Robot-assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular and Upper Tract Urothelial Cancer—Surgical Technique and Outcomes of a Single-surgeon Series

Abstract

Background and objective

Retroperitoneal lymph node dissection (RPLND) is essential in managing testicular and upper urinary tract urothelial cancer (UTUC). While open RPLND remains the gold standard, robot-assisted RPLND (RA-RPLND) is gaining traction in selected cases. This study aims to describe the surgical technique and our experience with RA-RPLND, and to demonstrate the peri-and postoperative safety and efficacy of this approach for the treatment of testicular cancer and UTUC.

Methods

We analyzed the data from a single-surgeon series of 96 patients (64 testicular cancer and 32 UTUC) who underwent RA-RPLND between 2016 and 2024. The procedures included left (n = 49), right (n = 31), and bilateral (n = 16) template dissection. Bilateral and unilateral templates were used for testicular cancer, while unilateral templates were applied to all UTUC cases involving high-grade disease in the kidney, proximal ureter, or midureter. Surgical indications, preoperative assessment, and postoperative care protocols are described. Baseline characteristics, peri- and postoperative data, and oncological outcomes were assessed. Complications were graded using the Clavien-Dindo classification.

Key findings and limitations

Median length of stay was 1 (IQR 1–1) d for testicular cancer and 2.5 (IQR 2–4) d for UTUC patients. Open conversion occurred in two testicular cancer salvage cases. Major complications (Clavien-Dindo ≥3a) occurred in 9% (testicular cancer) and 13% (UTUC) of patients. Two patients died within 90 d after RA-RPLND for UTUC: one due to an acute myocardial infarction and the other due to progressive disease. Six patients (19%) with UTUC died due to progressive disease within a median follow-up of 38 (range 4–66) mo, whereas all patients with testicular cancer were still alive after a median follow-up of 46 (range 1–97) mo. Overall and cancer-specific survival rates at the end of follow-up were 78% and 69% in patients with UTUC, and 100% and 100% in patients with testicular cancer, respectively. No retroperitoneal recurrences occurred in either cohort until the end of follow-up. Limitations include the steep learning curve and nonreproducibility by surgeons without expertise in advanced robotic surgery.

Conclusions and clinical implications

RA-RPLND remains a technically challenging operation, but is safe and effective in expert hands and should therefore be considered for selected patients in high-volume centers.

Patient summary

In this study, we examined the outcomes after robot-assisted retroperitoneal lymph node dissection. We conclude that it is a safe and effective procedure for patients with testicular cancer and cancer of the renal pelvis and ureter when performed by experienced surgeons. Therefore, it can be a suitable choice for certain patients, depending on their individual circumstances. Patients should also be given detailed instructions about what to expect after surgery, including how to take care of themselves at home to promote recovery and stay safe after being discharged from the hospital.