Retroperitoneal Lymph Node Dissection: A Robot Assisted Treatment for Testicular Cancer

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances. A Cleveland Clinic Podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig phase one and sarcoma programs. Today I'm happy to be joined by Dr. Christopher Weight, director of the Center for Urologic Oncology at Cleveland Clinic's Glickman Urological and Kidney Institute. Dr. Weight was here previously to talk about high intensity focused ultrasound or HIFU for treating localized prostate cancer. That episode is still available for you to listen to. Today he's here to talk to us about robot assisted RPLND for treatment of testicular cancer. So welcome back.

Christopher Weight, MD: Dale, thanks for having me on again. Happy to be back.

Dale Shepard, MD, PhD: All right. So remind us a little bit, I gave a little introduction there, but what's your role here at Cleveland Clinic?

Christopher Weight, MD: I am the center director for urologic oncology. That means I help oversee the patient care of the portion of urologic oncology that requires surgery or in the early stages, typically. And we have a great team here in northeast Ohio that many fellowship trained oncologists that treat the breadth of urologic cancers such as kidney, testis, prostate, penile, bladder. And then I also am the fellowship director for our urologic oncology fellowship.

Dale Shepard, MD, PhD: Excellent. Well, today we're going to talk about retroperitoneal lymph node dissection, robot assisted treatment for testicular cancer. And I guess just we have a lot of different people that might be listening in. Can you maybe give us an overview? What has traditionally been the surgical management of testicular cancer?

Christopher Weight, MD: Well, testicular cancer has really been one of the major success stories in multimodal management of cancer. Testicular cancer used to have a 95% death rate and now it's a 95% survival rate and it's been a real great example. And the initial diagnosis of testicular cancer is almost always surgical. Usually this is a disease that shows up in younger men, usually in their 20s or 30s. They usually notice an abnormality in their testicle. That is usually removed surgically with an inguinal incision. And then the diagnosis is made, that subtype testicular cancer's identified, and then that along with imaging and some blood work helps set the foundation for the staging and the grade of that tumor. And then that helps us to guide the subsequent steps.

What we're talking about today is an additional surgical procedure called the retroperitoneal lymph node dissection, which takes years of practice till it rolls off the tongue. But this is a surgery that is used for lymph nodes that appear to be involved with testicular cancer. The testicles, when they start in embryologic development, actually start up right under the kidneys and they descend into the scrotum throughout embryologic development. But the blood supply and the lymphatic drainage still goes up just underneath the kidneys along what we call the great vessels, the vena cava and the aorta.

And so if the testicle cancer spreads and there's concern that it has gone to those first chain lymph nodes, that's typically where it goes. And so we use this surgery both sometimes if we see early stage, stage one or two, we call that a primary retroperitoneal lymph node dissection. Or sometimes if we clearly see that it has spread into the retroperitoneal lymph nodes, the tumor markers are elevated and that patient undergoes chemotherapy and there is a residual cancer in the retroperitoneum, we will do the retroperitoneal lymph node dissection after the chemotherapy. And that's called a salvage retroperitoneal lymph node, or post chemo, RPLND.

Dale Shepard, MD, PhD: And I guess when we think about this procedure specifically being robot assisted, what drove the push to a robot assisted compared to a more traditional approach? What were the factors with traditional surgeries that led to this being more of a robot assisted procedure?

Christopher Weight, MD: Well, after the huge success was made in survival, as I mentioned, that swing from 95% death rate to 95% cure rate, now a lot of the attention and focus has turned on how can we make the treatments less morbid. Because these tumors show up in young men, we found a lot of the chemotherapy, though it works really well for the cancer, many of these men are left with some long-term complications related to their chemotherapy or their radiation therapy.

So in that spirit and in that vein there was this idea of, can we shift more people to surgery which has very few long term complications, and then further beyond that, can we make the surgery a more tolerable surgery? The traditional surgery, because the retroperitoneal lymph nodes are posterior or behind all of the intestines, the stomach, et cetera, all of those things have to be moved out of the way. But they're right in front of the spinal column so you can't come from the back either. And because you're operating around large blood vessels, you have to have a very controlled operative field because you need to be able to quickly resolve any bleeding if you get from these major blood vessels.

And so that was the impetus. Can we come up with a new way to approach this operation that can have a lot lower morbidity? Because the traditional approach, as I was mentioning, is a midline incision that usually goes from where the ribs come together to quite a ways below the belly button, right in the midline, so a very large incision. The intestines have to all be moved up and out of the way. And most patients would spend five to seven days in the hospital, even though they're young and healthy, and experience quite a bit of pain and difficulty in the perioperative period, although in the long term they did great.

And so that was the main driving force. Can we push more patients towards surgery and avoid chemotherapy and can we make that surgery even more tolerable and lower the morbidity so that these young men can get back to work and school or whatever is going on in their lives in that moment.

