Robotic retroperitoneal lymph node dissection (RPLND) for testicular cancer: an interview with Dr. Stephen Williams of St. Joseph Hospital in Orange

Interview conducted by April Cashin-Garbutt, MA (Editor)Jul 10 2013

Please can you give a brief introduction to robotic RPLND and how this procedure has traditionally been performed?

Robotic RPLND utilizes laparoscopy combined with robotic technology to perform dissection and removal of lymph node tissue in the retroperitoneum both as a staging as well as therapeutic procedure for patients with testicular cancer.

Robotic RPLND requires 6 small 8-10mm incisions to allow access to the abdomen. Traditionally, RPLND is performed via a large mid-line abdominal incision from just below the rib cage to just above the pubic symphysis.

The procedure performed either via the open or robotic approach is the same but differs in regards to sidedness of procedure. The primary landing site for right-sided tumors is the interaortocaval region followed by precaval and then preaortic nodes. Left-sided tumors primarily metastasize to the preaortic and para-caval nodes and then to the interaortocaval region. Contralateral spread is more common for right-sided tumors due to lymphatic cross-over (1).

The above knowledge combined with an understanding of the neuro-anatomy of ejaculation has aided in the development of modified right and sided templates with nerve sparing when deemed appropriate (2-5).

The modified right-sided RPLND template is bounded superiorly by the right renal artery, medially by the lateral aspect of the aorta, laterally by the ipsilateral ureter, and inferiorly by the inferior mesenteric artery and ipsilateral common and external iliac vessels. The right-sided template focuses on removal of lymph nodes in the interaortocaval, precaval and preaortic regions.

A modified left-sided template RPLND follows the same contralateral boundaries with the focus on removing lymph nodes in the interaortocaval, left paraortic and preaortic regions above the inferior mesenteric artery.

These modified templates have resulted in greater than 90% postoperative ejaculatory emission (4). Further nerve-sparing studies identifying and preserving sympathetic fibers intraoperatively have resulted in greater than 98% postoperative ejaculatory function (6).

1. Sogani PC. Evolution of the management of stage I nonseminomatous germ-cell tumors of the testis. Urol Clin North Am.1991;18: p. 561.
2. Richie JP. Clinical stage 1 testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol. 1990;144: p. 1160.
3. Fossa SD, Klepp O, Ous S et al. Unilateral retroperitoneal lymph node dissection in patients with non-seminomatous testicular tumor in clinical stage I. Eur Urol. 1984;10: p. 17.
4. Donohue JP, Foster RS. Retroperitoneal lymphadenectomy in staging and treatment. The development of nerve-sparing techniques. Urol Clin North Am. 1998;25: p. 461.
5. Heiken JP, Forman HP, Brown JJ. Neoplasms of the bladder, prostate, and testis. Rad Clin North Am. 1994;32: pp.81-96.
6. Donohue JP, Foster RS. Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation, J Urol. 1990;144: pp. 287–292.

When did robotic RPLND first become available and how was it developed?

Laparoscopic retroperitoneal lymph node dissection (RPLND) for patients with non-seminomatous germ cell tumors have met with great skepticism with results reported from high volume laparoscopic surgeons at few dedicated centers.¹

Unfortunately due to the inherent difficulty with dissection, incomplete dissection and limited number of patients there remains insufficient data to suggest superiority to open RPLND.¹

Robotic technology provides the necessary instrumentation and visualization to perform many complex urologic procedures such as partial nephrectomy² and radical nephrectomy with vena caval thrombectomy³ with lymph node dissection.

Robotic RPLND has been successfully performed previously.⁴ I previously reported the first case series of robotic assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I non-seminomatous testicular cancer.⁵

1. Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol. Nov 2008;54(5):1004-1015.
2. Rogers CG, Patard JJ. Open to debate. The motion: Robotic partial nephrectomy is better than open partial nephrectomy. Eur Urol. Sep 2009;56(3):568-570.
3. Abaza R. Robotic surgery and minimally invasive management of renal tumors with vena caval extension. Curr Opin Urol. Dec 30.
4. Davol P, Sumfest J, Rukstalis D. Robotic-assisted laparoscopic retroperitoneal lymph node dissection. Urology. Jan 2006;67(1):199.
5. Williams SB, Lau CS, Josephson DY. Initial Series of Robotic Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Non-Seminomatous Germ Cell Testicular Cancer. Euro Urol. 60(6): 1299-1302, 2011.

What are the benefits of robotic RPLND?

Robotic RPLND is truly a game changer in the multimodality treatment options for testicular cancer. While morbidity of traditional open surgery ranges between 3-4 days in the hospital there is greater than 4 weeks recovery to normal activity and normal bowel function in addition to pain requirements.

Robotic RPLND results in a 1-2 day hospital stay with most patients resuming normal bowel function and physical activity within 1-2 weeks and minimal pain requirements beyond 3-4 days after surgery. Surgical staging corroborates the open technique.

With enhanced three-dimensional visualization and precise surgical instrumentation provided by the robotic system I was able to perform a meticulous and complete modified nerve sparing RPLND template. The great vessels were mobilized and when necessary lumbar veins and arteries were easily identified and divided in a ‘split and roll’ fashion.⁵ The IVC and aorta were lifted off of the posterior abdominal wall and anterior spinous ligament to ensure complete resection of lymphatic tissue.

