Expanding Minimally Invasive Options for Early-Stage Testicular Cancer

Earlier this year, Alberto Pieretti, MD, a board-certified urologist and fellowship-trained urologic oncologist at Cleveland Clinic Weston Hospital, performed the first robotic-assisted retroperitoneal lymph node dissection (R-RPLND) at Cleveland Clinic in Florida.

This milestone marks a pivotal step in expanding minimally invasive surgical options for patients with early-stage testicular cancer, particularly in light of recent guideline changes by the American Urological Association (AUA).

Treating a rare cancer

Testicular cancer is a rare and highly curable malignancy, with a 5-year survival rate of 96%. Fewer than 10,000 cases will be diagnosed in the U.S. this year, and the vast majority will be germ cell tumors that originate in the cells that make sperm – seminomas and non-seminomas.

Standard treatment for testicular cancer typically involves a radical inguinal orchiectomy to remove the affected testicle combined with lymph node dissection, chemotherapy, and/or radiation therapy, depending on the type and stage of the cancer.

“The cure rate for testicular cancer is one of the greatest achievements in modern oncology, largely thanks to the development of effective chemotherapies,” states Dr. Pieretti. “Now our attention has shifted to managing the long-term health of survivors, and for some, that means avoiding the toxicities of chemotherapy or radiation, when it’s appropriate.”

Expanded indication for RPLND

Retroperitoneal lymph node dissection (RPLND) is a surgical procedure to remove lymph nodes in the retroperitoneum, the most common site for testicular cancer to spread. It is used following orchiectomy for diagnostic staging and treatment, most often in the primary setting of low-stage non-seminomas (stage IA, IB, and IIA) and residual retroperitoneal masses following chemotherapy.

According to retrospective cohort study published this year in the Journal of Urology, approximately 10% of patients in the National Inpatient Sample database diagnosed with testicular cancer between 2012 and 2019 underwent RPLND.

In 2023, the AUA updated its treatment guidelines for early stage testicular cancer to include RPLND as a treatment option for patients with stage IIA or IIB seminoma (with lymph nodes ≤3 cm) who wish to avoid long-term toxicities associated with chemotherapy or radiation therapy. Seminomas are a slower-growing and more predominant form of testicular cancer, accounting for 54% of cases diagnosed in the United States.

“Previously, patients with stage II seminomas were typically receiving chemotherapy or radiation and enduring significant long-term toxicities, such as cardiovascular disease, metabolic syndrome, and secondary cancers,” explains Dr. Pieretti. “When we intervene surgically in the early phase, we can cure a significant proportion of these patients while minimizing toxicity. So the guidelines have evolved, and we now embrace early surgery.”

Robotic vs. open RPLND

Retroperitoneal lymph node dissection has traditionally been performed via open surgery, requiring a large midline incision that is associated with significant morbidity. Studies have demonstrated that the robotic approach, first performed in 2006, offers comparable oncologic efficacy with significantly improved perioperative outcomes.

“We can achieve good cancer control robotically through small incisions with a much faster recovery and significantly reduced postoperative pain,” says Dr. Pieretti.

Key advantages of robotic RPLND include:

Shorter hospital stay.

Faster return of bowel function and mobility.

Minimal blood loss.

Decreased postoperative pain and opioid use.

Improved cosmetic outcomes.

Quicker return to daily activities.

Patients typically spend just one night in the hospital compared to 4-5 nights when undergoing open surgery. They are ambulating the day after surgery and begin a clear liquid diet until bowel function returns, says Dr. Pieretti.

“By the two-week mark, they’re on a full diet, passing gas, and experiencing minimal to no discomfort,” he notes. “We also advise no heavy lifting for four weeks and have them maintain a low-fat diet during that period to reduce the risk of lymphatic complications.”

Avoiding a large incision not only minimizes physical recovery time but also has a meaningful psychological benefit. Dr. Pieretti points out that this is especially pertinent in the younger patient population impacted by testicular cancer. It is the most common cancer in men aged 15-44, and the median age at diagnosis is 33.

“Body image and long-term quality of life are important considerations when discussing treatment options with these patients,” he adds.

Limited access to robotic approach

Despite its benefits, R-RPLND is a technically complex procedure with limited availability. Less than 5% of urologic surgeons perform open RPLND, according to American Board of Urology data, and far fewer use a robotic approach.

“This is a rare and highly specialized surgery that must be performed in centers with significant experience in both urologic oncology and advanced robotic surgery,” says Dr. Pieretti, who underwent extensive training in robotic urologic surgery during his fellowship. “We’re proud to now offer this option at Cleveland Clinic Weston Hospital, where we have a strong history of performing open RPLND in both the primary and salvage setting.”

Considerations in salvage surgery

RPLND becomes even more technically challenging in the post-chemotherapy setting. This is particularly true for seminomatous tumors, which are more likely to trigger desmoplastic reactions resulting in dense, fibrous tissue that can complicate lymph node dissection.

“There is a greater risk of bleeding and the need for vascular surgery in these situations,” reports Dr. Pieretti. “We may use a robotic approach for salvage lymph node dissection in patients with non-seminomatous tumors, but not for seminomas. In those cases, open surgery is used to ensure adequate exposure and vascular control.”

Tailoring the dissection

The extent of lymph node dissection during the procedure depends on tumor characteristics and prior treatment history. A template dissection, which is often unilateral, preserves critical structures involved in fertility and is typically sufficient for low-volume, stage IIA disease. A full template is indicated for high-risk or post-chemotherapy cases to ensure thorough disease clearance.

“For any patient who has undergone chemotherapy, we perform a full template dissection,” Dr. Pieretti states. “In early-stage IIA disease, a template dissection is oncologically sound and minimizes the risk of complications such as retrograde ejaculation.”

Preserving fertility and function

Fertility preservation is another key consideration in this patient population. During the first robotic case at Weston Hospital, Dr. Pieretti performed a right-sided template dissection on a young 29 man with stage IIA seminoma

“The patient opted for sperm banking, which we recommend since we can’t guarantee fertility preservation,” says Dr. Pieretti. “Fortunately, he maintained normal ejaculatory function postoperatively and retains the ability to have children naturally while also avoiding the long-term toxicities of chemotherapy.”

Looking ahead

Over the past three decades, the overall incidence of testicular cancer has been steadily increasing, climbing to 6.22 cases per 100,000 person-years, according to an analysis of the U.S. National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database (1992-2021).

In light of AUA guidelines supporting early surgical intervention in select patients with stage II seminomas, Dr. Pieretti anticipates more patients will opt for an alternative to chemotherapy and radiation therapy.

“Robotic RPLND offers a highly effective, minimally invasive option with favorable recovery profiles and preservation of function,” says Dr. Pieretti. “It is an important addition to the best-in-class oncologic care available at Weston Hospital for patients with testicular cancer.”