Laparoscopic and robotic-assisted retroperitoneal lymph node dissection

Introduction

Retroperitoneal lymph node dissection (RPLND) is the standard of care for postchemotherapy residual retroperitoneal masses >1 cm in nonseminomatous germ cell tumors (NSGCTs) and >3 cm positive fluorodeoxyglucose-positron emission tomography (FDG-PET) residual masses in seminoma and is a treatment option in the management of high-risk clinical stage 1 and low-volume clinical stage 2 NSGCTs. Further, there is renewed interest in RPLND as the primary treatment option in patients with low-volume seminoma. With the widespread utilization of minimally invasive surgery in urology, laparoscopic and robotic-assisted RPLND (RA-RPLND) have gained traction with the primary aim of lowering the morbidity related to open RPLND, including decreased pain, improved cosmesis, and improved convalescence profile. ^, The average complication rate for minimally invasive RPLND is comparable to if not lower than open RPLND. Moreover, laparoscopic and RA-RPLND are associated with less intraoperative blood loss and shorter length of stay compared with open RPLND. ^, Open RPLND is associated with excellent oncological outcomes. Early results from retrospective series evaluating oncological outcomes of patients who underwent laparoscopic or robotic-assisted RPLND revealed comparable early recurrence rates in well-selected patients. ^, While these data seem promising, unusual and variable recurrence locations in RA-RPLND, low nodal yields, high rates of stage pN0, high rates of adjuvant chemotherapy, and high rates of stage 1A patients may limit its usage in the management of testicular germ cell tumors. Although minimally invasive RPLND is technically feasible with acceptable morbidity, further randomized controlled trials comparing postoperative complications and long-term oncological safety between minimally invasive surgeries such as RA-RPLND and open RPLND are required to assess potential benefits of minimally invasive surgeries.

In this chapter, we describe the laparoscopic and robotic-assisted approaches to the retroperitoneal lymph nodes in the management of patients with testicular germ cell tumors.

Preoperative preparation

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Informed consent is obtained. Inform patient about the surgical procedure, potential complications, and the possibility of conversion to open operation.
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Consider at least a period of 5 weeks from the last chemotherapy treatment to RPLND allowing hematopoietic recovery.
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Avoid all anticoagulants and platelet inhibitors for 7 days before the procedure.
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Discuss preoperative sperm banking prior to surgery.
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Consider the preoperative pulmonary function test in patients who underwent prior chemotherapy with bleomycin. Intraoperative intravenous fluids should be limited due to pulmonary fibrosis in these patients.
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High-fat diet prior to surgery may facilitate identification and ligation of lymphatics.
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Patient may undergo mechanical and antibiotic bowel preparation one day preoperatively. Fasting starts at midnight before surgery.
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Group and crossmatch three blood units.
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Place compressive elastic stockings on the lower extremities before anesthesia induction.
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Use intravenous broad-spectrum antibiotic prophylaxis at the time of anesthesia induction.
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Thrombo-prophylaxis agent such as low molecular weight heparin is administered preoperatively and continued until the patient is discharged.
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A Foley catheter is placed for bladder decompression and urine output monitoring. A nasogastric tube is placed to decompress stomach and bowels.
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Open set should be in room in the case of urgent conversion to open procedure.
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Vascular suture should be available in the event of inferior vena cava or aortic repair.

RPLND templates

Unilateral templates (right or left) were defined to decrease intra- and postoperative complications, especially retrograde ejaculation. However, up to 32% of patients experience contralateral retroperitoneal metastases, while antegrade ejaculation can be preserved in nerve-sparing surgeries. Therefore, the full bilateral template is recommended for patients who undergo RPLND. For a left-sided template, lymph node packets are removed from the left common iliac, preaortic, paraaortic, precaval, and retroaortic areas ( Fig. 14.1 A). Right-sided template includes lymph nodes from the right common iliac, paracaval, precaval, interaortocaval, and preaortic spaces ( Fig. 14.1 B). Full bilateral template includes both right- and left-sided lymph nodes ( Fig. 14.2 ).

