the great vessels as a potential
922
© 2015 The Authors BJU International © 2015 BJU International
(50.0) (50.0) (236–299) (50–100) (6.3) (6.3) (23–35.5)
16 (100) 0 0 13.5 (5.8–20.1)
0.13 0.16 0.43 1.00 0.13 1.00
0.62 1.00 1.00 1.00
0.16
0.18
advantage of the robotic approach, the fact that the console surgeon is a distance from the patient’s bedside creates a unique challenge in cases of vascular injury. If such an injury cannot be repaired robotically, then the unsterile surgeon must take precious time to return to the operating table, as well as to undock the robot. In our present series, the one reported intraoperative complication in the R-RPLND group was an aortic injury requiring open conversion. In this case, robotic repair was unsuccessful. However, the bleeding could be controlled with a laparoscopic Satinsky clamp allowing for safe open conversion and primary repair of the vascular injury. In a similar case, Lee et al. [16] reported the successful management of a renal artery injury during robotic partial nephrectomy. Both cases underscore the importance of having an experienced bedside assistant, as well as a team well versed in the undocking of the robotic system. To our knowledge, the present study is the first comparative analysis of R-RPLND vs L-RPLND. Our results show that R-RPLND is at best equivalent to the laparoscopic approach in terms of safety and perioperative outcomes. More specifically, estimated blood loss, operative times, rates of complications and conversions were similar between groups. Moreover, LN yield, frequency of LN positivity, and ejaculatory status were also similar between groups. Limitations to the present study include the small size, thus limiting the power to detect differences between groups. However, the present study was meant to serve as a preliminary investigation to ascertain if there was any trend
R-RPLND vs L-RPLND for testicular cancer
towards superiority or inferiority of R-RPLND. In addition, our study represents a single-institution, single-surgeon experience; therefore the results may not be generalizable. However, this experience is based on a surgeon who has extensive experience with both laparoscopy and the robotic technique, so our present comparison does not include any differences due to inexperience or a learning curve. In conclusion, as an early checkpoint, R-RPLND appears comparable to the laparoscopic approach in terms of safety and perioperative outcomes. It remains unclear if R-RPLND offers any tangible benefits over standard laparoscopy. However, larger studies are needed to more fully explore this question.
7 8
9
10
11
12
Conflicts of Interest None.
References 1
2
3
4 5
6
National Comprehensive Cancer Network. Testicular Cancer, Version 1.2014. Available at: http://www.nccn.org/professionals/physician_gls/ f_guidelines.asp. Accessed April 2015 Rukstalis DB, Chodak GW. Laparoscopic retroperitoneal lymph node dissection in a patient with stage 1 testicular carcinoma. J Urol 1992; 148: 1907–10 Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003; 62: 324–7 Gerber GS, Bissada NK, Hulbert JC et al. Laparoscopic retroperitoneal lymphadenectomy: multi-institutional analysis. J Urol 1994; 152: 1188–92 Steiner H, Peschel R, Janetschek G et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10year experience. Urology 2004; 63: 550–5 Ahlering TE, Skarecky D, Lee D, Clayman RV. Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003; 170: 1738–41
13
14
15
16
Davol P, Sumfest J, Rukstalis D. Robotic-assisted laparoscopic retroperitoneal lymph node dissection. Urology 2006; 67: 199 Cheney SM, Andrews PE, Leibovich BC, Castle EP. Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients. BJU Int 2015; 115: 114–20 Williams SB, Lau CS, Josephson DY. Initial series of robot-assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer. Eur Urol 2011; 60: 1299–302 Dudderidge T, Pandian S, Nott D. Technique and outcomes for robotic assisted post-chemotherapy retroperitoneal lymph node dissection (RPLND) in stage 2 non-seminomatous germ cell tumour (NSGCT). BJU Int 2012; 110: 97 Guzzo TJ, Gonzalgo ML, Allaf ME. Laparoscopic retroperitoneal lymph node dissection with therapeutic intent in men with clinical stage I nonseminomatous germ cell tumors. J Endourol 2010; 24: 1759–63 Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ cell cancer: a report of