ABSTRACT
Introduction
Retroperitoneal lymphadenectomy (RPLND) is well established as a primary treatment, especially for high-risk stage I and stage IIA/B nonseminomatous tumors, but its value in seminomatous tumors is underreported (11. Ray S, Pierorazio PM, Allaf ME. Primary and post-chemotherapy robotic retroperitoneal lymph node dissection for testicular cancer: a review. Transl Androl Urol. 2020;9:949-58.). Classically, seminomas with isolated retroperitoneal lymphadenopathy are treated with external beam radiation therapy or systemic chemotherapy. Although these modalities are effective, they are associated with significant long-term morbidity (22. Aydin AM, Zemp L, Cheriyan SK, Sexton WJ, Johnstone PAS. Contemporary management of early stage testicular seminoma. Transl Androl Urol. 2020;9(Suppl 1):S36-S44., 33. Hu B, Shah S, Shojaei S, Daneshmand S. Retroperitoneal Lymph Node Dissection as First-Line Treatment of Node-Positive Seminoma. Clin Genitourin Cancer. 2015;13:e265-e269.). Some retrospective studies have demonstrated the potential of RPLND as a first-line treatment for stage IIa seminoma, and two very recent prospective trials, still with interim results: SEMS TRIAL and PRIMETEST(3-73. Hu B, Shah S, Shojaei S, Daneshmand S. Retroperitoneal Lymph Node Dissection as First-Line Treatment of Node-Positive Seminoma. Clin Genitourin Cancer. 2015;13:e265-e269.). The RPLND robotic technique has been previously described in the post-chemotherapy scenario, however, surgical videos of primary laparoscopic approach are lacking, especially in seminomatous disease (88. Gomes DC, Da Costa WH, Brazão ÉS Jr, Vergamini LB, Ricci BV, Zequi SC. Robot-assisted retroperitoneal lymphadenectomy (RPLND): video case report. Int Braz J Urol. 2021;47:907.).
Materials and Methods
We present two cases of primary videolaparoscopic RPLND, using different approaches.Case 1: Thirty four years-old, with prior right orchiectomy for mixed tumor. After 8 months he presented an two cm enlarged interaortocaval lymph node. Percutaneous biopsy showed pure seminoma metastasis.Case 2: Thirty three years-old, with previous left orchiectomy for stage I pure seminoma, without risk factors. After nine months, the patient had a three cm enlarged para-aortic lymph node.
Results
The surgical time ranged from 150 to 210 minutes, with a maximum bleeding of 300 mL and hospital discharge in 48 hours. In one of the cases, we identified a significant desmoplastic reaction, with firm adhesions to the great vessels, requiring vascular sutures, however, no major complication occurred. Pathological anatomy confirmed pure seminoma lymph node metastases in both cases.
Conclusion
Laparoscopic primary RPLND proved to be technically feasible, with less postoperative pain and early hospital discharge. We understand that more studies should be performed to confirm our oncological results.