Robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in the adolescent population.

BACKGROUND: Robot-assisted retroperitoneal lymph node dissection (RA-RPLND) has built on success and techniques of laparoscopic RPLND, with the added benefits of robotic technology. This paper demonstrates use of the da Vinci Xi® system for RA-RPLND in two adolescent patients. METHODS: Case #1: A 17-year-old male presented with a left testicular mass and elevated alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). Pathology revealed a mixed non-seminomatous germ cell tumor (60% embryonal, 35% yolk sac, 5% choriocarcinoma, + lymphovascular invasion). Tumor marker normalized post-orchiectomy, and staging imaging was without evidence of metastatic disease. After discussion of options he opted to undergo RA-RPLND. Case #2: A 15-year-old male presented with a right para-testicular mass and negative tumor markers. He underwent inguinal exploration and excision of the paratesticular mass. Final pathology revealed an ectomesenchymoma with a spindle cell rhabdomyosarcoma component. Staging imaging was negative, and after discussion of options he underwent completion orchiectomy and RA-RPLND. RESULTS: The patient in Case #1 underwent a left modified-template nerve-sparing RA-RPLND. Sixteen lymph nodes were negative for tumor. The patient in Case #2 underwent complete bilateral nerve-sparing RA-RPLND. Forty-two lymph nodes were negative for tumor. Estimated blood loss was <50 cc for both cases, and console time averaged 262 min. CONCLUSION: This was a report of two cases of RA-RPLND in the adolescent population. RA-RPLND is technically feasible in this population, and further study of RA-RPLND is needed to determine long-term outcomes, as this technique is becoming more widely adopted.

Perioperative effects of caudal and transversus abdominis plane (TAP) blocks for children undergoing urologic robot-assisted laparoscopic surgery.

INTRODUCTION: Regional anesthesia is often used in combination with general anesthesia for pediatric surgery, however, it is unknown if adjunctive regional blocks are beneficial to children undergoing urologic laparoscopic or robot-assisted laparoscopic (RAL) procedures. OBJECTIVE: To compare perioperative outcomes in children with adjunctive caudal blocks, transversus abdominis plane (TAP) blocks, or no regional anesthesia for common RAL surgical procedures in pediatric urology. STUDY DESIGN: Inclusion in this retrospective study was limited to children who underwent RAL renal or ureteral/bladder procedures and received a standardized regimen of scheduled intravenous ketorolac and oral acetaminophen for acute postoperative pain control, with opioids as needed (PRN). Perioperative outcomes were compared between patients with an adjunctive caudal block (n = 25), bilateral TAP blocks (n = 44), or no regional anesthesia (n = 51). RESULTS: Children with a preoperative caudal block received less intraoperative opioids than children with TAP blocks or no regional anesthesia (p < 0.001). This difference was observed both for renal procedures (p < 0.01) and ureteral/bladder procedures (p = 0.01). Patients with caudal blocks were also the least likely to require postoperative antiemetics (p = 0.03). There were no significant differences between groups in postoperative opioid use, maximum pain scores within 6 and 24 hours postoperatively, or length of hospital stay (LOS). No complications attributable to regional blocks were identified by chart review. DISCUSSION: Use of adjunctive caudal blocks for pediatric RAL renal or ureteral/bladder surgical procedures may reduce need for alternate analgesic and/or anesthetic agents intraoperatively, as well as decrease postoperative nausea and vomiting. These findings may be related, since nausea and vomiting are common side effects of opioids and inhalational anesthetics. Consideration of the potential impact of caudal blocks on general anesthetic requirements is timely in light of concerns regarding the risk of anesthetic neurotoxicity in young patients. There was no evidence of improved postoperative pain control or shorter LOS for children who received regional anesthesia. It is unknown if regional blocks would have a greater impact in the absence of scheduled pain medications, which all patients in our study received. Limitations of this study include its retrospective nature and moderate sample size. Future randomized controlled trials are necessary to provide a more definitive understanding of regional anesthesia's role in minimizing pediatric surgical and anesthetic morbidity. CONCLUSION: Administration of caudal blocks should be considered for children of suitable age undergoing RAL surgery involving either the upper or lower urinary tract.