Single-Port Robot-Assisted Post-Chemotherapy Unilateral Retroperitoneal Lymph Node Dissection: Feasibility and Surgical Considerations

Abstract

Introduction: 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).

Methods: 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.

Results: 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.

Conclusions: 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.