Testicular germ cell tumors (TGCT) represent the most prevalent solid neoplasms in males aged 20 to 44 years. There has been a persistent rise in the incidence of both seminomatous and non-seminomatous subtypes of TGCT during the past two decades (1). Retroperitoneal lymph node dissection (RPLND) is usually used as an effective treatment for testicular germ cell tumors, primarily in patients with clinical stage I and II non-seminomatous germ cell tumors (NSGCT) and those who present with residual masses after chemotherapy (2, 3). In addition, recent pilot studies have shown that RPLND may also be a therapeutic option for testicular seminomas with clinically low-volume retroperitoneal lymphadenopathy (4).

Open retroperitoneal lymph node dissection (O-RPLND) is the preferred method for retroperitoneal surgical management of NSGCT. Nevertheless, compared to other modalities, the heightened destructiveness of this procedure can contribute to notable postoperative complications and an extended hospital stay (5). In primary clinical stage I and II NSGCT, minimally invasive RPLND has emerged as an appealing alternative to O-RPLND, exhibiting promising initial oncological outcomes alongside a reduced complication rate (6, 7). The advent of laparoscopic retroperitoneal lymph node dissection (L-RPLND) was first reported in 1994, showcasing characteristics such as a quicker postoperative recovery period, diminished blood loss, and a lower frequency of complications compared to O-RPLND (8). However, the long-term oncological outcomes of L-RPLND have yet to be studied as rigorously as those of O-RPLND, and the learning curve for this procedure is very steep (9, 10). The relatively short duration of follow-up for L-RPLND, along with concerns surrounding the need for postoperative chemotherapy in cases of positive masses and the potential compromise of lymph node yield due to incomplete clearance of large vessels, has prompted researchers to express certain reservations (11). The natural progression within the minimally invasive urological oncology surgery field from laparoscopic to robotic techniques set the stage for the pioneering use of robotic retroperitoneal lymph node dissection (R-RPLND) by Davol et al. (12) in 2006. The advantages of R-RPLND, including a shorter learning curve, three-dimensional visualization, and enhanced maneuverability of instruments, have positioned it as a promising option for the management of clinical stage I and II NSGCT, as well as post-chemotherapy RPLND (13, 14). However, there remains ongoing debate regarding the safety and efficacy of R-RPLND in the context of testicular cancer (15). To gain further insights into the clinical value of R-RPLND for testicular germ cell tumors, especially in NSGCT, this study aims to conduct a systematic review and meta-analysis, providing a comprehensive analysis and evaluation of available literature on the subject.

The present investigation adheres to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and meta-Analyses (PRISMA) (16). We have duly registered this study with PROSPERO, and the registration number is (2023 CRD42023411696).

In summary, this meta-analysis involving eight studies (19–26) aimed to compare the safety and efficacy of R-RPLND and NR-RPLND in managing early NSGCT. The results showed that R-RPLND and O-RPLND/L-RPLND were safe and effective for retroperitoneal lymph node dissection. Compared to NR-RPLND, R-RPLND significantly reduced surgical blood loss, decreased total postoperative complication rate, shorter hospital stay, and faster patient recovery, and should be considered a viable alternative to O-RPLND/L-RPLND. In addition, there were no statistical differences between the two groups regarding perioperative and oncological outcomes regarding total operative time, the incidence of postoperative complications grade≥III, abnormal ejaculation rate, lymph node yield, and postoperative recurrence rate.

