Testicular cancer is the most common malignancy in young American men, with an estimated 9190 new cases and 470 deaths in 2023.¹ Retroperitoneal lymph node dissection (RPLND) is a management option for early-stage nonseminomatous germ cell tumors and postchemotherapy residual masses.² An open RPLND has historically been the standard approach. However, it is associated with significant pain and morbidity. For this reason, many patients opt for surveillance or chemotherapy. Surveillance is the preferred management strategy in stage IA nonseminomatous germ cell tumors, but its effectiveness can be reduced by noncompliance in this young and highly mobile population.³ Although chemotherapy is highly curative, it is accompanied by numerous long-term risks including cardiovascular disease, pulmonary complications, nephrotoxicity, infertility, and secondary malignancies.⁴ A high-quality RPLND can cure up to 80% of patients who harbor small volume pN1 disease, thereby avoiding the toxicity of chemotherapy.⁵,⁶

Laparoscopic RPLND brought about reduced morbidity, but the steep learning curve and technical complexity meant very few patients could reap the benefits.⁷ With the advent of robotics, minimally invasive surgery in urology became widely adopted due to breakthroughs in optics, dexterity, precision, and ergonomics. Application of the robotic platform to RPLND yielded major advantages including better control of lumbar vessels and safer dissection of lymph nodes posterior to the great vessels. Since the first robotic RPLND in 2006,⁸ innovations in technology and technique have made this surgery more pragmatic. The da Vinci Xi robot enabled both retroperitoneal and spermatic cord dissection to be performed without the need to redock. And the development of the supine approach with a linear port configuration (Figure) allowed a full template bilateral lymphadenectomy to be performed without the need to reposition the patient or place additional ports as is the case with flank positioning.⁹

Despite these advances, there remain concerns about the effectiveness and safety of the robotic approach. Outcomes data have largely been derived from single institution case series. A recent systematic review summarized the past 15 years of publications on robotic RPLND.¹⁰ When compared to open, robotic RPLND had similar operative times, lower blood loss, fewer transfusions, and half the overall complications. Ureteral, splenic, bowel, and pancreatic injuries were reported, though all were successfully managed robotically. The open conversion rate for a primary robotic RPLND was 2.2% and 9% in a postchemotherapy setting. The median hospital stay for a robotic RPLND was 2 days compared to 4 to 6 days for an open RPLND.¹¹,¹² Lymph node yields were no different between the 2 approaches.^12-14 Oncologic outcomes rivaled open RPLND data with a disease recurrence rate of 6.7%.^12-14 Thus, a growing body of literature suggests a robotic RPLND in experienced hands can replicate the oncologic outcomes of open surgery while mitigating morbidity and shortening convalescence. With continued refinement of the technique, patients will have more choice in the management of their testicular cancer.