I did not feel limited in this dissection and the placement of our robotic trocars eliminated clashing which is sometimes an issue with other robotic procedures.

Patients with high-risk features such as embryonal carcinoma with or without lymphovascular invasion are primarily offered chemotherapy due to the oncologic efficacy and minimal morbidity when compared to open RPLND.

Robotic RPLND may provide these patients and practitioners a minimally invasive diagnostic and therapeutic alternative and thus be an attractive alternative to immediate chemotherapy.

1. Williams SB, Lau CS, Josephson DY. Initial Series of Robotic Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Non-Seminomatous Germ Cell Testicular Cancer. Euro Urol. 60(6): 1299-1302, 2011.

Is there a large learning curve associated with robotic RPLND?

There are few centers of excellence that perform traditional open RPLND and even fewer centers that have attempted to perform robotic RPLND. There is a tremendous learning curve associated with understanding the precise anatomy of the retroperitoneum and specifically how this relates to testicular cancer ‘landing zones’.

I was fortunate to train under one of the world leaders in open RPLND as well as formal training in robotic surgery. This procedure was challenging and only surgeons with extensive open urologic oncology training in RPLND and robotic surgical experience should consider this approach.

What are the downsides of current robotic RPLND procedures and how do you think these can be overcome?

Laparoscopic RPLND has been purported to offer a minimally invasive alternative to the open approach with precise lymph node staging.¹ Laparoscopic dissection has been limited in that retrocaval and retroaortic tissue is not routinely resected owing to the difficulty with the laparoscopic approach.¹

It should be mentioned that these laparoscopic RPLND data are derived from well experienced laparoscopic surgeons at select tertiary centers. Robotic technology overcomes this limitation with the ability to a perform meticulous and complete lymph node dissection.²

1. Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol. Nov 2008;54(5):1004-1015.
2. Williams SB, Lau CS, Josephson DY. Initial Series of Robotic Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Non-Seminomatous Germ Cell Testicular Cancer. Euro Urol. 60(6): 1299-1302, 2011.

Where is robotic RPLND currently available and which testicular cancer patients are eligible for this procedure?

Robotic RPLND is offered by few urologic oncologists at centers of excellence. Patients with clinical stage I (CSI) non-seminomatous germ cell tumors specifically with high risk features such as embryonal carcinoma with or without lymphovascular invasion are primarily offered chemotherapy due to the oncologic efficacy and minimal morbidity when compared to open RPLND.

Robotic RPLND may provide these patients and practitioners a minimally invasive diagnostic and therapeutic alternative and thus be an attractive alternative to immediate chemotherapy. As I observed in our series, robotic RPLND provided a meticulous and clean dissection which may not only eliminate viable tumor but chemoresistant teratoma as well.

While promising, further application to CS IIa and post-chemotherapy patients should be investigated only once additional study for CSI patients deem it oncologic and functionally equivalent to the open approach.

1. Williams SB, Lau CS, Josephson DY. Initial Series of Robotic Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Non-Seminomatous Germ Cell Testicular Cancer. Euro Urol. 60(6): 1299-1302, 2011.

What impact do you think robotic assisted procedures will have on patient outcomes?

The use of robotics will result in fewer hospital stays, less pain, smaller incisions and hopefully allow greater number of patients to be offered procedures they may have not been offered beforehand due to increased morbidity with open procedures.

What are your plans for the future?

I continue to be actively involved in both the clinical and research aspects of urologic oncology primarily dedicated to outcomes research. This will become imperative as we embark upon a new era in health care.

I serve on the Foundation Board of Directors at St. Joseph Hospital in Orange and I look forward to additional administrative responsibilities to improve the quality of care to our patients.

Where can readers find more information?

Readers may refer to my websites www.ocurology.com and in addition to www.sjo.org/cancer. Lastly, appointments may be made by contacting my office directly at 714-639-1915 and/or email via website portal access above.

About Dr. Stephen Williams

Dr. Williams’ clinical interests lie largely in robotic and minimally invasive surgical treatments of urologic cancers (prostate, kidney, bladder, testicular) and enlarged prostate (BPH).

His training is unique in that he has completed residency training at Harvard Medical School with specific focus in Urologic Oncology and Advanced Laparoscopic/Robotic Assisted Surgery as well as general urology.

He has specifically helped pioneer robotic surgery at Harvard in the treatment of prostate, renal, ureteral and testicular cancers.

He has more than 100 peer-reviewed publications, book chapters and presentations at local and national meetings.

He is an expert reviewer for The Journal of Urology, The Journal of Robotic Surgery, Urology, European Urology, Journal of Endourology, Canadian Journal of Urology, The Journal of Reproduction and Infertility and Clinical Genitourinary Cancer. His experience with female urology, kidney stone management and other aspects of general urology is equally extensive.

Dr. Williams strives to uphold the clinical guidelines set by the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN).

Lastly, he serves on the Foundation Board of Directors at St. Joseph Hospital in Orange and serves as a medical consultant to help the medical community better serve patients.