Retroperitoneal lymph node dissection (RPLND) allows for the accurate diagnosis of retroperitoneal disease in patients with nonseminomatous germ cell tumor (NSGCT), thereby permitting stage-directed therapy. In patients with low-volume retroperitoneal disease, RPLND alone can be therapeutic and avoids the side effects and long-term toxicities of chemotherapy. The open approach for RPLND is well established but results in significant morbidity for these young, active patients and may deter them from surgery, resulting in two cycles of chemotherapy.
In an effort to reduce the side effects of RPLND, a minimally invasive approach through laparoscopic or robotic-assisted RPLND provides a less morbid alternative to the open operation, with the goal of re-creating the dissection of the open approach. Although technically challenging, minimally invasive RPLND has been shown to be safe and reproducible and results in substantially less pain and morbidity for patients with testicular cancer as compared with the open approach. Minimally invasive RPLND has also demonstrated the ability to cure patients with low-volume stage II NSGCT, thus avoiding chemotherapy and meeting the same criteria established for the open approach.
In this chapter, we describe the technical evolution of minimally invasive RPLND for the treatment of patients with NSGCT. Our goal is to provide the technical framework for performing minimally invasive RPLND and thereby allow more young men with testicular cancer to experience the benefits of this approach and avoid unnecessary chemotherapy.
Indications and Contraindications
The indications for minimally invasive RPLND are the same as those for open surgery. This includes patients with clinical stages I, IIA, or IIB NSGCT who demonstrate normalization of tumor marker status after orchiectomy. In general, patients with low-risk clinical stage I disease (no lymphovascular invasion and <50% embryonal carcinoma in the orchiectomy specimen) are best followed with surveillance because many of these patients will not require additional therapy. With significant experience, patients with residual postchemotherapy masses can be treated by minimally invasive RPLND. Minimally invasive RPLND would be contraindicated in patients who cannot tolerate pneumoperitoneum or those with pure seminoma and postchemotherapy residual masses. Prior abdominal surgery is a relative contraindication to minimally invasive RPLND, but the vast majority of such patients can be successfully treated after initial minimally invasive adhesiolysis.
A unilateral nerve-sparing approach can be performed laparoscopically for stage I disease ( Fig. 14-1 ). Modified and full bilateral templates can be performed either laparoscopically or with the assistance of the robotic platform. With the expected desmoplastic reaction in postchemotherapy patients as well as for larger burdens of disease as in stage IIA and IIB, some surgeons find the robotic systems to offer improved angles of dissection and help with vascular control in the event of bleeding from the area of dissection.
Patient Preoperative Evaluation and Preparation
The preoperative evaluation includes assessment of tumor markers α-fetoprotein (AFP), β subunit of human chorionic gonadotropin (β-HCG), and lactate dehydrogenase (LDH) and computed tomography (CT) imaging of the abdomen and chest. Patients with persistently elevated tumor markers are not candidates for RPLND and should receive chemotherapy. In addition to staging the extent of disease, imaging studies allow for identification of patient-specific anatomic variations that could influence the surgery, such as multiple renal arteries, a retroaortic renal vein that could be confused for a lumbar vessel, or even a reversed aorta and inferior vena cava (IVC) ( Fig. 14-2 ).
Patient preparation includes bowel preparation with a clear liquid diet and ingestion of oral laxatives (magnesium citrate) the day before surgery. Patients are asked to avoid all anticoagulants and platelet inhibitors for 7 days before the procedure. Sperm bank storage is discussed with patients and encouraged in young men who have yet to father children. A type and screen is performed on all patients. For patients in whom a difficult dissection is anticipated, a type and crossmatch for 2 units of packed red blood cells may be indicated.
Operating Room Configuration and Patient Positioning
After induction of general anesthesia and the administration of intravenous antibiotics, a Foley catheter and an orogastric tube are placed. Pneumatic compression devices are routinely used to prevent thromboembolic complications. Complete neuromuscular blockade is maintained throughout the procedure to allow for stable pneumoperitoneum.
The lateral position can be used for both the laparoscopic and robotic approaches; however, our experience has evolved so that we use the lateral position for laparoscopic RPLND and perform robotic-assisted RPLND using the supine approach. The patient is placed in a 60-degree modified flank position and well padded with pillows and blankets ( Fig. 14-3 ). The upper arm can be supported with an arm hammock or pillows or tucked close to the body in a praying position. Great care should be taken with positioning to ensure padding of all bony prominences because these procedures can take 5 to 6 hours. We have found patient fixation with a beanbag to be less than ideal because this creates a hard contact surface with the dependent side of the patient. Once the patient is positioned, the room is configured for the laparoscopic approach as in Figure 14-4 . The surgeon and first assistant are anterior to the patient, and the second assistant is positioned at the patient’s back, to allow tissue retraction through the laterally placed assistant trocar.
After the abdomen has been prepared and draped in a sterile manner, a Veress needle is placed at Palmer’s point in the left upper quadrant for a left-sided case and approximately 5 cm below the right costal margin in the midclavicular line for a right-sided case. The right-sided modification of Palmer’s point is used to avoid Veress needle passage into the right lobe of the liver. Initial CO 2 insufflation is then performed to a pressure of 20 mm Hg until all the ports are placed, after which insufflation is taken down to 12 to 15 mm Hg.
Robotic-assisted RPLND with the supine approach allows a full bilateral dissection for patients with stage I NSGCT found to have positive nodes on frozen section as well as for patients undergoing postchemotherapy RPLND. Patients are placed in the supine position with the arms padded and tucked ( Fig. 14-5 ). A full-size gel pad is placed in contact with the patient’s back from shoulders to buttocks to prevent the patient from sliding once placed in Trendelenburg position. After insufflation is achieved via Palmer’s point, the patient is placed in Trendelenburg position to allow the intestines to fall cephalad. If the da Vinci Si system (Intuitive Surgical, Sunnyvale, Calif.) is being used, the robot is brought in from the head of the bed over the patient’s left shoulder and the assistant stands on the right side of the patient. If the procedure is performed with the da Vinci Xi system, the robot is side docked on the ipsilateral side of dissection and the assistant is positioned on the contralateral side.
The trocar configuration for laparoscopic RPLND is shown in Figure 14-6 . A 12-mm camera port site is placed just cephalad to the umbilicus in the midline. A 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. A second 5-mm assistant trocar is placed just medial to the ipsilateral anterior superior iliac spine (ASIS) and allows for tissue retraction by the second assistant. The 12-mm right-handed trocar is needed 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 because the dissection takes place around the great vessels in the midline. For right-sided dissections, an additional 5-mm port site can be used as for a liver retractor placed just inferior to the xiphoid process.