Management of a challenging case of post chemotherapy retroperitoneal mass in testicular tumour by RASE-RPLND: A novel technique

Abstract

Objective: Retroperitoneal lymph node dissection (RPLND) is a recommended surgical treatment for nonseminomatous germ cell testicular cancer (NSGCT), in post-chemotherapy residual retroperitoneal lymphnode masses. In this video, we present our novel surgical approach, termed robot-assisted supine extraperitoneal RPLND (RASE-RPLND), for managing retroperitoneal lymph metastasis in NSGCT. Patients and surgical procedure: A 32-year-old married gentleman who was initially diagnosed to have NSGCT of left testicle and Stage T1N2M0S2, received four cycles of BEP chemotherapy, showed a residual para-aortic lymph node measuring 3.5 × 2.4 cm on follow up and was planned for RPLND. He underwent RASE-RPLND and the retroperitoneum was approached from the right flank and dissection was done across the midline to the opposite side to clear all residual lymph nodular masses. The entire paracaval, interaortocaval, and para-aortic lymph nodes were removed according to the standard bilateral template. Postganglionic sympathetic efferent fibers were preserved. Following sufficient vascular control, a portion of the left renal vein was resected along with the nodal mass, and the vein was subsequently repaired using prolene suture. Patient was discharged after 48 h. Results: We performed 13 cases of RASE-RPLND in post-chemotherapy patients, with a mean age of 27.8 ± 6.64 years and BMI of 22.8 ± 2.26Kg/m2. All cases involved NSGCT. The median operative time was 350 min with 180 ml mean blood loss. One patient required preoperative IVC filter placement, and two cases needed conversion due to adhesions and pneumoperitoneum. A renal vein injury was repaired intraoperatively. Postoperatively, lymphocele was the most common complication, managed conservatively. Conclusion: Nerve-sparing RPLND via the RASE approach in a post-chemotherapy setting shows favourable outcomes, including minimal bowel handling, managing intra-operative challenging situations and, early post-operative recovery. Complicated vascular reconstruction is possible with this approach.

Keywords

• Robot-assisted
• Extraperitoneal RPLND
• RASE-RPLND
• Testicular tumor
• Retroperitoneal lymph node dissection
• Robotic RPLND