Perdonà Sisto, Izzo Alessandro, Contieri Roberto, Passaro Francesco, Pandolfo Savio Domenico, Corrado Roberto, Canfora Giovanna, Damiano Rocco, Autorino Riccardo, Spena Gianluca
Department of Urology, Istituto Nazionale Tumori di Napoli, IRCCS, Fondazione "G. Pascale", Napoli, Italy.
Department of Neurosciences and Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy.
Int Braz J Urol. 2025 Sep-Oct;51(5). doi: 10.1590/S1677-5538.IBJU.2025.0091.
Retroperitoneal lymph node dissection (RPLND) is indicated for testicular cancer patients with residual masses post-chemotherapy or stage I-II non-seminomatous germ cell tumors (NSGCT) (1, 2). Open RPLND remains the standard but carries significant morbidity. The laparoscopic approach, while minimally invasive, presents notable technical challenges (3). Robotic-assisted RPLND (rRPLND) offers a minimally invasive alternative with comparable oncological outcomes (4, 5). The Da Vinci Single Port (SP) system presents new possibilities for reducing surgical morbidity (6, 7).
We report a case of SP-rRPLND using a unilateral modified template and a lower anterior access (LAA) in a 41-year-old man with NSGCT (pT2, UICC Stage IB) who underwent left orchiectomy, followed by adjuvant chemotherapy. A CT scan revealed a 3.5 cm residual retroperitoneal mass in the left hilar region. The surgical procedure, performed with the Da Vinci SP system, involved a 2.5 cm McBurney incision for retroperitoneal access. Instrument configuration followed a "Camera below" setting. The unilateral left-sided modified template guided dissection from the aortic bifurcation to the renal hilum, preserving vascular structures. A 3,5 cm residual mass and para-aortic nodes were excised with the help of flexible Greena® applicator for clips.
Anesthetic management prioritized opioid-sparing techniques to enhance recovery. The patient received regional anesthesia, multimodal analgesia, and had an NRS pain score of 0 at discharge. The console time was 79 minutes, with minimal blood loss and no complications. The patient resumed oral intake on postoperative day 1 and was discharged on day 2. Postoperative recovery was uneventful, with no complications or need for conversion to open or laparoscopic surgery. Final histopathological examination revealed a germ cell tumor with features suggestive of immature teratoma, along with over 10 lymph nodes showing sinus histiocytosis. At six months post-RPLND, the patient remains disease-free, with a good general condition and no new symptoms. Tumor markers (AFP, β-hCG, LDH) are within normal limits, and CT imaging shows no evidence of recurrence or residual retroperitoneal masses. Renal function and hormonal profile are stable. Given prior chemotherapy exposure, cardiovascular monitoring is advised. Follow-up will continue with clinical exams and tumor markers every 3-4 months, with the next CT scan planned at 12 months, unless symptoms warrant earlier imaging.
As far as we know this is the first reported case of SP-rRPLND in Europe. The LAA provides safe access while minimizing morbidity, potentially improving recovery (8). A unilateral approach, avoiding transperitoneal access, may further reduce morbidity (9). Future studies should validate long-term oncological outcomes and compare SP-rRPLND with multiport and open approaches. SP-rRPLND represents a promising advancement in minimally invasive testicular cancer surgery.
腹膜后淋巴结清扫术（RPLND）适用于化疗后有残留肿块的睾丸癌患者或Ⅰ-Ⅱ期非精原细胞性生殖细胞肿瘤（NSGCT）患者（1,2）。开放性RPLND仍是标准术式，但会带来显著的发病率。腹腔镜手术虽然微创，但存在显著的技术挑战（3）。机器人辅助RPLND（rRPLND）提供了一种微创替代方案，其肿瘤学结局相当（4,5）。达芬奇单孔（SP）系统为降低手术发病率带来了新的可能性（6,7）。
我们报告了一例41岁NSGCT（pT2，国际抗癌联盟分期IB）男性患者，采用单侧改良模板和前下入路（LAA）进行SP-rRPLND的病例。该患者接受了左睾丸切除术，随后进行辅助化疗。CT扫描显示左肾门区域有一个3.5 cm的腹膜后残留肿块。使用达芬奇SP系统进行的手术，通过一个2.5 cm的麦氏切口进入腹膜后。器械配置采用“摄像头在下”设置。单侧左侧改良模板指导从主动脉分叉至肾门的解剖，保留血管结构。借助可弯曲的Greena®施夹器切除了一个3.5 cm的残留肿块和腹主动脉旁淋巴结。
麻醉管理优先采用减少阿片类药物的技术以促进恢复。患者接受了区域麻醉、多模式镇痛，出院时数字疼痛评分（NRS）为0分。控制台操作时间为79分钟，失血极少，无并发症。患者术后第1天恢复经口进食，第2天出院。术后恢复顺利，无并发症，无需转为开放或腹腔镜手术。最终组织病理学检查显示为生殖细胞肿瘤，具有提示未成熟畸胎瘤的特征，同时有超过10个淋巴结显示窦组织细胞增生。RPLND术后6个月，患者无疾病复发，一般状况良好，无新症状。肿瘤标志物（甲胎蛋白、β-人绒毛膜促性腺激素、乳酸脱氢酶）在正常范围内，CT成像未显示复发或腹膜后残留肿块的证据。肾功能和激素水平稳定。鉴于之前接受过化疗，建议进行心血管监测。后续将每3 - 4个月进行临床检查和肿瘤标志物检查，计划在12个月时进行下一次CT扫描，除非出现症状需要更早进行影像学检查。
据我们所知，这是欧洲首例报道的SP-rRPLND病例。前下入路提供了安全的入路，同时将发病率降至最低，可能改善恢复情况（8）。单侧入路，避免经腹入路，可能进一步降低发病率（9）。未来的研究应验证长期肿瘤学结局，并将SP-rRPLND与多端口和开放手术方法进行比较。SP-rRPLND代表了微创睾丸癌手术中一项有前景的进展。
