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Background: Post- chemotherapy retroperitoneal lymph node dissection is a technically complex surgery due to significant fibrosis causing dense adherence of nodal tissue and any residual masses to the major vessels. While open- retroperitoneal lymph node dissection (O-RPLND) remains the standard of care in stage I non-seminomatous germ cell tumor and patients with post-chemotherapy masses greater than 1 cm, minimally invasive approaches such as laparoscopic and robotic have become more wide-spread in high volume centers over the past decade. Early research confirms the safety and early oncologic efficacy of post-chemotherapy robotic retroperitoneal lymph node dissection (R-RLPND), demonstrating comparable nodal yield, shorter operative times, lower estimated blood loss, shorter length of stay, and fewer overall post- operative complications. Methods and results: At City of Hope, we are performing both primary and post-chemotherapy XI R- RPNLD on select patients. For post-chemotherapy RPLNDs, a bilateral retroperitoneal lymph node dissection is performed according to standard templates. Patient preparation, positioning, and port position is demonstrated. The steps of the operation, including gonadal vein dissection, bowel mobilization and suspension with Keith needles, paracaval, inter-aortic, and para-aortic dissections are showed. Post-operative care is discussed. Conclusion: Post-Chemotherapy R-RPLND is feasible and safe. Patients are commonly able to discharge either same day or on post-operative day one.

Background: Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY. Methods: A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher’s exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance. Results: Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs ( p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion ( p < 0.0001). No complications attributable to the use of SPY were noted. Conclusion: Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.