robotic rplnd is as good as open rplnd · 9 (75%) nsgct 3 (25%) seminoma tumors clinical stage was:...
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Robotic RPLND is as good as open RPLND
Alejandro R Rodríguez, M.D. Chief of Urology and Urology Oncology
Director of Robotic and Minimally Invasive Surgery
Samaritan Medical Center
Watertown, New York
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Financial and Other Disclosures
No Financial relationship
Disclosure code : N
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Introduction Testicular Cancer
In USA for 2018: 9,310 new cases 400 deaths
NIH-NCI –Seer.cancer.gov.2018
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RPLND for Clinical Stage I NSGCTs
In the USA, it is the most commonly used option for stage I patients who elect adjuvant therapy.
In Europe, a risk-adapted approach has been proposed by the EAU guidelines:
Low risk = Surveillance
High risk (LVI present) = 2 cycles of BEP
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RPLND for Clinical Stage I NSGCTs
For men with high-risk pathologic features
For those who are unable to comply with a surveillance schedule
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RPLND for Clinical Stage I NSGCTs
Advantages over surveillance or adjuvant chemotherapy:
Accurate pathologic staging
Low short and long-term morbidity
Minimizes de risk of relapse due to Chemo-resistant GCT and Teratoma
Simplified FU regimen, limited to tumor markers and chest imaging.
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RPLND for NSGCTs
RPLND is the standard approach to the surgical management of NSGCTs in both the primary and post-chemotherapy setting
A template dissection or a nerve-sparing approach to minimize the risk of ejaculatory disorders should be considered in patients undergoing primary RPLND for stage I non seminoma.
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Post Chemotherapy Setting:
A full bilateral template RPLND should be performed in all patients undergoing RPLND with boundaries being:
Superiorly: Renal hilar vessels
Laterally: Ureters
Inferiorly: Common iliac arteries
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Robotic Bilateral RPLND Supine Position
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Following Surgical Principles of Open RPLND
Beveridge TS, et al J Urol 2016
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Following Surgical Principles of Open RPLND
Beveridge TS, et al J Urol 2016
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Is Robotic RPLND as good as Open RPLND?
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Robotic RPLND Prevents
Large Incision:
Pain Ileus Poor Cosmesis
Increased: EBL Transfusion Rate Hospitalization
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Subramanian VS et al. Urol Oncol 2010
Type of Complication P-RPLND PC-RPLND P value Intraoperative: 5% 12% NS Postoperative: 24% 32% NS Late: 7 % 7% NS Grade III-V 3% 8% NS Ileus 63% 45% NS
1982-2007: 204 patients and 208 RPLND
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Subramanian VS et al. Urol Oncol 2010
Type of Complications P-RPLND PC-RPLND P value Blood loss 450 cc 1000cc <0.001 Transfusion rate 6% 42% <0.001 Incisional Hernia: 4 patients in each cohort (Total of 8 patients) Hospitalization: Median of 6 days in both cohorts.
1982-2007: 204 patients and 208 RPLND
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Williams SB et al. BJU Int. 2009;105: 918
2001-2008: 190 patients P- RPLND: 7% complications
Ileus: 3 Chylous Ascitis: 2
PC- RPLND: 11 % complications Ileus: 2 Chylous Ascitis: 2 Aortic Lesion (10 units of blood): 1
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Williams SB et al. BJU Int. 2009;105: 918
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Robotic RPLND
1st reported in 2006.1
Has the advantages of the laparoscopic approach in addition to: 3-D imaging Articulating instruments
Several small single-institutional case series have been reported. 2,3
1. Davol P, et al. Urology 2006; 67: 199. 2. Williams SB et al. Eur Urol 2011; 60: 1299-302. 3. Cheney SM et al. BJU Int 2015; 115: 114-20
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Robotic RPLND
Abdul-Muhsin HM, et al. J Surg Onc 2015;112: 736-740
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2011 – 2015 : 47 Robotic P-RPLND Clinical stage I-IIA NSGCT
42 (89%) CS I 5 (11%) CS IIA
Operative time: 235 min EBL: 50 cc (50-100 cc) Length of stay: 1 day
Complications:
Intraoperative : 2 (4%) Early post operative: 4 (9%) Antegrade ejaculation: 100%
Pearce SM et al Eur Urol 2017; 71: 476-482
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Node count : 26 (18-32) 8 (17%) positive nodes
pN1 = 7 pN2 = 1
5 (62%) received adjuvant chemotherapy One recurrence was out of the template in the pelvis after
adjuvant chemo (resected teratoma)
Median FU: 16 months 2 year recurrrence free survival was 97%
Pearce SM et al Eur Urol 2017; 71: 476-482
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2011-2015: 12 PC- Robotic RPLND 9 (75%) NSGCT 3 (25%) seminoma tumors
Clinical Stage was: CS II A in 1 (8.03%) CS II B in 2 (16.7%) CS II C in 3 (25%) CS III in 6 (50%)
Mean Operative Time: 312 min Mean EBL: 475 cc Mean Hospital Stay: 3.2 days
Kamel MH et al J Endourol 2016;30 (5): 510-519
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Mean LN count: 12 Teratoma in 5 (45.5%) Benign/necrosis in 5 (45.5%) Viable Germ cells in 1 (9%)
Median FU - 31 months: no recurrences
Kamel MH et al J Endourol 2016;30 (5): 510-519
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Conclusions
With strict adherence to open oncology principles, Robotic RPLND can be performed
safely with the same oncologic control as open RPLND and a marked reduction in
patient morbidity.