the second meeting of the European Germ Cell Cancer Consensus group (EGCCCG): part I. Eur Urol 2008; 53: 478–96 Hyams E, Pierorazio P, Mullins JK, Ward M, Allaf M. A comparative cost analysis of robot-assisted versus traditional laparoscopic partial nephrectomy. J Endourol 2012; 26: 843–7 Hyams ES, Mullins JK, Pierorazio PM, Partin AW, Allaf ME, Matlaga BR. Impact of robotic technique and surgical volume on the cost of radical prostatectomy. J Endourol 2013; 27: 298–303 Patel HD, Mullins JK, Pierorazio PM et al. Trends in renal surgery: robotic technology is associated with increased use of partial nephrectomy. J Urol 2013; 189: 1229–35 Lee JW, Yoon YE, Kim DK, Park SY, Moon HS, Lee TY. Renal artery injury during robot-assisted renal surgery. J Endourol 2010; 24: 1101–4
Correspondence: Mohamad E. Allaf, 600 North Wolfe Street, Park 223, Baltimore, MD 21287, USA. e-mail: [email protected] Abbreviations: IQR, interquartile range; LN, lymph node; NSGCT, non-seminomatous germ cell tumours; (L-)(R-) RPLND, (laparoscopic-) (robotic-) retroperitoneal lymph node dissection.
© 2015 The Authors BJU International © 2015 BJU International
923
A comparative analysis of robotic vs laparoscopic retroperitoneal lymph node dissection for testicular cancer Kelly T. Harris, Michael A. Gorin, Mark W. Ball, Phillip M. Pierorazio and Mohamad E. Allaf The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Objective To compare the safety and perioperative outcomes of robotic retroperitoneal lymph node dissection (R-RPLND) vs laparoscopic RPLND (L-RPLND).
and perioperative outcomes including operative time, estimated blood loss, lymph node yield, complicate rate, and ejaculatory status were similar between groups (all P > 0.1).
Patients and Methods
Conclusions
Our Institutional Review Board-approved retrospective testicular cancer registry was queried for patients who underwent a primary unilateral R-RPLND or L-RPLND by a single surgeon for a stage I testicular non-seminomatous germ cell tumour. Groups were compared for differences in baseline and outcome variables.
Results
As an early checkpoint, R-RPLND appears comparable to LRPLND in terms of safety and perioperative outcomes. It remains unclear if R-RPLND offers any tangible benefits over standard laparoscopy.
Keywords robotic surgery, testicular cancer, retroperitoneal lymph node dissection, RPLND
Between July 2006 and July 2014, 16 R-RPLND and 21 L-RPLND cases were performed by a single surgeon. Intra-
Introduction According to current guidelines, primary retroperitoneal lymph node dissection (RPLND) remains a recommended treatment option for select men with stage I or II non-seminomatous germ cell tumours (NSGCT) [1]. Given that most men diagnosed with testicular cancer are young and otherwise healthy, RPLND is an ideal option for patients who wish to avoid long-term surveillance or chemotherapy. Traditionally performed via an open approach, the first primary laparoscopic RPLND (L-RPLND) was described by Rukstalis et al. [2] in 1992. The laparoscopic technique has since been shown to yield faster recovery times, less blood loss, and reduced complication rates [3,4]. Furthermore, L-RPLND was found to have comparable oncological outcomes and improved morbidity when compared with open RPLND [5]. In recent years, robotic surgery has largely replaced standard laparoscopy for many urological procedures, including radical prostatectomy and partial nephrectomy. Proponents of robotic surgery cite that this technology helps bridge the
BJU Int 2015; 116: 920–923 wileyonlinelibrary.com
three-dimensional benefits of open surgery with the minimally invasive benefits of laparoscopy. In addition, robotics offers superior freedom of movement compared with laparoscopic surgery [6]. However, the cost of the robotic system is one of the main drawbacks to its use. The first use of the robot during RPLND (R-RPLND) was described in 2006 by Davol et al. [7]. Since the time of this original report, promising results in the primary setting for stage I disease as well as in the post-chemotherapy setting for stage II disease have been reported [8–10]. To date, there has been no comparative analysis of R-RPLND and L-RPLND to ascertain if the robotic approach offers any advantages to laparoscopy. The aim of the present study was to compare the safety and perioperative outcomes of R-RPLND vs L-RPLND.
