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Extraperitoneal Single-Port Robot-Assisted Bilateral Retroperitoneal Lymph Node Dis-section for Primary
Lichen Chen1,2,3,4, Kai Dong1,2,3,4, Tongtong Zhang1,2,3,4
1Urology Centre, Shuguang Hospital Afiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China.
Introduction:
Retroperitoneal lymph node dissection (RPLND) is an established treatment option for clinical stage I-II non-seminomatous germ cell tumors (NSGCT), among which bilateral template dissection represents the most oncologically rigorous approach (1, 2). Robot-assisted RPLND has demonstrated reduced surgical morbidity while maintaining oncologic equivalence to open surgery (3). However, the prevailing multiport transperitoneal approach requires extensive bowel mobilization for bilateral exposure, adding operative complexity and bowel-related complication risk (4-6). A completely extraperitoneal single-port approach may circumvent these limitations by avoiding peritoneal entry and visceral manipulation (7).
Materials And Methods:
We present a 21-year-old male with clinical stage IIA NSGCT who underwent right radical orchiectomy and was found to have multiple enlarged retroperitoneal lymph nodes on CT. The procedure was performed using the da Vinci Xi system with the patient in the supine position. A 4.0-cm right pararectal incision was made to access the retroperitoneal space, and a single-port multichannel device was deployed. Robotic instruments were introduced in a chopstick configuration, including a 30° endoscope, monopolar scissors, and bipolar forceps. The bilateral ureters and great vessels were first exposed to delineate the standard boundaries of the bilateral template while establishing an adequate retroperitoneal working space. A split-and-roll technique was then applied from the right ureter medially, progressively skeletonizing and preserving the vascular structures through sharp dissection to achieve complete lymphadenectomy within the bilateral template, with meticulous clipping of lymphatic channels.
Results:
Operative time was 175 minutes with an estimated blood loss of 35 mL. The patient resumed oral intake on postoperative day 1 and was discharged on day 2 (VAS: 2) without complications. Thirty-two lymph nodes were retrieved; three harbored teratoma (pN1). At 36-month follow-up, the patient remains disease-free with normal tumor markers and no retroperitoneal recurrence.
Conclusions:
To our knowledge, this represents the first reported extraperitoneal single-port bilateral robot-assisted RPLND. This approach achieves oncologically thorough dissection while minimizing morbidity and facilitating rapid recovery.
Insights
This study introduces a novel single-port, extraperitoneal robot-assisted retroperitoneal lymph node dissection (RPLND) for non-seminomatous germ cell tumors (NSGCT). The technique offers a less invasive option with rapid recovery and oncologic effectiveness.
Area of Science:
- Urology
- Surgical Oncology
- Robotic Surgery
Background:
- Retroperitoneal lymph node dissection (RPLND) is a key treatment for clinical stage I-II non-seminomatous germ cell tumors (NSGCT).
- Robot-assisted RPLND (RARP) reduces surgical morbidity compared to open surgery.
- The standard multiport transperitoneal approach involves extensive bowel mobilization, increasing complexity and complication risk.
Purpose of the Study:
- To describe the first reported extraperitoneal single-port robot-assisted RPLND.
- To evaluate the feasibility and outcomes of this minimally invasive approach for NSGCT.
Main Methods:
- A 21-year-old male with clinical stage IIA NSGCT underwent a single-port, extraperitoneal RARP using the da Vinci Xi system.
- The procedure involved accessing the retroperitoneal space via a pararectal incision and performing bilateral template dissection.
- Key structures like ureters and great vessels were identified and preserved during meticulous lymphadenectomy.
Main Results:
- The surgery was completed in 175 minutes with minimal blood loss (35 mL).
- The patient experienced rapid recovery, resuming oral intake on postoperative day 1 and discharge on day 2.
- Thirty-two lymph nodes were retrieved, with three positive for teratoma (pN1); the patient remained disease-free at 36 months.
Conclusions:
- This extraperitoneal single-port bilateral robot-assisted RPLND is a novel, oncologically sound approach.
- It minimizes surgical morbidity and facilitates faster patient recovery.
- This technique offers a promising alternative for managing NSGCT requiring RPLND.
