Dr. Hiester highlighted the important role of RPLND in testicular cancer treatment including post-chemotherapy non-seminoma germ cell tumors (NSGCT), clinical-stage 1 NSGCT, marker negative clinical stage II NSGCT, marker negative late relapse, and potentially in metastatic seminoma (an area currently under investigation in the SEMS trial and the PRIMETEST trial).
Dr. Hiester offered that open RPLND remains the gold standard on the basis of oncologic outcomes and long-term follow-up data; intraoperative and postoperative complications and adjunctive surgery; the definition and determination of the site and extent of the surgical field; and the excellent function outcomes in terms of antegrade ejaculation based on nerve-sparing. However, in making the argument for robotic-assisted RPLND, he highlighted data on complications from open RPLND including incision related morbidity of 3.7-10%. Further, he argued that patients are increasingly demanding minimally-invasive surgical approaches for cosmetic reasons and suggested that, in some cases, some patients would decline surgery rather than opting for open RPLND. He cited the case of a young gentleman with clinical stage IIB NSGCT who had a residual mass following 3 cycles of BCP chemotherapy. This patient refused open post-chemo RPLND. Given the risks of teratoma in 39% and viable cancer in 17%, Dr. Hiester suggested that observation would not be a reasonable option.
The first case of laparoscopic RPLND was described in 1992, with utilization limited to mostly clinical stage I and IIa tumors with limitations in the number of lymph nodes removed and a lack of defined template. As a result, this was often used as a diagnostic, rather than therapeutic, procedure, followed by subsequent chemotherapy.
The first robotic approach was described in 2006 with a subsequent 13 studies, each with fewer than 200 patients. The minority (78 patients) had clinical evidence of metastatic disease (clinical stage II or greater) and 40 patients had post-chemotherapy procedures. Using a supine position, a bilateral templated resection may be performed. In patients treated with this approach, limited available data suggest that functional outcomes and in-field recurrence rates may be comparable to open approaches.
When unilateral resection is planned, a flank approach may be undertaken. As with the bilateral approach, limited available data demonstrate reasonable functional and in-field recurrence rates.
Dr. Hiester concluded that robotic RPLND remains an experimental approach as the number of patients treated with this report remains sparse and more data is needed to assess oncologic outcomes. Further, he emphasized that this should be performed in high volume centers to allow for appropriate patient selection and optimized treatment.
Presented by: Andreas Hiester, MD, Department of Urology, Heinrich-Heine University, Düsseldorf, Germany.