SAFETY AND EFFICACY OF OUTPATIENT ROBOTIC RETROPERITONEAL LYMPH NODE DISSECTION FOR STAGE 2 NONSEMINOMATOUS GERM CELL TUMOR PATIENTS WITH/WITHOUT NEOADJUVANT CHEMOTHERAPY

Abstract

Introduction

Retroperitoneal lymph node dissection (RPLND) is a complex surgical procedure typically performed at high volume tertiary centers for testicular germ cell cancer. Historically an open approach has been utilized but since the first reported robotic RPLND (rRPLND) in 2006, this approach has gained popularity offering possible advantages including less operative blood loss and earlier recovery particularly. While early reports were primarily in patients with stage 1 disease, increased experience has expanded rRPLND to patients with more advanced disease and in the post-chemotherapy setting. We report our experience at a single large tertiary center and assess the safety and efficacy of outpatient rRPLND in patients with Stage 2 nonseminomatous germ cell tumor (NSGCT) disease who had and had not undergone neoadjuvant chemotherapy.

Methods

A retrospective analysis was conducted on patients who underwent outpatient rRPLND at a single tertiary center from January 2021-July 2024. Appropriate templated dissection and utilization of nerve-sparing was performed in accordance with NCCN guidelines. Data collected included the patient's age, body mass index (BMI), pathology, surgical time, estimated blood loss, length of stay, intraoperative complications (iAE CLASSIC Grade > 1), postoperative complications (Clavien Dindo > 2), and 30 day readmissions.

Results

Twenty patients were identified who underwent outpatient rRPLND. The median demographics included age 31 years (range 20 - 71 years) and BMI 28 kg/m2 (range 20.2 - 42 kg/m2). Primary tumor laterality consisted of 45% (n=9) left, and 55% (n=11) right side. Clinical stages included 7 (35%) Stage 2A NSGCT, 9 (45%) Stage 2B NSGCT, 4 (20%) Stage 2C. Eighty five percent of patients had neoadjuvant chemotherapy (n = 17). The median operative time was 165 minutes (range 85 - 267 minutes). The median estimated blood loss was 55 mL (range 5 -300 mL). Two intraoperative class Grade 2 complications were observed. One venotomy requiring primary closure and one small bowel enterotomy which was primarily repaired. Postoperative complications included one case of cellulitis treated with antibiotics and one case of chylous ascites requiring readmission that resolved following drain placement (Clavien Dindo 2 and 3, respectively). This was the only readmission.

Conclusions

rRPLND can be safely and effectively performed as an outpatient procedure in patients with Stage 2 NCGCT who have or have not received neoadjuvant chemotherapy. When performed as an outpatient surgery there was an acceptable rate of readmission and postoperative complications similar to historic controls. Further research is needed to identify factors that contribute to appropriate patient selection for rRPLND. Longer term follow up is needed to assess long-term oncologic outcomes and preservation of ejaculatory function compared to an open approach.