Patients and Methods Our Institutional Review Board-approved retrospective testicular cancer registry was queried for patients who underwent a primary unilateral R-RPLND or L-RPLND by a
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13121 Published by John Wiley & Sons Ltd. www.bjui.org
R-RPLND vs L-RPLND for testicular cancer
single surgeon (M.A.E.) for a stage I NSGCT between July 2006 and July 2014. Of note, patients presenting during the study period with a stage I NSGCT were offered the choice of management with active surveillance, chemotherapy or minimally invasive RPLND. The study cohort includes only those patients who elected for RPLND. Before 2011, all minimally invasive RPLNDs were performed laparoscopically. After this year, robotic technology became readily available at our institution and cases were preferentially performed with this approach. Surgical Technique Our laparoscopic technique for RPLND has previously been reported [11]. For robotic cases, the patient is placed in the modified flank position. After insufflation, a four-port configuration is used with two assistant ports. The ipsilateral colon is reflected, the gonadal vein identified, ligated proximally and dissected to the inguinal ring. A modified template dissection is used, bounded by the renal vessels cranially, the ureter laterally, and the iliac bifurcation caudally. For right-sided procedures, the paracaval, interaortocaval and pre-aortic lymph nodes (LNs) superior to the inferior mesenteric artery are sequentially dissected. For left-sided procedures, the para-aortic, pre-aortic cranial to the inferior mesenteric artery, interaortocaval and pre-caval lymph LNs are dissected. Lymphatics are meticulously dissected and clips are used liberally to prevent postoperative lymphatic leak. Postoperative Surveillance Postoperative surveillance was conducted according to the National Comprehensive Cancer Network (NCCN) guidelines based on the clinical stage and postoperative pathological staging [1].
vs 28.9 (26.1–32.8) kg/m2 (P = 0.10). In the L-RPLND group, there was a significantly more pT2 cases (52.4% vs 12.5%; P = 0.02). As detailed in Table 2, RPLND operative times, estimated blood loss, intraoperative complications, LN yield, and frequency of LN positivity were similar between groups. RPLND specimens included only embryonal and teratomatous features, with no differences in pathological subtypes between groups. Additionally, the follow-up duration was comparable, at a median (IQR) of 2.8 (0.2–31.0) vs 13.5 (5.8–20.1) months (P = 0.18). There was also similar rates of postoperative complications and ejaculatory status outcomes.
Discussion For patients with stage I or II NSGCTs, long-term survival with initial observation, RPLND or chemotherapy approaches 100% [12]. Therefore, the decision about the initial mode of treatment for stage I disease is largely based on patient preference. For many, the choice to pursue treatment with RPLND is premised on the desire to avoid chemotherapy, as well as the extensive follow-up of surveillance. When L-RPLND was first introduced in 1992 [2], the main criticism was concern for lower overall LN yield and its impact on oncological outcomes. However, over time the technique has improved, so that retro-aortic and retro-caval LNs are now routinely removed laparoscopically. Recent studies have shown L-RPLND to have comparable oncological outcomes with superior morbidity when compared with the open approach [5]. In the last decade, robot-assisted technology has emerged in the field of urology as an alternative to traditional Table 1 Characteristics of the study cohort.
