Minimally invasive RPLND safe, efficacious in testis cancer

San Diego-Minimally invasive retroperitoneal lymph node dissection in testicular cancer reduces length of stay while obtaining a perioperative safety profile comparable to that seen with the open procedure, researchers from the University of California, San Diego Health System reported.

However, it is a challenging procedure, one usually performed in high-volume centers by experienced surgeons who appear to select healthier patients, say the study’s authors. This may color the study’s findings and indicates the need for a prospective study to fully assess the safety and efficacy of the procedure, first author Seth A. Cohen, MD, told Urology Times following his presentation of the study at the 2012 AUA annual meeting in Atlanta.

“In selected patients, minimally invasive RPLND has a safety profile equivalent to open RPLND and provides a shorter length of hospitalization. While encouraging, these data call for a multicenter prospective study to examine not only perioperative outcomes and complications, but longer term oncological and non-oncologic sequelae,” said Dr. Cohen, a urology resident at the University of California San Diego Health System, who worked on the study with Ithaar Derweesh, MD, and colleagues.

Such a study would take time, given the tumor biology of testicular cancer and the relative rarity of the disease. The current study should be considered an interim step, one that offers an overview of the procedure’s short-term safety outcomes on a national level, Dr. Cohen told Urology Times.

For the study, the authors surveyed the Nationwide Inpatient Sample, a U.S. database, to identify 6,926 men who had undergone open RPLND and 153 treated with minimally invasive RPLND (laparoscopic or robot assisted) between 1998 and 2009. They found that there were no differences between the two procedures in terms of mortality, complications, or prevalence of patient safety events, an indicator of complications. However, the median length of stay with the minimally invasive procedure (2 days) was significantly shorter than with the open procedure (5 days, p<.001).

The findings come with some caveats, Dr. Cohen told Urology Times.

“First, this is not a common disease. The studies to date have been those of a relatively few surgeons, working in high-volume centers. These surgeons tend to be experienced and comfortable with complex minimally invasive surgery,” he explained.

Selection bias detected

Dr. Cohen added that the study also detected a selection bias in that the patients undergoing the minimally invasive procedure had a significantly lower mean Charlson comorbidity index.

“There is a likely significant selection bias, with healthier patients being selected to undergo minimally invasive RPLND. The results of this study should be viewed in that context,” Dr. Cohen said.

The authors also noted that although the frequency of the minimal procedure was low (roughly 2% of the procedures in the study), it was increasing at a steady annual rate. Dr. Cohen said he expects the procedure to continue to grow, with widening application of the robotic platform to major and complex operations such as RPLND.

“This is a procedure that needs to be conducted by an experienced surgeon and deserves further, prospective study to ensure safe diffusion and appropriate application of this technology,” said Dr. Cohen. He added that he knew of no plans as yet to conduct a national prospective trial.