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.