Robotic retroperitoneal lymph node dissection: a stepwise technical guide

Retroperitoneal lymph node dissection remains a critical operation in selected patients with testicular cancer, including defined settings of early metastatic disease, post-chemotherapy residual masses, and emerging indications for primary retroperitoneal lymph node dissection in low-volume seminoma. Despite advances in minimally invasive surgery, this operation remains technically demanding because of its proximity to the great vessels, renal hilum, lumbar branches, ureters, and sympathetic neural structures. To present a standardized stepwise technical guide for robotic retroperitoneal lymph node dissection, emphasizing reproducible exposure, peritoneal flap suspension, nerve-aware dissection, posterior plane development, controlled vascular and lymphatic management. This technical report describes robotic retroperitoneal lymph node dissection as a sequential operative workflow. Key steps include patient positioning, port placement, mesenteric incision, creation of a broad L-shaped peritoneal flap, bilateral flap suspension, cephalad stay sutures, entry into the retroperitoneal template, early neural identification, split-and-roll dissection, posterior-first interaortocaval development, and selective clip-based control of vascular and lymphatic branches. The patient is positioned supine in Trendelenburg to facilitate bowel displacement. A broad peritoneal flap is developed and suspended to maintain durable exposure. Dissection proceeds using fixed anatomic landmarks, beginning with controlled access to stable avascular planes. Sympathetic fibers are identified early when nerve preservation is oncologically appropriate. Interaortocaval and para-aortic dissection are performed using a posterior-first strategy to improve orientation and permit deliberate management of lumbar vessels. Mechanical clip control is favored for lymphatic channels and higher-risk vascular branches. Robotic retroperitoneal lymph node dissection can be performed as a structured operation centered on exposure, orientation, neural preservation, posterior plane development, and selective vascular control. Standardization may improve technical clarity during this complex retroperitoneal procedure.