Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection

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Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection

James R. Porter

Providence Health and Services Swedish Urology Group, Seattle, WA, USA

Introduction

The management of patients with clinical stage I non‐seminomatous germ cell tumors (NSGCT) of the testis remains controversial. Treatment options include retroperitoneal lymph node dissection (RPLND), surveillance, and primary chemotherapy. Fortunately, the survival rate is in the range of 95–99% with each treatment modality [1–3]. Therefore, the patient’s perception of treatment toxicities and quality of life, without compromising cancer control, has become of paramount importance in decision‐making when choosing therapy.

Open RPLND (O‐RPLND) has been the standard of care for the surgical management of clinical stage I NSGCT. The approach provides both diagnostic information on the stage of the tumor and is curative in 75–80% of patients with low‐volume retroperitoneal disease. With refinements in surgical technique to preserve the postganglionic sympathetic nerves, retrograde ejaculation has been minimized [4]. Nevertheless, there can be significant morbidity from O‐RPLND, with associated bowel dysfunction, prolonged hospitalization, and delay in resumption of daily activities and work [5, 6].

The National Cancer Comprehensive Network (NCCN) guidelines for the treatment of stage I NSCGT include surveillance, 1–2 cycles of chemotherapy, or primary RPLND, with surveillance being preferred for low‐risk patients [7]. In practice, the role of RPLND as a primary treatment for stage I NSGCT has diminished, and the European Association of Urology Guidelines for NSGCT does not recommend RPLND as a treatment option for even high‐risk clinical stage I disease [8]. There are probably several factors contributing to the decline in RPLND, including the significant morbidity associated with O‐RPLND. Young men with high‐risk NSGCT (evidence of lymphovascular invasion and >50% embryonal cancer) given the choice between two cycles of chemotherapy or an O‐RPLND, will usually choose chemotherapy. In addition, as surveillance becomes more prevalent, many urologists may not feel comfortable performing RPLND and chemotherapy then becomes the natural progression of surveillance.

In an attempt to make RPLND less morbid, several investigators have applied minimally invasive techniques to RPLND [9–12]. The effort initially began with laparoscopic RPLND (L‐RPLND) and more recently has evolved to include the robot‐assisted surgical platform that has gained prevalence with other urologic procedures. This review will highlight the current role of both laparoscopic and robotic RPLND (R‐RPLND) in the management of patients with testicular cancer. The goal of this review is to provide a framework for urologists to perform minimally invasive RPLND (MI‐RPLND), and at the same time maintain the current standard of cancer care while reducing surgical morbidity for these patients.

Indications for minimally invasive RPLND

The goal of treating patients with stage I NSGCT should be the timely recognition and treatment of those men with metastatic disease. To avoid overtreatment this goal is best accomplished by the availability of accurate staging information. Of the three treatment options commonly employed for patients with NSGCT, surveillance, chemotherapy, and RPLND, the latter meets these criteria better than the other two options. O‐RPLND provides accurate staging information and is curative in 75–80% of patient with stage II disease. MI‐RPLND has the potential to provide the same benefits of O‐RPLND but with a marked reduction in morbidity. Thus, MI‐RPLND could provide the diagnostic and therapeutic advantages of O‐RPLND but with a marked reduction in morbidity.

The indications for L‐RPLND and R‐RPLND are the same. Patients with NSGCT found on radical orchiectomy (T1–3) with no evidence of nodal involvement on computed tomography (CT) of the abdomen, no signs of lung involvement on CT of the chest, and negative or normalized tumor markers are appropriate candidates for MI‐RPLND. In select patients with small‐volume nodal involvement in the abdomen (stage IIa) and predominantly teratoma on orchiectomy, MI‐RPLND can be considered depending on the marker status. Patients are counseled regarding all treatment options for NSGCT, including O‐RPLND, surveillance, and primary chemotherapy.

As experience has been gained with MI‐RPLND, the indications have expanded to patients with residual masses after primary chemotherapy. Masses greater than 1 cm in patients with negative tumor markers may be candidates for MI‐RPLND with the caveat that larger masses (N3) and tumors involving renal hilum may be better addressed with O‐RPLND.

Contraindications to MI‐RPLND include pure seminoma, patients with elevated tumor markers despite negative nodes on CT scan and patients who have had prior abdominal radiation. Relative contraindications include extreme obesity (body mass index >40), prior episodes of peritonitis, and coagulopathy. Patients with prior abdominal surgeries can usually undergo successful MI‐RPLND after takedown of adhesions.

Patient preparation

Patients being considered for MI‐RPLND should undergo complete staging of the disease with radiographic imaging of the chest and abdomen, and tumor marker assessment including alpha‐fetoprotein, beta‐human chorionic gonadotropin, and lactate dehydrogenase. If there is a delay of more than six weeks from the initial CT scan of the abdomen to the time of surgery, it is prudent to repeat the CT to look for evidence of nodal enlargement as this may affect the clinical stage of the disease and the operative plan. Patients should be counseled that there is a possibility of conversion to open surgery due to vascular or bowel injury and this should be clearly stated in the informed consent. This is especially important in patients undergoing a postchemotherapy MI‐RPLND, where there can be significant fibrosis and scarring between the tumor and great vessels. The patient should also be informed of the possibility of nephrectomy as this is sometimes necessary due to tumor involvement of the renal hilum. They should be aware of the risk of blood transfusion. We routinely counsel patients that they will be on a low‐fat diet (20 g of fat per day) for two weeks after the procedure to decrease the risk of developing chylous ascites that may require bowel rest with total parenteral nutrition and reoperation if it does not resolve. Finally, we encourage patients to bank sperm prior to surgery in the event of retrograde ejaculation.