For patients with early NSGCT, there are three treatment options following surgical orchiectomy and biopsy: active surveillance, chemotherapy, and RPLND. It is crucial that surveillance is appropriate for a subset of patients with stage I NSGCT who can be successfully treated by surgical resection (28). Chemotherapy is effective, but the side effects of chemotherapeutic agents and the risk of cardiovascular disease and secondary tumors are challenging to overcome (29). Currently, RPLND provides accurate staging, is the effective method for detecting these lesions, and provides a 95% good prognosis (30).Perioperative complications are the main drawbacks of the open RPLND surgical approach, such as long operative time, high intraoperative bleeding, high chance of postoperative complications, extended hospital stay, and ease of recurrence (31, 32). The robotic surgical system exhibits remarkable stability, effectively eliminating the minor hand tremors that can occur during manual procedures. Furthermore, the robotic endoscopic wrist possesses superior flexibility, enabling access to narrow and otherwise inaccessible spaces beyond the human hand’s reach. Consequently, applying this advanced technology in minimally invasive retroperitoneal lymph node dissection procedures results in reduced trauma minimized bleeding, and a decreased incidence of postoperative complications (33). A comprehensive analysis was conducted using data from the largest open inpatient care database in the United States, which compared the outcomes of 44 robotic-assisted Retroperitoneal Lymph Node Dissections (R-RPLNDs) with 319 open RPLNDs (O-RPLNDs) (20). The study revealed notable advantages in favor of R-RPLND, with significantly lower rates of bowel obstruction (0.0% vs. 8.4%), genitourinary complications (0% vs. 7.2%), and the need for blood transfusion (0% vs. 5.6%) compared to O-RPLNDs. Moreover, patients who underwent O-RPLND had a median length of stay more than twice as long as those who underwent R-RPLND, with a median of 1.5 days (IQR: 1-3) versus 4 days (IQR: 3-6) respectively. These findings underscore the favorable outcomes and reduced postoperative complications associated with R-RPLND compared to the conventional open approach. The examination conducted by Cheney et al. (34) encompassed a cohort of 18 patients, 8 of whom underwent Retroperitoneal Lymph Node Dissection (RA-RPLND) following chemotherapy. Impressively, none of these 8 patients experienced any major complications throughout a median follow-up duration of 22 months. Furthermore, no instances of recurrence were observed, and an overwhelming majority (91%) of patients maintained normal ejaculatory function. Multiple studies have consistently demonstrated that robotic RPLND outperforms traditional approaches by significantly reducing perioperative complications (0% vs. 16.6%, p<0.01) (20). These results underscore the remarkable advantages of robotic RPLND in minimizing risks associated with the procedure, thereby establishing it as an optimal and minimally invasive alternative. In our research, a comprehensive analysis was conducted to compare the outcomes of Retroperitoneal Lymph Node Dissection (RPLND) using different surgical modalities, including Open RPLND (O-RPLND), Laparoscopic RPLND (L-RPLND), and Robotic-Assisted RPLND (RA-RPLND). The results demonstrated several significant advantages associated with RA-RPLND when compared to O-RPLND/L-RPLND. Specifically, RA-RPLND exhibited reduced estimated blood loss (MD = -436.39; 95% CI -707.60 to -165.19; P = 0.002), a lower transfusion rate (OR = 0.06; 95% CI 0.01 to 0.26; P = 0.0001), lower total complications (OR = 0.39; 95% CI 0.21 to 0.70; P = 0.002), and a shorter length of hospital stay (MD = -3.74; 95% CI -4.69 to -2.78; P < 0.00001). These findings align with previous studies that have reported similar outcomes. However, when we conducted subgroup analyses based on surgical modality, the findings remained consistent with previous results regarding O-RPLND (OR = 0.36; 95% CI 0.19 to 0.68; P = 0.002). Interestingly, the results for L-RPLND contradicted previous findings, as there was no statistically significant difference in total postoperative complication rates compared to RA-RPLND (OR = 0.64; 95% CI 0.15 to 2.78; P = 0.55). It is important to note that this inconsistency may be attributed to the inclusion of fewer studies in the L-RPLND subgroup analysis, which could potentially introduce a higher likelihood of false-positive or false-negative results. This highlights the need for further research and larger sample size to obtain more conclusive results in this particular subgroup.

Several studies have highlighted the potential limitations of the robotic-assisted retroperitoneal lymph node dissection (R-RPLND) technique. One primary concern centers around the extended duration of the robotic approach compared to the conventional open RPLND procedure. Contemporary investigations utilizing robotic methods have identified a median operative time ranging from 235 to 330 minutes, whereas open RPLND typically encompasses a timeframe of 132 to 214 minutes (7, 15). Nevertheless, our research findings indicate that the operative time between robotic and open/laparoscopic retroperitoneal lymph node dissection is comparable (MD = -1.22; 95% CI -62.47 to 60.04; P = 0.97). Another concern concerns the escalated costs incurred due to the increased operative time associated with robotic RPLND. Prolonged surgical procedures result in heightened expenditure on anesthesia (35). Additionally, the utilization of robotic surgery necessitates investments in specialized instruments, further contributing to the higher cost of robotic RPLND compared to open surgery. The majority of studies conducted to date have had follow-up durations of less than 24 months, thus offering limited insights into the long-term oncological effectiveness of R-RPLND, particularly when juxtaposed against the robust evidence supporting O-RPLND. Furthermore, considerable heterogeneity is observed in the number of lymph nodes extracted during R-RPLND procedures, with some instances recording as few as seven lymph nodes (36).

The study still showed several limitations: (1) different inclusion and exclusion criteria in the included studies, with significant differences between patients enrolled; (2) the included studies were all non-randomized controlled studies, which may have led to a high degree of heterogeneity in the results; (3) no subgroup analysis was performed for studies of pre- versus post-chemotherapy retroperitoneal lymph node dissection; (4) fewer studies comparing robotic and laparoscopic were included fewer; (5) significant heterogeneity in the results of some of the analyses, and attempts to perform sensitivity analyses and subgroup analyses were not able to fully identify the sources of heterogeneity.

In the realm of testicular cancer management, there is promising potential for the utilization of R-RPLND. R-RPLND demonstrates advantageous attributes such as reduced blood loss, decreased overall surgical complications, and shorter hospitalization periods, facilitating quicker patient recovery when compared to patient-specific O-RPLND or L-RPLND. These factors render R-RPLND a safe and efficacious treatment option for testicular cancer patients, comparable to NR-RPLND. However, it is essential to acknowledge certain limitations within the existing body of research. The substantiating evidence for R-RPLND primarily stems from small-scale, single-institution studies that need more adequate comparisons with L-RPLND or O-RPLND. This inherent limitation raises concern regarding potential publication bias and necessitates cautious interpretation of the findings. To validate the current conclusions and establish a comprehensive understanding of R-RPLND’s role in testicular cancer treatment, further investigations employing larger sample sizes, prospective design, multiple centers, extended follow-up durations, and randomized controlled trials are warranted. In summary, while R-RPLND holds promise in the management of testicular cancer, several considerations deserve attention. Future research endeavors should confirm the current findings and enhance our knowledge regarding the long-term oncological efficacy and overall utility of R-RPLND.

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

YY: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Writing – original draft, Writing – review & editing. DZ: Conceptualization, Data curation, Investigation, Methodology, Supervision, Writing – review & editing. YN: Conceptualization, Data curation, Investigation, Methodology, Software, Writing – review & editing. HL: Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing. XQ: Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing. YT: Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing. YL: Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing. XY: Conceptualization, Data curation, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing.