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| Robot-assisted retroperitoneal lymphadenectomy: The state of art |
Gilberto J. Rodriguesa,Giuliano B. Guglielmettia,Marcelo Orvietob,Kulthe Ramesh Seetharam Bhatc,Vipul R. Patelc,Rafael F. Coelhoa,*( )
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a Sao Paulo State Cancer Institute, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
b Clínica Alemana, Santiago, Chile
c Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, United States |
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Abstract Objective: To perform a narrative review about the role of robot-assisted retroperitoneal lymphadenectomy (R-RPLND) in the management of testicular cancer. Methods: A PubMed search for all relevant publications regarding the R-RPLND series up until August 2019 was performed. The largest series were identified, and weighted means calculated for outcomes using the number of patients included in each study as the weighting factor. Results: Fifty-six articles of R-RPLND were identified and eight series with more than 10 patients in each were included. The weighted mean age was 31.12 years; primary and post chemotherapy R-RPLND were performed in 50.59% and 49.41% of patients. The clinical stage was I, II and III in 47.20%, 39.57% and 13.23% of patients. A modified R-RPLND template was used in 78.02% of patients, while 21.98% underwent bilateral full template. The weighted mean node yield, operative time and estimated blood loss were, respectively, 22.15 nodes, 277.35 min and 131.94 mL. The weighted mean length of hospital stay was 2 days and antegrade ejaculation was preserved in 92.12% of patients. Major post-operative complications (Clavien III or IV) occurred in 5.34%. Positive pathological nodes were detected in 24.54%, while the recurrence free survival was 95.77% with a follow-up of 21.81 months. Conclusion: R-RPLND has proven to be a reproducible and safe approach in experienced centers; short-term oncologic outcomes are similar to the open approach with less morbidity and shorter convalescence related to its minimal invasiveness. However, longer follow-up and new trials comparing head-to-head both techniques are expected.
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Received: 17 February 2020
Available online: 20 January 2021
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Corresponding Authors:
Rafael F. Coelho
E-mail: coelhouro@yahoo.com.br
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PRISMA 2009 Flow Diagram. R-RPLND, robot-assisted retroperitoneal lymphadenectomy; L-RPLND, laparoscopic retroperitoneal lymph node dissection; PRISMA, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. From: Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6 (7): e1000097. https://doi.org/10.1371/journal.pmed1000097. For more information, visit http://www.prisma-statement.org/.
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| Scenario | Pearce et al., 2017 [13] | Harris et al., 2015 [14] | Stepanian et al., 2016 [10] | Cheney et al., 2015 [15] | Li et al., 2019 [18] | Singh et al., 2017 [11] | Kamel et al., 2016 [17] | Overs et al., 2018 [16] | Weighted means | | pR-RPLND | pR-RPLND and PC-R-RPLND | PC-R-RPLND | | Median age, years (IQR) | 30 (26-38) | 30 (25-38) | 31 | 35 (23-39) | 30 (26-36) | 26 (21-37) | 38 (20-55) | 33 (22-49) | 31.12 | | Number of patients | 47 | 16 | 20 | 18 | 30 | 13 | 12 | 11 | 27.08 | | pR-RPLND n (%) | 47 (100) | 16 (100) | 16 (75) | 11 (36) | 0 | 0 | 0 | 0 | 50.59% | | PC-R-RPLND, n (%) | 0 | 0 | 4 (25) | 7 (64) | 30 (100) | 13 (100) | 12 (100) | 11 (100) | 49.41% | | cTNM Stage n (%) | | I | 42 (89) | 16 (100) | 11 (55) | 10 (56) | 0 | 0 | 0 | 0 | 47.20% | | II | 5 (11) | 0 | 6 (30) | 7 (39) | 19 (63) | 13 (100) | 6 (50) | 10 (91) | 39.57% | | III | 0 | 0 | 3 (15) | 1 (6) | 11 (37) | 0 | 6 (50) | 1 (9) | 13.23% |
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Characteristics of patients and scenario from the largest series of R-RPLND with the weighted means calculated.
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| Scenario | Pearce et al., 2017 [13] | Harris et al., 2015 [14] | Stepanian et al., 2016 [10] | Cheney et al., 2015 [15] | Li et al., 2019 [18] | Singh et al., 2017 [11] | Kamel et al., 2016 [17] | Overs et al., 2018 [16] | Weighted means | | pR-RPLND | pR-RPLND and PC-R-RPLND | PC-R-RPLND | | Patient positioning-robot docking, n (%) | | Flank-lateral | 42 (89) | 16 (100) | 11 (55) | 0 | 30 (100) | 12 (92) | 6 (50) | 11 (100) | 76.52% | | Supine-cranial | 5 (11)a | 0 | 9 (45) | 18 (100) | 0 | 1 (8) | 6 (50) | 0 | 23.48% | | RPLND template, n (%) | | Modified | 45 (96) | 16 (100) | 14 (70) | 7 (39) | 17 (57) | 11 (85) | 9 (75) | 11 (100) | 78.02% | | Bilateral | 2 (4) | 0 | 6 (30) | 11 (61) | 13 (43) | 2 (15) | 3 (25) | 0 | 21.98% | | Node yield | 26 (18-32)b | 30 (23-36)b | 20 (14-27)b | 22 (10)c | 24 (17-30)b | 20d | 12 (5-21)e | 7 (1; 24)f | 22.15 | | Operative time, min | 235 (214-258)b | 271 (236-299)b | 293 (258-317)b | 329 (40)c | 372 (329-437)b | 200d | 312 (205-408)e | 150 (45-300)e | 277.35 | | Estimated blood loss, mL, | 50 (50-100)b | 75 (50-100)b | 50 (50-100)b | 103 (78)c | 235 (160-300)b | 120d | 475 (50-1800)e | 120 (5-300)f | 131.94 | | Length of stay, day | 1 (1-1)b | NR | 1 (1-2)b | 3 (2.3)c | 2d | 4 (3-5)b | 3 (2-5)e | 3 (2-4)f | 2.00 |
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Operative outcomes from the eight largest series of R-RPLND with the weighted means calculated.
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| Scenario | Pearce et al., 2017 [13] | Harris et al., 2015 [14] | Stepanian et al., 2016 [10] | Cheney et al., 2015 [15] | Li et al., 2019 [18] | Singh et al., 2017 [11] | Kamel et al., 2016 [17] | Overs et al., 2018 [16] | Weighted means | | pR-RPLND | pR-RPLND and PC-R-RPLND | PC-R-RPLND | | Complications | | Overall, n (%) | 6 (13) | 1 (6) | 1 (5) | 6 (33) | 10 (33) | 10 (77) | 5 (42) | 1 (9) | 23.92% | | Trans-operative, n (%) | 2 (4) | 1 (6) | 1 (5) | 3 (17) | 4 (13) | 1 (8) | 2 (17) | 0 | 8.31% | | Injury, no conversion | 1 pancreatic | 0 | 1 ureter | 0 | 1 diaphragmatic | 1 aortic | 1 aortic | 0 | NA | | Conversion, n (%) | 1 (2) | 1 (6) | 0 | 3 (17) | 3 (10) | 0 | 1 (8) | 0 | 5.34% | | Reason | 1 aortic injury | 1 aortic injury | 0 | 1 robotic malfunction
1 poor exposure
1 risk of bleeding | 2 poor visualization
1 vascular injury | 0 | 1 inferior mesenteric artery injury | 0 | NA | | Post-operative, ≤90 day, n (%) | 4 (9) | 0 | 0 | 3 (17) | 6 (20) | 9 (69) | 3 (25) | 1 (9) | 15.19% | | Clavien-Dindo I-II | 1 chylous ascites
1 ileus | 0 | 0 | 1 ileus
1 transfusion
1 hyperkalemia | 2 wound infection
1 delirium tremens | 5 ileus
1 chylous ascites | 1 ileus
1 neuropathy in the upper limb | 1 chylous ascites | 9.80% | | Clavien-Dindo III-IV | 1 chylous ascites
1 body wall hematoma | 0 | 0 | 0 | 1 chylous ascites
1 colon perforation leading to multiple organ failure
1 pneumothorax | 3 chylous ascites | 1 aortic pseudoaneurysm repaired by endovascular technique | 0 | 5.39% |
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Complications from the largest series of R-RPLND with the weighted means calculated.
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| Scenario | Pearce et al., 2017 [13] | Harris et al., 2015 [14] | Stepanian et al., 2016 [10] | Cheney et al., 2015 [15] | Li et al., 2019 [18] | Singh et al.,
2017 [11] | Kamel et al., 2016 [17] | Overs et al., 2018 [16] | Weighted means | | pR-RPLND | pR-RPLND and PC-R-RPLND | PC-R-RPLND | | Antegrade ejaculation, n (%) | | No | 0 | 0 | 2 (10) | 1 (9)d | 0 | 2 (15) | 1 (10)f | 1 (11)f | NA | | Yes | 44 (94) | 16 (100) | 18 (90) | 10 (91)d | 0 | 11 (85) | 9 (90)f | 8 (89)f | 92.12% | | Unknown | 3 (6) | 0 | 0 | 0 | 30 (100) | 0 | 2 (17) | 2 (18) | NA | | Patients pN+a, n (%) | 8 (17) | 2 (13) | 8 (42) | 8 (44) | 5 (17) | 3 (23) | 5 (46) | 1 (9)g | 24.54% | | Adjuvant chemotherapy (if pN+), n (%) | | No | 3 (38) | NR | 18 (90) | 16 (89) | 3 (17) | 13 (100) | 0 | 11 (100) | NA | | Yes | 5 (62) | NR | 2 (10) | 2 (11) | 2 (7) | 0 | 1 (8) | 0 | 23.96% | | Recurrence | | In-field recurrence, n | 0 | NR | 0 | 0 | 0 | 0 | 0 | 0 | NA | | RFSb, % | 97 | NR | 100 | 89 | 90 | 100 | 100 | 100 | 95.77 | | Follow-up, month | 16 (9-23)c | NR | 49 (37-71)c | 22 (1-58)c | 15 (1-51)e | 23 (3-58)e | 31 (5-39)e | 4 (1-48)e | 21.81 |
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Functional and oncological outcomes from the largest series of R-RPLND with the weighted means calculated.
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Supine position and docking and flank position and docking. (A) Trocar placement; (B) Patient positioning; (C) Robot docking; (D) Supine; (E) Flank decubitus; (F) The doctors were performing R-RPLND. R-RPLND, robot-assisted retroperitoneal lymphadenectomy.
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Trans-operative relevant moments of RPLND in supine position. (A) Peritoneum suspension in abdominal wall to begin dissection and access the retroperitoneum; (B) Beginning of paracaval template, above the ureter cross the right iliac artery; (C) Precaval, preaortic, interaortocaval and retrocaval template with identification and sparing of postganglionic sympathetic nerve fibers (crossing between the IVC and AO); (D) Interaortocaval and retrocaval dissection reaching the right superior boundaries of the template (right renal hilum); (E) Preaortic and paraortic superior boundaries reaching the left renal hilum; (F) Final template showing the retroperitoneum vessels. AO, aorta; IVC, inferior vena cava; RPLND, retroperitoneal lymph node dissection.
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Schematic templates and boundaries for retroperitoneal lymphadenectomy. 1. Boundaries of paracaval template (superior: Right renal hilum including dissection of renal arteries; lateral: Right ureter; medial: Interaortocaval template; inferior: Right ureter crossing the right iliac vessels. 2. Boundaries of interaortocaval, precaval, retrocaval, preaortic and retroaortic templates (superior: Renal vessels; lateral: Paracaval and paraortic templates; inferior: Aorta bifurcation. 3. Boundaries of paraaortic template (superior: Left renal hilum including dissection of renal arteries; lateral: Left ureter; inferior: Left ureter crossing the left iliac vessels [laterally]).
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