Technique and Early Surgical Outcomes for Robotic Retroperitoneal Lymph Node Dissection on the Da Vinci Xi Surgical System
Vincent D. D'Andrea, MD, Jillian M. Egan, MD, Zhiyu (Jason) Qian, MD, Thomas J. Hwang, MD, Kendrick Yim, MD, Venkat M. Ramakrishnan, MD, PhD, Timothy N. Clinton, MD, MPH
Brigham & Women's Hospital, Boston, MA, USA
Background: Retroperitoneal lymph node dissection (RPLND) is a key modality in the treatment of testicular cancer. Open RPLND has long been the standard approach, but is associated with significant morbidity. More recently, the utilization of robotic RPLND has gained traction as an attractive alternative. A growing base of literature has shown robotic RPLND to have similar oncologic and surgical outcomes, as well as improved length of hospital stay (LOS) compared to the open approach. In this single-institution prospective analysis, we demonstrate our technique for robotic RPLND in the primary setting and evaluate early patient outcomes. We aimed to describe our approach, report preliminary efficacy, and discuss the safety and feasibility of our unique post-operative care pathway. Methods: Robotic RPLND was performed with the DaVinci XI surgical system and recorded using the embedded software. Patient baseline characteristics and operative outcomes were obtained. All patients were administered a standard post-operative regimen; this included the deferral of surgical drain placement, advancement to a low-fat chyle-leak diet (with a nutrition consultation for additional patient guidance) and removal of the Foley catheter on post-operative day one, and discharge with a prescription for 28 days of apixaban for deep vein thrombosis (DVT) prophylaxis. Primary outcome was LOS. Secondary outcomes included operative time, transfusion rate, and estimated blood loss (EBL). The surgical footage was edited and narrated using video editing software to display the surgical steps and relevant anatomy. Results: Patient baseline characteristics and operative outcomes are recorded in Table 1. In total, four robotic primary RPLNDs were completed during the study period. Median age was 32.5 years (interquartile range [IQR] = 29.5-38.0 years) and median BMI was 29.5 (IQR = 24.8-34.4). Mean EBL was 87.5cc (standard deviation [SD] = 47.9), mean OR time was 335 minutes (SD = 47.7 minutes), and all patients stayed in the hospital for two days. No patients required intra-operative or post-operative transfusion. There have been no post-operative bleeding or DVT events. Conclusions: Overall, we find that our approach to primary robotic RPLND is safe and feasible. The study population was relatively young and healthy. Compared with the standard open approach, our initial experience indicates that the robotic approach may decrease LOS and EBL, which is in line with current literature. Similarly, our approach to post-operative care with no drain and rapid diet advancement and Foley catheter removal may increase patient comfort. Post-operative DVT prophylaxis appears to be safe and effective. Limitations of this study include small patient sample size and short length of patient follow-up. Future direction includes further patient accrual and long-term patient follow-up to assess oncologic outcomes and efficacy of the unique post-operative regimen.
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