Dale Shepard, MD, PhD: So I guess as a medical oncologist my question would be, are there particular technical advances that, as you mentioned, you're trying to get lymph nodes that are behind all of the intestinal organs and you mentioned close to really important blood vessels, an important part and difficult to get to? Were there technological advances that made this a reality?

Christopher Weight, MD: There were two advances. There were fits and starts of attempting this with a laparoscopic approach where you blow air into this space and then use straight instruments to go in and try to perform this operation. But it was a very challenging operation and your options for control of the blood vessels were really limited. Furthermore, because of the challenge and the difficulty in accessing all the different quadrants of the abdomen that you needed to access, I feel like there was a compromising on the operation itself.

People would do part of the surgery, or they would only do the most concerning part, or they would just take out a lymph node and then say, okay, there's a lymph node, you need to do chemotherapy. So the robotic instrument has been around for about 20 years. People also tried that but it was not adaptable enough and did not have enough flexibility that really made it possible to recreate the open operation.

So what really made a big difference is the most recent iteration of the robot has much more flexibility and you can dock the robot from the side of the patient and still get into the location that you need. And so it was the most current generation of the robot had more flexibility, the robot arms were smaller. And we found that if we tilt the patient on their head and use gravity to pull most of the intestines away, then we can create a hammock of tissue to sew the rest of the intestines up against the abdominal wall and keep them behind and then access this really critical space where these lymph nodes go.

Dale Shepard, MD, PhD: With the robotic approach, is this primarily being used for a primary surgery or is it being more for salvage procedures or really a little of both?

Christopher Weight, MD: A little of both but certainly more commonly in the primary setting. As you know, Dale, that after chemotherapy or radiation for that matter, we usually will find a significant amount of tissue change. And we primarily do these in the primary setting prior to chemo. We have done them in the post chemo setting. They have to be the right candidate in that scenario because even though we have far more access and space with this new robotic approach, you still have somewhat limited options if you get into major bleeding. And so you have to be carefully selected for choosing the right patient in the post chemo setting.

Dale Shepard, MD, PhD: And I guess from a patient selection standpoint, are there other factors that play in terms of comorbidities? These tend to be younger people of course, but are there comorbidities or patient factors?

Christopher Weight, MD: Obesity makes this operation far more challenging because the weight of the intestines is harder to hold, both against the lungs, because the patient again is inverted in the Trendelenburg position. So the mesentery and the intestines push up against the diaphragm and if the patient weighs too much, they cannot ventilate well in that position.

And then the second, the weight of the mesentery and the intestines make it sometimes so you cannot retract adequately to have the safety margin necessary to operate around these blood vessels. So those are the main comorbidities that make this approach more challenging.

Dale Shepard, MD, PhD: How about, and again younger patients so maybe not as much of a factor, prior surgeries. Do you have to worry about that as well?

Christopher Weight, MD: Sometimes, although we are quite accustomed to operating in reoperative fields, but potentially if there was a major bowel resection, we would still probably be able to do it but it may take a little bit more effort. And occasionally patients, for example if there was a stoma for example or some major abdominal surgery, that might make it nearly impossible or unsafe, and we would do it through the traditional open approach.

Dale Shepard, MD, PhD: What about access? Certainly we do a lot of things here at the Cleveland Clinic that may not be necessarily widely available. What about access to these robotic procedures?

Christopher Weight, MD: The access is very limited to this particular approach at this time. There are very few of us around the country that are doing them. It comes from several reasons. One is certainly that this is an exceedingly complex operation, as we mentioned around the major blood vessels. And so you have to be often in the tertiary or quaternary medical center to be able to quickly respond to intense bleeding.

Second, testicular cancer fortunately is fairly rare, although the rates unfortunately are on the rise, and therefore not a lot of people have experience doing this procedure, period, let alone to then transfer a very complex open operation to a complex robotic operation. And so the uptake has been slow and it has really been regionalized to only a few centers around the country that are offering this approach.

And as I did mention earlier, one frustration I've had with some who offer it is they compromise on the operation. So they'll do a template operation when maybe a full template would be mandated if they were going to have it done open. And so I think there has been some hesitancy from the larger oncologic community to embrace the approach as well, partially because of the complexity, but partially because some of the advocates have not been rigorous in their oncologic principles and have chosen the reduction in morbidity over perhaps the correct cancer approach.

Dale Shepard, MD, PhD: And I guess since that's a really important thing when people may be considering sending a patient for a procedure, could you give us a little bit more information on template, full template, what you mean by that, just so people can think through that when they're thinking about choices for their patients?

Christopher Weight, MD: Well, what we're referring to this is of course there are two testicles and each testicle has a typical drainage zone where the lymph nodes, if you have a cancer in the right testicle for example, it will typically drain primarily to the right side, although it can cross over a little bit onto the left side because the right testicular artery actually comes from the aorta which is on the left side of the body. And so the right template is a little bit more broad. And then the left template is a little bit more narrow because the left artery and vein both are on the left side. And so the lymph drainage is primarily on the left side, although there are some cases of it crossing over to the right side.

