Robotic Primary RPLND for Stage I Testicular Cancer: a Review of Indications and Outcomes

Heather J. Chalfin, Wesley Ludwig, Phillip M. Pierorazio, Mohamad E. Allaf

Patients diagnosed with stage I non-seminomatous germ cell tumor (NSGCT) face the task of selecting a management strategy. Whereas these options all offer excellent survival, unfortunately, each has drawbacks. Retroperitoneal lymph node dissection (RPLND) is a major operation with low, but significant risks of bleeding, chylous ascites, and retrograde ejaculation. Platinum-based chemotherapy is associated with a number of long-term side effects, not all of which are quantified, but include secondary malignancy and early cardiovascular disease. While surveillance minimizes the chances of exposure to unnecessary treatment, it is not infrequently salvaged with chemotherapy and requires a compliant patient willing to undergo serial imaging often with ionizing radiation. Although fewer than one-third of patients will relapse without intervention, the current guidelines propose treatment for stage I patients with high-risk features. New developments in minimally invasive techniques may mitigate the harms of RPLND and avoid the side effects of chemotherapy, making it an ideal option for this cohort of patients. Unlike laparoscopic RPLND, which was introduced as a staging procedure and heavily criticized for the advanced skill set required to achieve oncologic equivalence, robotic RPLND may offer the benefits of a minimally invasive technique without a steep learning curve and a true therapeutic operation in experienced hands.