Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Eur Urol Oncol. 2021 Aug;4(4):651-658. doi: 10.1016/j.euo.2019.01.014. Epub 2019 Mar 29.
Postchemotherapy retroperitoneal lymph node dissection (pcRPLND) is mandated in patients with nonseminomatous germ cell tumor found to have residual masses after chemotherapy. Performed via the open approach, pcRPLND can incur significant perioperative morbidity.
To demonstrate the feasibility of robotic pcRPLND (r-pcRPLND) and provide evidence for its selection criteria.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective search identified 93 patients undergoing pcRPLND between April 2007 and March 2018, comprising 30 r-pcRPLND and 63 open pcRPLND (o-pcRPLND) procedures performed by a single surgeon.
r-pcRPLND and o-pcRPLND.
Baseline clinicopathologic characteristics and intraoperative variables including operating room (OR) time, estimated blood loss (EBL), resection of adjacent organs, and intraoperative consultation with other surgical services were recorded. Hospital length of stay (LOS) and perioperative complications were assessed as per the Clavien-Dindo classification, and oncologic outcomes such as nodal yield, histologic distribution, pathologic staging, time to recurrence, and cancer-specific survival were compared.
r-pcRPLND was performed in a well-selected cohort with lower clinical stage (p=0.006), favorable International Germ Cell Cancer Collaborative Group classification (p=0.01), and smaller retroperitoneal mass (p=0.001). o-pcRPLND required more frequent bilateral template dissection (88.9% vs 43.3%; p<0.001), resection of adjacent organs (36.5% vs 10%; p=0.007), consultation with other surgical services (46% vs 2%; p<0.001), and auxiliary procedures (54.0% vs 20%; p=0.003) to achieve complete oncologic control. OR time was similar between the two groups (o-pcRPLND 375min vs r-pcRPLND 388min; p=0.16) and EBL was significantly lower in r-pcRPLND (234 vs 825ml; p<0.001). Median LOS was significantly shorter after r-pcRPLND (2 vs 7d; p<0.001). A total of 31 patients (33%) suffered postoperative complications, of whom 18 (19.4%) had major complications. Nodal yield was similar (o-pcRPLND 23 vs r-pcRPLND 24; p=0.8). The distribution of lesion histology (necrosis/teratoma/GCT) was also similar pcRPLND (o-pcRPLND 25.4%/57.1%/17.4% vs r-pcPLND 33.3%/50%/16.7%; p=0.51). Overall, tumor recurred in 15 patients (16.1%), including three following r-pcRPLND (10%), all outside the operative field. On univariate analysis, surgical approach was not a significant predictor of time to recurrence (p=0.34). One limitation was that antegrade ejaculation was not assessed.
With rigorous patient selection, r-pcRPLND can be safely performed and may reduce perioperative morbidity while maintaining oncologic proficiency.
Resection of residual retroperitoneal mass after chemotherapy in patients with metastatic testicular cancer can be performed safely via a robotic approach. Robotic surgery can reduce the morbidity of the procedure.
对于化疗后发现有残留肿块的非精原细胞瘤生殖细胞肿瘤患者，必须进行化疗后腹膜后淋巴结清扫术（pcRPLND）。通过开放手术进行的 pcRPLND 会导致显著的围手术期发病率。
展示机器人 pcRPLND（r-pcRPLND）的可行性，并为其选择标准提供证据。
设计、地点和参与者：通过回顾性搜索，确定了 2007 年 4 月至 2018 年 3 月期间接受 pcRPLND 的 93 名患者，其中包括由同一位外科医生进行的 30 例 r-pcRPLND 和 63 例开放 pcRPLND（o-pcRPLND）手术。
r-pcRPLND 和 o-pcRPLND。
记录了基线临床病理特征和术中变量，包括手术室（OR）时间、估计失血量（EBL）、相邻器官切除和与其他外科服务的术中咨询。根据 Clavien-Dindo 分类评估住院时间（LOS）和围手术期并发症，比较肿瘤学结果，如淋巴结产量、组织学分布、病理分期、复发时间和癌症特异性生存。
r-pcRPLND 在选择良好的队列中进行，临床分期较低（p=0.006），国际生殖细胞癌协作组分类较好（p=0.01），腹膜后肿块较小（p=0.001）。o-pcRPLND 需要更频繁的双侧模板切除（88.9%对 43.3%；p<0.001）、相邻器官切除（36.5%对 10%；p=0.007）、与其他外科服务的咨询（46%对 2%；p<0.001）和辅助手术（54.0%对 20%；p=0.003）以实现完全的肿瘤控制。两组的 OR 时间相似（o-pcRPLND 375min 对 r-pcRPLND 388min；p=0.16），r-pcRPLND 的 EBL 明显较低（234ml 对 825ml；p<0.001）。r-pcRPLND 的中位 LOS 明显缩短（2 对 7d；p<0.001）。共有 31 名患者（33%）发生术后并发症，其中 18 名（19.4%）有严重并发症。淋巴结产量相似（o-pcRPLND 23 对 r-pcRPLND 24；p=0.8）。病变组织学（坏死/畸胎瘤/GCT）的分布也相似（o-pcRPLND 25.4%/57.1%/17.4%对 r-pcPLND 33.3%/50%/16.7%；p=0.51）。总体而言，15 名患者（16.1%）肿瘤复发，其中 3 名（10%）在 r-pcRPLND 后复发，均在手术野外。单因素分析显示，手术方式不是复发时间的显著预测因素（p=0.34）。一个限制是没有评估逆行射精。
通过严格的患者选择，r-pcRPLND 可以安全进行，同时保持肿瘤学疗效，可减少围手术期发病率。
对于转移性睾丸癌化疗后残留腹膜后肿块的切除，可以通过机器人手术安全进行。机器人手术可以减少手术的发病率。
