[Retroperitoneal lymphadenectomy (RPLND) for the treatment of testicular germ cell tumors-open or robotic? Pro open surgery : RPLND in the management of testis cancer].

Retroperitoneal lymphadenectomy (RPLND) represents an established surgical treatment option for patients with testicular germ cell tumors and might be performed at various clinical stages depending on individual risk factors. Typically, RPLND is performed via a trans- or extraperitoneal open approach with dissection of a unilateral or bilateral template. Since robot-assisted approaches have been established in uro-oncological surgery, the question arises whether there is already an established indication to perform robot-assisted RPLNDs (R-RPLND). International guidelines recommend that such a surgical procedure should only be performed for selected patients in testicular cancer referral centers by highly experienced testicular cancer surgeons. We reviewed the recently published data of R‑RPLND and we conclude that R‑RPLND is technically feasible and that it can be performed with equal complication rates if done in an expert center. However, there is no benefit in terms of oncological and functional outcome. Based on the results of multicenter trials and meta-analyses, antegrade ejaculation is only preserved in 65-70% of the patients, which is inferior to open surgery done in expert centers. Duration of surgery is significantly longer compared to open surgery. Oncological outcome following R‑RPLND is difficult to validate due to the short follow-up intervals and the selection of patients. Comparison of postchemotherapeutic R‑RPLND with open surgery is also hampered due to highly selected patients with only small residual masses and short follow-up periods. In summary, R‑RPLND should only be established in testicular cancer expert centers. Currently, we perform R‑RPLND especially for marker negative clinical stage IIA/B with lymph node metastases with a size of less or equal to 3 cm.