Statistical Analysis Variable
Demographic, pathological, intraoperative and perioperative data were compared between the R-RPLND and L-RPLND groups. Continuous variables were compared with the Mann– Whitney U-test and categorical variables with Fisher’s exact test. Statistical analysis was performing using Stata Version 13 (College Station, TX, USA). A two-sided P < 0.05 was considered to indicate statistical significance.
Results During the study period, 16 R-RPLND and 21 L-RPLND cases were performed by a single surgeon (M.E.A.) at our institution for stage I NSCGT. The preoperative characteristics of the groups are shown in Table 1. The median age was similar between groups. There was a trend towards higher body mass index in the R-RPLND cohort, with a median (interquartile range, IQR) of 25.7 (22.5–31.5)
Number of cases Median (IQR) Age, years BMI, kg/m2 N (%) Race White Other Primary laterality Left Right pT Stage pT1 pT2 Orchidectomy pathology Choriocarcinoma Embryonal Seminoma Teratoma Yolk sac
L-RPLND
R-RPLND
21
16
28.8 (23.4–32.9) 25.7 (22.5–31.5)
29.8 (24.7–37.6) 28.9 (26.1–32.8)
P
0.61 0.10
20 (95.2) 1 (4.8)
15 (93.7) 1 (6.3)
0.69
8 (38.1) 13 (61.9)
8 (50.0) 8 (50.0)
0.52
10 (47.6) 11 (52.4)
14 (87.5) 2 (12.5)
0.02
2 13 4 12 10
0.18 0.63 1.00 1.00 0.33
19 6 15 9
0 (90.5) (28.6) (71.4) (42.9)
(12.5) (81.3) (25.0) (75.0) (62.5)
© 2015 The Authors BJU International © 2015 BJU International
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Harris et al.
Table 2 Comparison of intraoperative, pathological and perioperative outcomes of R-RPLND vs L-RPLND. Variable RPLND template, n (%) Left Right Median (IQR) operative time, min Median (IQR) estimated blood loss, mL Intraoperative complication, n (%) Conversion, n (%) Median (IQR) LN yield pN Stage, n (%) pN0 pN1 pN2 RPLND pathology, n (%) Choriocarcinoma Embryonal Seminoma Teratoma Yolk sac Postoperative complication, n (%) Clavien Grade, n (%) I–II III–IV Antegrade ejaculation, n (%) Yes No Unknown Median (IQR) follow-up, months
L-RPLND (N = 21)
R-RPLND (N = 16)
P
8 13 294 125 0 1 22
8 8 270.5 75 1 1 30
0.52
(38.1) (61.9) (259–370) (50–150) (4.8) (18–30)
17 (81.0) 3 (14.3) 1 (4.8)
14 (87.5) 2 (12.5) 0
0 3 (14.3) 0 1 (4.8) 0 2 (9.5)
0 1 (6.3) 0 1 (6.3) 0 1 (6.3)
1 (4.8) 1 (4.8)
0 1 (6.3)
16 2 3 2.8
(76.2) (9.5) (14.3) (0.2–31.0)
laparoscopic surgery. The robot provides greater degrees of freedom of movement and better three-dimensional visualisation, while maintaining the benefits of a minimally invasive approach. The major controversy over the use of robotics lies in the increased cost associated with this technology [13,14]. These costs include the purchase and maintenance of the robot itself, as well as the price of disposable limited-life instruments and robotic drape. Thus, unless there is a demonstrable advantage to using the robot, the cost-benefit ratio generally steers towards laparoscopy or an open approach. However, due to the relatively recent advent of robotic surgery there currently is no comparative data as to whether R-RPLND offers any advantages over laparoscopy. For both prostatectomy and nephrectomy, advocates of robotic technology refer not only to the superior perioperative outcomes, but also to the ease of intracorporeal suturing and improved control around vessels and nerve plexuses. These technical advantages of robotics are critical for RPLND, particularly with respect to the number of LNs resected, success of a nerve-sparing technique as evidenced by antegrade ejaculation, and protection of the great vessels. Not only may the robotic approach be more technically advantageous for RPLND, there is evidence in other urological procedures, specifically partial nephrectomy, that use of robotics leads to increased use of the procedure [15]. It is worth noting that while proponents of R-RPLND cite improved control around the great vessels as a potential
922
