Nerve-sparing Robot-assisted Retroperitoneal Lymph Node Dissection: The Monoblock Technique.BACKGROUND
 Retroperitoneal lymph node dissection (RPLND) is a treatment option for men with stage 1 or 2 testis cancer and the standard of care for men with postchemotherapy retroperitoneal residual disease.  Given the morbidity of RPLND, four important surgical modifications have been proposed: minimally invasive access, nerve-sparing resection, template resection, and en-bloc resection.


 OBJECTIVE
 To describe the surgical steps and perioperative outcomes of robotic nerve-sparing unilateral template RPLND with en-bloc resection (roboRPLND-NS+).


 DESIGN SETTING AND PARTICIPANTS
 From 2017 to 2019, five patients with suspicion of retroperitoneal metastatic testicular cancer on abdominopelvic computed tomography underwent roboRPLND-NS+ at a single referral center.  All surgeries were carried out by a single surgeon who has performed more than 500 extended and more than 50 super-extended robot-assisted lymph node dissections.


 SURGICAL PROCEDURE
 A lateral transperitoneal robotic approach with a da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in six-arm configuration was used.  The sympathetic chains, postganglionic sympathetic fibers, and hypogastric plexus were preserved as much as possible to ensure a nerve-sparing procedure.  The template borders consisted of the renal vein cranially, the ureter laterally, the interaortocaval space medially, the common iliac artery caudally, and the psoas muscle dorsally for the right and left modified RPLND templates.  Lymph nodes and the surrounding fatty tissue were progressively resected from the common iliac vessels and the abdominal aorta using the split-and-roll technique, and all of the template tissue was resected as a single specimen.  Intraoperative and postoperative complications were recorded.


 Lymph node yield and perioperative and postoperative oncological and functional outcomes were measured.


 Node metastases were pathologically confirmed in three patients.  No patient experienced intraoperative or postoperative complications.  Maintenance of antegrade ejaculation was achieved in all patients.  After median follow-up of 15 mo (IQR 14-30), all patients were alive and no recurrence was observed.  Limitations include the low number of patients and the single surgeon experience.


 CONCLUSIONS
 RoboRPLND-NS+ is a safe and feasible technique that allows removal of a high number of lymph nodes with good functional outcomes.  Short-term survival outcomes were excellent, with no recurrences or deaths recorded.


 We describe a feasible and safe robot-assisted surgical procedure for removal of lymph nodes in patients with testicular cancer.  Our technique has potential to decrease the medical problems arising as side effects of the surgery while achieving good cancer control.
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