EURURO Vol. 72 No. 5

819 860

without conversion, with minimal EBL (median 84 ml) and
reasonable operative time, but LOS was still 4 d. Importantly,
the mean transverse size of the masses in this cohort was
1.0 cm, which represents a group that can be safely observed,
and the lymph node yield was not mentioned. The technical
difficulty of performing this surgery laparoscopically is
reflected in the high rates of open conversion in other series,
and the steep learning curve has resulted in limited adoption
of this technique for RPLND. Robot-assisted laparoscopic
RPLND (R-RPLND) has been increasingly described, although
reports are sparse and mainly pertain to the primary setting.
First reported in 2006, there have since been several small
case series demonstrating feasibility and minimal EBL
. For a recent series of 47 patients undergoing
R-RPLND for stage I (n = 42) and stage IIA (n = 5) disease,
the median operative time was 235 min and EBL was only
50 ml, with an adequate lymph node yield of 26 (96% of cases
were unilateral templates) One open conversion for
aortic injury was required, but otherwise the 30-d complica-
tion rates were in line with open series at 8.5%, and median
LOSwas just 1 d. Overall, it remains difficult at this juncture to
assess the applicability and safety of a minimally invasive
technique in the PC setting.
A shortcoming of our study is that evolving clinical
pathways at our institution may have contributed to our
positive outcomes, which may be a confounding factor. For
instance, while we do not administer medications such as
alvimopan that are typically found in enhanced recovery
protocols, we do emphasize principles of early mobilization,
early resumption of oral intake, minimal use of narcotics,
and avoidance of excessive intravenous fluid administra-
tion, which may have contributed to better clinical
outcomes. Most of these principles, however, were part
of the prior postoperative management protocols and thus
we believe that most of the benefits seen in this study are
attributable to the EP approach. A comparative study of TP
versus EP cases with the same postoperative management
would be needed to confirm this.
5. Conclusions
This midline EP approach reduces surgical morbidity,
accelerates the return of bowel function, and may eliminate
the long-term risk of SBO without compromising the
completeness of the template resection or sparing of the
postganglionic sympathetic nerves.
Author contributions: Siamak Daneshmand had full access to all the data
in the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Syan-Bhanvadia, Daneshmand.
Acquisition of data: Syan-[10_TD$DIFF]Bhanvadia, Bazargani, Clifford, Miranda.
Analysis and interpretation of data: Syan-Bhanvadia, Daneshmand,
Bazargani, Clifford, Cai.
Drafting of the manuscript: Daneshmand, Syan-Bhanvadia, Bazargani.
Critical revision of the manuscript for important intellectual content: Syan-
Bhanvadia, Daneshmand.
Statistical analysis: Cai.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Daneshmand, Syan-Bhanvadia.
Other: None.
Financial disclosures: Siamak Daneshmand certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None[1_TD$DIFF].
Appendix A. Supplementary data
The Surgery in Motion video accompanying this article can
be found in the online version at
.
References
[1]
.
[2] National Cancer Institute. SEER Stat fact sheets: testis cancer.
.
[3]
.
[4]
.
[5]
.
[6]
.
[7]
[8]
.
[9]
[10]
[11]
[12]
.
[13]
E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 8 1 4 – 8 2 0 819