The use of the da-Vinci robotic system allowed laparoscopic surgery to mimic an open bilateral approach without repositioning the patient. The robot also enables easier and more complex dissections that may allow for further resection of post-chemotherapy masses and more complete dissection behind the great vessels.
The development of the supine approach to robotic RPLND allows surgeons to better mimic open techniques and perform a complete, bilateral dissection.
Initially, during robotic RPLND, patients are placed in the lateral decubitus position to facilitate modified template dissection. This approach allows for modified template-based dissection as previously published and is sufficient for early-stage disease, but may require repositioning if a complete bilateral dissection is attempted.
The use of the robotic system (Davinci Xi) allows for wider dissection. This technique is particularly useful when performing large postchemotherapy retroperitoneal dissections. Although the complication rates between open and R-RPLND are comparable, the rate of chylous ascites is reported to be <1% versus approximately 4% in the L-RPLND and R-RPLND series, respectively. Meticulous use of surgical clips around the left renal vein and lymphatic ducts can minimize the risk of chylous ascites. Anterograde loss of ejaculation is another frequently cited complication associated with RPLND. In R-RPLND, 100% of patients can maintain ejaculatory function, at least in the primary setting with modified templates.