Abstract
The major long-term morbidity of RPLND consists in the loss of antegrade ejaculation, and this is a substantial problem in the adolescent population, being at the very beginning of sexual life. There are two possibilities to spare the sympathetic postganglionic nerves responsible for ejaculation—template dissection and nerve-sparing dissection. The feasibility of both approaches by means of laparoscopy has been shown. 1,2 One has to realize, however, that nerve-sparing template dissection is feasible only with a strictly ipsilateral template, and the template for a left tumor is most critical. Some authors include the interaortocaval space, which contains the right sympathetic nerve; their ipsilateral left template results in destruction of both the left and right sympathetic nerve so that antegrade ejaculation gets lost. The cornerstone study of Weissbach and associates 3 has clearly demonstrated that the interaortocaval space does not need to be included in a left template, and this concept has been proven in many clinical series. Even John Donohue changed his mind in this respect. He not only introduced nerve sparing to RPLND, but also reduced the size of his initially large template for a left tumor to that described by Weissbach. 3 –5 This latter aspect is not well recognized, but with a dissection limited to a ipsilateral template, additional nerve sparing is an overtreatment.
It is very difficult to judge the completeness of lymph node dissection. Counting of the nodes is one inadequate solution, which has several drawbacks. No validated data exist telling about the number of nodes within a right, left, and bilateral template. Even a high node count tells neither if these nodes were removed from within the correct template nor how many nodes were overlooked. Complete removal of all nodes within clearly defined boundaries is the only way to go, and the number of relapses within the retroperitoneum in pathologic stage I patients will tell the truth. In this context, it has to be warned to attempt a full bilateral dissection without changing the position as described in case 2. This may be feasible in an exceptional patient, but should not be considered standard and may result in incomplete dissection. 2
So far it is believed that the major advantage of the da Vinci robot consists in performing surgery in a small contained space, such as in radical prostatectomy. With the early generation of the robot, exploration of a larger space was difficult or even impossible and resulted in clashing of the arms of the robot. Because of some modifications, this problem has vanished to a great extent. The authors show the feasibility of robot-assisted RPLND, but the series is too small to draw further conclusions. The problems involved with RPLND substantially differ from those of radical prostatectomy and of renal surgery so that the respective experiences can only be translated carefully. The addition of the robot to laparoscopic RPLDN, however, is a great chance to involve more surgeons with this procedure, which may allow it to increasingly replace open surgery. In the end, our patients will profit.