RESUMEN
Objective: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) represents an integral component of the management of patients with non-seminomatous germ cell tumor (NSGCT). Modified templates have been proposed to minimize the surgical morbidity of the procedure. Moreover, the implementation of robotic surgery in this setting has been explored. We report our experience with unilateral post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-rRPLND) for clinical Stages IIA and IIB NSGCTs. Methods: A retrospective single institution review was performed including 33 patients undergoing PC-rRPLND for Stages IIA and IIB NSGCTs between January 2015 and February 2019. Following orchiectomy, patients were scheduled for chemotherapy with three cycles of bleomycin-etoposide-cisplatin. Patients with a residual tumor of <5 cm and an ipsilateral metastatic disease on pre- and post-chemotherapy CT scans were eligible for a unilateral template in absence of rising tumor markers. Descriptive statistics were provided for demographics, clinical characteristics, intraoperative and postoperative parameters. Perioperative, oncological, and functional outcomes were recorded. Results: Overall, 7 (21.2%) patients exhibited necrosis or fibrosis; 14 (42.4%) had mature teratoma; and 12 (36.4%) had viable tumor at final histology. The median lymph node size at surgery was 25 (interquartile range [IQR] 21-36) mm. Median operative time was 180 (IQR 165-215) min and no major postoperative complications were observed. Anterograde ejaculation was preserved in 75.8% of patients. Median follow-up was 26 (IQR 19-30) months and a total of three recurrences were recorded. Conclusion: PC-rRPLND is a reliable and technically reproducible procedure with safe oncological outcomes and acceptable postoperative ejaculatory function in well selected patients with NSGCTs.
RESUMEN
Radical cystectomy (RC) remains a highly morbid urologic procedure, and erectile dysfunction (ED) represents a significant burden for bladder cancer survivors. While inflatable penile prosthesis (IPP) offers a definitive treatment option for post-RC ED, the hostile postoperative anatomy of RC patients poses some technical challenges for IPP implantation. We report the case of a 54-year-old male with high grade bladder cancer who was managed with a robotic-assisted RC with Bricker ileal conduit urinary diversion and simultaneous implantation of a 3-piece IPP. Operative time was 310 min (230 min for the RC and ileal conduit portion, 80 min for IPP implantation). Estimated blood loss was 300 ml. Postoperative course was regular. The patient was discharged home on postoperative day 6. A robotic RC with concomitant IPP implantation can be offered as "one-step" solution to bladder cancer male patients. This approach can potentially offer the advantage of better outcome in terms of sexual function, while minimizing surgical risks, ultimately improving the quality of life of these patients.
RESUMEN
INTRODUCTION: Over the years, the robotic surgery is gaining increasing importance in the treatment of bladder cancer. Some doubts remain about the oncological safety of robotic approach and alerts have been raised about the occurrence of atypical recurrences, including peritoneal carcinomatosis and port-site metastasis. CASE PRESENTATION: The patient referred to our Emergency Department because of acute confusional state probably due to severe anemia and sepsis. A left nephroureterectomy, left hemicolectomy with end colostomy and the surgical excision of the huge mass was performed through a xipho-pubic incision associated to another left peri-stomal incision. The histological specimen analysis showed a high-grade sarcoma, not otherwise specified (sarcoma, NOS-type), measuring 29 cm × 8 cm × 5 cm in diameters. The left kidney and ureter were not infiltrated by the neoplasm while serosa membranes and muscular layers of left colon were infiltrated by the mass. The patient died because of a cardiac arrest 4 days after surgery. DISCUSSION: RARC is a safe and feasible alternative to open radical cystectomy (ORC) with satisfactory operative time, little blood loss, and low transfusion rates. Despite this, RARC is associated with a low, but not neglectable, risk of atypical metastases like peritoneal implants and port-site metastasis. Although a small amount (7%) of RARC were performed in non-urothelial variants of bladder cancer, the sarcomatoid one can be related to a greater risk of atypical recurrence and special precaution should be taken to reduce potential causes of tumor seeding.