To decrease the size of the intestines and provide more working space for MI‐RPLND, patients are asked to undergo a modified bowel preparation the day prior to surgery with a clear liquid diet and magnesium citrate orally. We request that patients avoid platelet inhibitors such as aspirin and nonsteroidal anti‐inflammatory medications for seven days prior to the procedure. Patients are typed and crossed for blood in the event of acute hemorrhage during the procedure.

Preoperative preparation

Anesthesia and patient position

Patients undergoing both L‐RPLND and R‐RPLND require general endotracheal anesthesia with continuous attention by the anesthesiologist to deep paralysis to maintain adequate pneumoperitoneum. A Foley catheter and orogastric tube are placed prior to positioning the patient to decompress the bladder and stomach and decrease the risk of injury during port placement as well as to provide more room in the peritoneal space for the procedure. Sequential compression stockings are placed on the lower extremities and a cephalosporin antibiotic is administered just prior to making the incision.

For L‐RPLND and R‐RPLND using the lateral approach patients are placed in a 60° modified flank position with the side of prior orchiectomy up (Figure 91.1). The patients are well padded on a gel pad and the legs are supported with pillows. The arms are placed on an arm board with pillows placed between the arms, although we sometime place the arms in a “prayer” position for patients undergoing R‐RPLND. For R‐RPLND using the supine approach, patients are placed supine with the arms padded and tucked by the sides and the legs are straight with sequential compression stockings (Figure 91.2). Because the patient is placed in a slight Trendelenburg position, a full body gel pad is placed between the patient and operating table to prevent patient movement. As with the lateral position, Foley catheter, orogastric tube, and pre‐incision antibiotics are employed.

Image described by caption and surrounding text. — **Figure 91.1** Lateral modified flank position for minimally invasive retroperitoneal lymph node dissection with arms on arm board.

Operating room setup and equipment: L‐RPLND

L‐RPLND is routinely accomplished with two assistants and a scrub nurse helping the primary surgeon (Figure 91.3). The room configuration for L‐RPLND requires the primary surgeon and the first assistant to be standing on the side contralateral to the side of prior orchiectomy. The second assistant and scrub nurse stand on the side opposite the primary surgeon and first assistant. The anesthesia team is at the patient’s head with full access to the airway and face. Video monitors are located on both sides of the patient to allow all involved personal to have an optimum view of the operative field. The first assistant’s primary role is to hold the endoscope and maintain a steady operative view. The second assistant usually controls a grasping device or retractor to provide tissue exposure.

Laparoscopic instruments routinely used during L‐RPLND include endoscopic scissors, graspers, clip appliers, and blunt dissectors. A 30° endoscope is usually used. In the event of vascular injury, laparoscopic needle drivers should be available along with a “rescue stitch” to allow rapid control of bleeding if this is encountered. A rescue stitch in our experience is a 4‐0 polypropelene suture cut to 12 cm with a polymer clip on the end of the suture opposite the needle. This allows multiple throws of the needle without the need to tie the suture, although the clip can be removed and the sutured tied once bleeding is controlled if this is the surgeon’s preference. Lymph nodes are removed with the aid of an endoscopic retrieval bag that decreases the risk of potential tumor cells coming into contract with the abdominal wall or an extraction port. Hemostatic agents are used at the end of the procedure to aid in the sealing of lymphatic changes that may remain open after lymph node removal. As with any laparoscopic procedure an open laparotomy set is in the room, opened and prepared in the event of rapid conversion to open surgery.

Operating room setup and equipment: R‐RPLND

The robotic setup will depend on whether the lateral or supine approach is used or whether the da Vinci® Si or Xi (Intuitive Surgical, Inc., Sunnyvale, CA, USA) is employed. For the lateral approach with the da Vinci Si the robot is docked over the patient’s back on the side of the bed ipsilateral to the orchiectomy (Figure 91.4). The bedside assist and scrub nurse are on the side opposite the robot and the primary surgeon resides at the surgeon’s console. The anesthesia team is again located at the patient’s head. A second assistant is not routinely used during R‐RPLND. For the supine approach using the da Vinci Si, the robot is docked over the patient’s left shoulder after the patient is placed in a 15–20° Trendelenburg position (Figure 91.5). The bedside assistant stands on the patient’s right directed toward the head of the patient and the scrub nurse is usually on the same side. The anesthesiologist will be on the right side of the patient’s head opposite the robot. The patient side vision cart holds the insufflator, electrosurgical unit, light source, and accessory energy components and can be placed in the optimum position depending on room size and configuration specific to the room.