Technique and outcomes for robotic assisted post-chemotherapy retroperitoneal lymph node dissection (RPLND) in Stage 2 non-seminomatous germ cell tumour (NSGCT) Introduction Laparoscopic (L-)RPLND is an established alternative to open RPLND for stage I NSGCT. L-RPLND patients experience a faster recovery without compromising oncologic outcomes. Post-chemotherapy (PC-)L-RPLND has also been reported in a number of case series with acceptable outcomes. However only a small number of centres globally offer this procedure due to the technical challenges and limited number of suitable cases. The daVinci robotic platform offers a number of potential advantages over conventional laparoscopy, in particular, the ability to suture vascular injuries with wristed needle drivers. Here we present our technique of Robotic (R-)PC-RPLND with nerve sparing and present results from our initial 5 R-RPLND cases. Patients and Methods A 28 year-old man presented with Stage II NSGCT (AFP 13, BHCG 9). Following orchidectomy, he received 3 cycles of BEP chemotherapy and subsequent imaging confirmed a residual retroperitoneal mass measuring 2cm. A modified right template R-RPLND with nerve sparing was performed. Intraoperatively a small injury to the inferior vena cava was repaired with a 4/0 polypropylene suture. Results The procedure console time was 1 hour 50 minutes. Blood loss was 75ml. Inpatient stay was 3 nights. Pathology showed 2/20 lymph nodes with metastatic teratoma differentiated. The patient returned to sporting activity at 3 weeks. In 2012 we have undertaken five R-RPLNDs, 3 post-chemotherapy and 2 for diagnostic purposes. A complete unilateral modified template dissection without nerve sparing was performed in 3 cases, with nerve sparing in 1 case and tumour excision only was required in 1 case. There were no conversions to open surgery, mean blood loss was 112ml and mean inpatient stay was 2 days. High dependency care was required for 1 patient who developed unexplained hyperkalaemia. There were no other complications. Pathology revealed non-malignant changes in two patients, teratoma differentiated in two cases and one with ganglioneuroma. All patients rapidly returned to normal activity, including three men with physically demanding occupations who returned to work within 3 weeks. Conclusions This video presentation demonstrates our technique for R-RPLND. All patients have made and excellent recovery from surgery, experienced shorter hospitals stay and an earlier return to normal activities compared to our experience of open RPLND. With careful case selection, we have found robotic PC-RPLND to be feasible, safe and efficacious.

• published: 16 Jun 2012
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