© 2015 The Authors BJU International © 2015 BJU International
(50.0) (50.0) (236–299) (50–100) (6.3) (6.3) (23–35.5)
16 (100) 0 0 13.5 (5.8–20.1)
0.13 0.16 0.43 1.00 0.13 1.00
0.62 1.00 1.00 1.00
0.16
0.18
advantage of the robotic approach, the fact that the console surgeon is a distance from the patient’s bedside creates a unique challenge in cases of vascular injury. If such an injury cannot be repaired robotically, then the unsterile surgeon must take precious time to return to the operating table, as well as to undock the robot. In our present series, the one reported intraoperative complication in the R-RPLND group was an aortic injury requiring open conversion. In this case, robotic repair was unsuccessful. However, the bleeding could be controlled with a laparoscopic Satinsky clamp allowing for safe open conversion and primary repair of the vascular injury. In a similar case, Lee et al. [16] reported the successful management of a renal artery injury during robotic partial nephrectomy. Both cases underscore the importance of having an experienced bedside assistant, as well as a team well versed in the undocking of the robotic system. To our knowledge, the present study is the first comparative analysis of R-RPLND vs L-RPLND. Our results show that R-RPLND is at best equivalent to the laparoscopic approach in terms of safety and perioperative outcomes. More specifically, estimated blood loss, operative times, rates of complications and conversions were similar between groups. Moreover, LN yield, frequency of LN positivity, and ejaculatory status were also similar between groups. Limitations to the present study include the small size, thus limiting the power to detect differences between groups. However, the present study was meant to serve as a preliminary investigation to ascertain if there was any trend
R-RPLND vs L-RPLND for testicular cancer
towards superiority or inferiority of R-RPLND. In addition, our study represents a single-institution, single-surgeon experience; therefore the results may not be generalizable. However, this experience is based on a surgeon who has extensive experience with both laparoscopy and the robotic technique, so our present comparison does not include any differences due to inexperience or a learning curve. In conclusion, as an early checkpoint, R-RPLND appears comparable to the laparoscopic approach in terms of safety and perioperative outcomes. It remains unclear if R-RPLND offers any tangible benefits over standard laparoscopy. However, larger studies are needed to more fully explore this question.
7 8
9
10
11
12
Conflicts of Interest None.
References 1
2
3
4 5
6
National Comprehensive Cancer Network. Testicular Cancer, Version 1.2014. Available at: http://www.nccn.org/professionals/physician_gls/ f_guidelines.asp. Accessed April 2015 Rukstalis DB, Chodak GW. Laparoscopic retroperitoneal lymph node dissection in a patient with stage 1 testicular carcinoma. J Urol 1992; 148: 1907–10 Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003; 62: 324–7 Gerber GS, Bissada NK, Hulbert JC et al. Laparoscopic retroperitoneal lymphadenectomy: multi-institutional analysis. J Urol 1994; 152: 1188–92 Steiner H, Peschel R, Janetschek G et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10year experience. Urology 2004; 63: 550–5 Ahlering TE, Skarecky D, Lee D, Clayman RV. Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003; 170: 1738–41
13
14
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Correspondence: Mohamad E. Allaf, 600 North Wolfe Street, Park 223, Baltimore, MD 21287, USA. e-mail: [email protected] Abbreviations: IQR, interquartile range; LN, lymph node; NSGCT, non-seminomatous germ cell tumours; (L-)(R-) RPLND, (laparoscopic-) (robotic-) retroperitoneal lymph node dissection.
© 2015 The Authors BJU International © 2015 BJU International
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