And so in a primary setting, it's probably in a primary setting with no clear sign of metastatic disease, a templated operation is probably justified from an oncologic standpoint because there's no clear sign that it has metastasized and it is primarily an evaluation of the lymph nodes to see if there's any evidence of it having left. However, in a post chemo setting, usually in that scenario we know that there have been metastases, we know that chemotherapy has been completed, and the standard in that scenario is usually to do a bilateral template. So regardless of which side the testicle tumor originated, we would recommend removing both the left side lymph nodes and the right side or a full, what we call, bilateral retroperitoneal template.

Dale Shepard, MD, PhD: Excellent. So I guess a question that comes to mind is, we've had other episodes of this podcast, we've talked about lymphedema, when there's been disruption of lymph nodes, what might happen as a consequence. What are the consequences of taking out lymph nodes in this setting?

Christopher Weight, MD: The good news is there are very, very few long term complications of these lymph nodes. These lymph nodes are quite central. There's a lot of duplication of lymph drainage. So as opposed to lymph node dissections in the groin or leg or in the armpits where those may be the only lymph nodes or the only lymph vessels draining the extremities, there seems to be duplicated lymph drainage. So we don't see any long term lymphedema of the lower extremities or the upper extremities.

What we do see of these particular lymph nodes as they drain, what are called chylomicrons, and these are molecules that your body processes when you eat a lot of fat. And they drain through these and go back into your bloodstream and there's a possibility that these can leak out into the retroperitoneal space and you can accumulate a significant amount of fluid. And there's about a 10 to 15% risk of this happening.

And therefore we encourage our patients to eat a low fat diet for four weeks after this surgery. And if they do that, the risk of what we would call chylous ascites, is very low. Almost no patients will get it if they stick to that diet. But it is a little tricky because it is a low fat diet and many of these young men are at the point in life where they haven't really thought about what they eat and the average American eats far more than 20 grams of fat in a day. And so that is something that we encourage our patients to do and usually they will not experience that problem.

And if they do get it, then we're very strict. We control and count every gram of fat that they eat and then that usually resolves it, although they may have to have the fluid drained off before they get to the point where their body can process it and everything heals up adequately.

Dale Shepard, MD, PhD: You mentioned that patients with testicular cancer, they have a really good survival rate. We're really trying to do what we can to minimize really harm from their treatments. What do you think, with this technique, with robotic surgeries, what do you think have been the biggest wins? You mentioned before about less pain, quicker recovery. What do you think have been the biggest wins in this case?

Christopher Weight, MD: I think the recovery is remarkably faster. So the average patient, I think in the United States after an open surgery, spends about five to six days in the hospital and then about six weeks before they report feeling back to normal. Our average patient with this minimally invasive robotic approach has spent one day in the hospital.

And I had a patient come back two weeks later for his postoperative follow up and he had told me had been playing basketball. And I said, well, even though you did have a minimally invasive approach, I don't want you to be playing basketball two weeks after this kind of surgery, but was also amazed to see that he was feeling well enough to go out and play basketball.

And so I think the total recovery time is much quicker. And we've also had a slightly lower rate of chylous ascites. Part of this could be selection again, because those patients have a lower risk of chylous ascites, but also we have about five to 10 fold magnification. And so we may be able to see the vessels a little bit more clearly, the lymph vessels, and may be able to control them with clips, et cetera, maybe a little bit better, but that remains to be seen.

Dale Shepard, MD, PhD: So good success. What are the gaps? Are we where we need to be or do you still see gaps? Do you still see some room for improvement?

Christopher Weight, MD: I think there's still some opportunities to broaden this approach to a wider audience because I think one thing that I find very appealing about it as well, is that in what we call stage one B, there's a significant risk of relapse, about 50% chance that the tumor is going to come back. And we know we can lower that by RPNLD. We didn't often offer it that way and really encourage surveillance because the open RPLND was a significant procedure to undergo and often put people out for six weeks.

But also, many of these young men are in very transient phases of life where they're changing where they're living, they're in college, they're changing jobs frequently, they're on their parents' insurance, then they're off their parents' insurance. And we've actually always known that surveillance and follow up on testis cancer patients has always been a challenge because of some of those logistical details. And if we have a fairly low morbidity procedure that can help really lower that risk even better without too much of a cost to the patient, then I think that can also help for men who are in a very transient phase.

But I think we also need to figure out the details on how to get this surgery done more effectively in the post chemo setting and safely and into more obese patients because that remains a challenge that those patients may not be eligible and they may stand to benefit the most because obese patients have higher risks of wound complications, and those risks are far higher when you have an open incision compared to minimally invasive incisions.

Dale Shepard, MD, PhD: Well, you're doing good work and I appreciate all of your insight today.

Christopher Weight, MD: Well, thanks for having us on. It's been a pleasure to talk with you again.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visitingclevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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