Max Institute of Cancer Care, New Delhi, India.
J Robot Surg. 2019 Dec;13(6):747-756. doi: 10.1007/s11701-018-00903-0. Epub 2019 Jan 17.
Retroperitoneal lymph node dissection (RPLND) is a therapeutic standard of care for post-chemotherapy residual masses in testicular cancer. While a robotic approach to this procedure has the potential of decreasing the morbidity associated with this major endeavour, it is often criticised for its inability to provide a bilateral complete template resection without redocking and repositioning the patient. Herein, we present the technique and initial outcomes of a supine approach to Robotic RPLND (R-RPLND) using the da Vinci Xi system, which obviates the need for repositioning or redocking for a bilateral full template resection. Three patients (age 21-36) with nonseminomatous germ cell tumours of the testis underwent R-RPLND for post-chemotherapy residual retroperitoneal masses with normalised tumor markers. Salient steps of the procedure were as follows: port placement in supine Trendelenburg position, docking of the da Vinci Xi system from one side, exposure of retroperitoneum, dissection of paracaval, retrocaval, interaortocaval, paraaortic and bilateral common iliac templates, and excision of gonadal vein. Mean console time and estimated blood loss were 257 (190-305) minutes and 333 (300-400) ml, respectively. Mean lymph node yield was 52 (29-94). One patient had a common iliac vein injury which was managed robotically without further consequence. No drains were placed in all three. There were no postoperative complications and all of them were advanced to a normal diet within 24 h and discharged on the second postoperative day. Histopathology reports were suggestive of necrosis and mature teratoma without any viable tumour. There have been no recurrences in these patients at a mean follow-up of 14 (1-22) months. R-RPLND in the supine position is practical, safe and feasible in the post-chemotherapy setting of testicular cancer. It eliminates the need for repositioning the patient or redocking the robot to achieve a complete resection with adequate lymph node yields, while preserving the benefits of a minimally invasive surgical approach.
腹膜后淋巴结清扫术（RPLND）是治疗睾丸癌化疗后残留肿块的标准治疗方法。虽然机器人手术在降低这种重大手术相关的发病率方面具有潜力，但它通常因其无法在不重新定位或重新对接患者的情况下提供双侧完整模板切除而受到批评。在此，我们介绍了使用达芬奇 Xi 系统进行仰卧位机器人腹膜后淋巴结清扫术（R-RPLND）的技术和初步结果，该方法避免了为双侧全模板切除重新定位或重新对接的需要。3 名年龄在 21-36 岁的非精原细胞瘤生殖细胞肿瘤患者因化疗后腹膜后残留肿块和肿瘤标志物正常而行 R-RPLND。手术的主要步骤如下：在仰卧位特伦德伦伯格体位下放置端口，从一侧对接达芬奇 Xi 系统，暴露腹膜后，解剖腔静脉旁、腔静脉后、主动脉旁、主动脉旁和双侧髂总模板，切除精索静脉。控制台平均时间和估计失血量分别为 257（190-305）分钟和 333（300-400）ml。平均淋巴结产量为 52（29-94）个。1 例患者发生髂总静脉损伤，经机器人处理后无需进一步处理。所有 3 例均未放置引流管。无术后并发症，所有患者均在 24 小时内恢复正常饮食，并在术后第 2 天出院。组织病理学报告提示为坏死和成熟畸胎瘤，无任何存活肿瘤。这些患者在平均 14（1-22）个月的随访中均无复发。在睾丸癌化疗后，仰卧位 R-RPLND 是实用、安全和可行的。它消除了重新定位患者或重新对接机器人以实现完整切除和足够淋巴结产量的需要，同时保留了微创外科手术的益处。