Positioning of the patient

The patient is placed in the modified flank position with the chest rotated back slightly at 30 degrees for modified unilateral RPLND (right side up for right-sided dissection and left side up for left-sided dissection). The table is then slightly flexed at the umbilicus. The lower padded hand is placed on an armrest, and the lower leg is flexed 90 degrees at the knee, while the upper leg is left extended. Pillows are placed between the legs, and the patient is strapped to the table carefully to facilitate tilting of the table during surgery. For bilateral RPLND, after completing unilateral dissection, the patient is repositioned for contralateral dissection as needed, or alternatively, the patient is positioned in the supine position with abducted legs and the arms placed by the patient’s side. The patient then is placed in the Trendelenburg position, allowing the bowel to fall cephalad. For RA-RPLND, both the da Vinci Si and Xi systems can be used. The Xi system allows access to all quadrants without the need to redock the robot. Moreover, the da Vinci Xi linear port configuration in modified flank position allows for a bilateral dissection without the need for patient repositioning.

Port placement

Laparoscopic approach, unilateral RPLND

Five ports are placed to perform the procedure. After abdominal insufflation using a Veress needle or Hasson technique, a 12-mm camera port is placed just cranial to the umbilicus in the midline. Two ports (5-mm left-hand port and 12-mm right-hand port) are placed just lateral to the midline through the middle portion of the rectus muscle. An additional 5-mm assistant port is placed just medial to the ipsilateral anterior superior iliac spine. The 12-mm right-handed trocar is used for clip appliers and placement of the extraction sac for lymph node removal. In general, the left-hand, right-hand, and camera trocars are placed more medially than for laparoscopic renal surgery to have better access to the great vessels in the midline. The right-hand instrument is monopolar scissors or a monopolar hook cautery instrument, while the left-hand instrument is an atraumatic grasper. Polymer locking clips are used to control large lymphatic channels, and titanium laparoscopic clips are used to control vascular structures. For right-sided dissection, an additional 5-mm port can be used for a liver retractor placed just inferior to the xiphoid process ( Fig. 14.3 A).

Alternatively, four 10/12-mm ports are equally spaced in the midline. The most cranial port is placed 1–2 cm below the xiphoid process ( Fig. 14.3 B). Again, an additional 5-mm port can be used as liver retractor in the midaxillary line.

Laparoscopic approach, bilateral RPLND

Bilateral RPLND may be performed using the same port configuration as unilateral RPLND. In case of difficult access to the contralateral lymph node zones, change in patient positioning or RPLND in the supine position is recommended. In the supine position, four 10/12-mm ports are placed with equal interport spaces in the midline. The most cephalad port is placed 1–2 cm below the xiphoid process ( Fig. 14.3 B).

Robotic-assisted approach, da Vinci Xi system

Four 8-mm robotic ports are equally spaced in the midline. For the right-sided RPLND, from cranial to caudal, the monopolar scissors for the right hand, camera, bipolar forceps in the left hand and prograsp forceps in the most caudal port. An additional trocar in the midline 2 cm caudal to the xiphoid process is useful for liver retraction during a right-sided RPLND. A 12-mm assistant port is placed below the midline between the camera and right-hand ports ( Fig. 14.3 C). Unilateral and bilateral RPLND is feasible in the flank position and the described port configuration using the da Vinci Xi system.

In the supine position, a linear port configuration including five ports is used, while the assistant port is placed in the lower quadrant opposite the side of the template ( Fig. 14.3 D).

Robotic-assisted approach, da Vinci Si system

In the da Vinci Si system, bilateral RPLND is performed in the supine position using five ports. A 12-mm camera port is placed between the umbilicus and pubic symphysis in the midline position. Two 8-mm robotic ports are placed in the left lower quadrant. Moreover, an 8-mm robotic port and a 12-mm assistant port are placed in the right lower quadrant ( Fig. 14.3 E). With this configuration, unilateral and bilateral RPLND are feasible.

Surgical technique ( )

Step 1: Colon mobilization

The white line of Toldt along the colon is incised from the colonic flexure to the pelvic brim to medialize the ascending and descending colon from the anterior surface of the kidneys, aorta, and inferior vena cava (IVC) ( Fig. 14.4 ). On the right side, the peritoneal incision is extended inferiorly to the spermatic cord and internal inguinal ring and superiorly by Kocherization of the duodenum allowing optimal exposure to the great vessels ( Fig. 14.5 ). On the left side, the peritoneum is incised along the white line similar to the right side. Incision of the splenicocolic ligament allows the retraction of bowel and spleen and provides better visualization. For both sides, the ureters should be identified carefully as the lateral border of lymph node dissection template and to avoid inadvertent injury.