Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results

Contemporary Role of Lymph Node Dissection in Genitourinary Cancers: Where Are We in 2023?

CONTEXT

Lymphadenectomy during surgery for genitourinary malignancies has varying benefits.

OBJECTIVE

To review contemporary evidence on lymph node dissection in genitourinary cancers.

EVIDENCE ACQUISITION

We performed a collaborative review to summarize current evidence supporting lymph node dissection in urothelial, prostate, kidney, penile, and testis cancers. We present the evidence on patient selection and recommended dissection templates, and highlight knowledge gaps and ongoing areas of investigation.

EVIDENCE SYNTHESIS

Lymph node dissection remains the reference standard for lymph node staging. Pathologic nodal stage informs prognosis and guides adjuvant treatment. Appropriate template and patient selection are paramount to optimize outcomes and capitalize on the selective therapeutic benefits.

CONCLUSIONS

Accurate staging with lymphadenectomy is contingent on appropriate template selection. The cumulative benefit will depend on judicious patient selection.

PATIENT SUMMARY

We performed a collaborative review by a diverse group of experts in urology. We reviewed current evidence on lymph node dissection.

Regional lymph node mapping in patients with penile cancer undergoing radical inguinal lymph node dissection - a retrospective cohort study

BACKGROUND

Radical inguinal lymph node dissection (rILND) is the most available treatment to cure penile cancer (PC) with limited inguinal-confined disease. However, guidelines regarding acceptable boundaries of rILND are controversial, and consensus is lacking. The authors aimed to standardize the surgical boundaries of rILND with definite pathological evidence and explore the distribution pattern of inguinal lymph nodes (ILNs) in PC.

METHODS

A total of 414 PC patients from two centers who underwent rILND were enrolled. The ILN distribution was divided into seven zones anatomically for pathological examination. Student's t test and Kaplan-Meier survival analysis were used.

RESULTS

ILNs displayed a funnel-shaped distribution with high density in superior regions. ILNs and metastatic nodes are present anywhere within the radical boundaries. Positive ILNs were mainly concentrated in zone I (51.7%) and zone II (41.3%), but there were 8.7% and 12.3% in inferior zones V and VI, respectively, and 7.1% in the deep ILNs. More importantly, a single positive ILN and first-station positive zone was detected in all seven regions. Single positive ILNs were located in zones I through VI in 40.4%, 23.6%, 6.7%, 18.0%, 4.5%, and 1.1%, respectively, and 5.6% presented deep ILN metastasis directly.

CONCLUSIONS

The authors established a detailed ILN distribution map and displayed lymphatic drainage patterns with definite pathological evidence using a large cohort of PC patients. Single positive ILNs and first-station metastatic zones were observed in any region, even directly with deep ILN metastasis. Only rILND can ensure tumor-free resection without the omission of positive nodes.

Surgical templates for inguinal lymph node dissection in cN0 penile cancer: A comparative study

PURPOSE

Modified and superficial inguinal lymph node dissection (MILD and SILD) are the 2 widely used templates for surgical staging of clinically node negative (cN0) penile cancer (PeCa); however, no previous reports have compared their outcomes. We compared these 2 surgical templates for oncological outcomes and complications.

MATERIALS AND METHODS

We retrospectively reviewed records of cN0 PeCa patients who underwent MILD/SILD at our cancer care center from January 2013 to December 2019. Patients who developed a penile recurrence during follow up were excluded from analysis of oncological outcomes. The 2 groups (MILD and SILD) were compared for baseline clinico-pathological characteristics. The primary outcome was the groin recurrence free survival (gRFS). Secondary outcomes included the false negative rate (FNR) and disease free survival (DFS) for both templates and also the post-operative wound related complication.

RESULTS

Of the 146 patients with intermediate and high risk N0 PeCa, 74 (50.7%) and 72 (49.3%) underwent MILD and SILD respectively. The 2 groups were comparable with regards to the distribution of T stage, tumor grade and the proportion of intermediate and high-risk patients. At a median follow up of 34 months (47 for SILD and 23 for MILD), a total of 5 groin recurrences were encountered; all of them occurred in the MILD group. The gRFS and DFS for the MILD group was 93.2% and 91.8% respectively; while that for the SILD group was 100% and 94.4% respectively. Too few events had occurred to determine any statistically significant difference. The FNR for MILD and SILD was 26.3% and 0% respectively. The overall complication rate was significantly higher in the SILD group (46% vs 20.3%, p=0.001), especially for Clavien Dindo 3A complications.

CONCLUSION

MILD can fail to pick up micro-metastatic disease in a small proportion of cN0 PeCa patients, while SILD provides better oncological clearance with no groin recurrences. This oncological superiority comes at the cost of a higher incidence of wound-related complications.

Inguinal lymphadenectomy in penile cancer patients: a comparison between open and video endoscopic approach in a multicenter setting

OBJECTIVES

To compare differences of operative outcomes, post-operative complications and survival outcomes between open and laparoscopic cases in a multicenter study.

METHODS

This was a retrospective cohort study performed at three European centers from September 2011 to January 2019. The surgeon decision to perform open inguinal lymphadenectomy (OIL) or video endoscopic inguinal lymphadenectomy (VEIL) was done in each hospital after patient counselling. Inclusion criteria regarded a minimum follow-up of 9 months since the inguinal lymphadenectomy.

RESULTS

A total of 55 patients with proven squamous cell penile cancer underwent inguinal lymphadenectomy. 26 of them underwent OIL, while 29 patients underwent VEIL. For the OIL and VEIL groups, the mean operative time was 2.5 vs. 3.4 h (p=0.129), respectively. Hospital stays were lower in the VEIL group with 4 vs. 8 days in OIL patients (p=0.053) while number of days requiring drains to remain in situ was 3 vs. 6 days (p=0.024). The VEIL group reported a lower incidence of major complications compared to the OIL group (2 vs. 17%, p=0.0067) while minor complications were comparable in both groups. In a median follow-up period of 60 months, the overall survival was 65.5 and 84.6% in OIL and VEIL groups, respectively (p=0.105).

CONCLUSIONS

VEIL is comparable to OIL regarding safety, overall survival and post-operative outcomes.

Outcomes following radical inguinal lymphadenectomy for penile cancer using a fascial-sparing surgical technique

PURPOSE

To describe our surgical technique and report the oncological outcomes and complication rates using a fascial-sparing radical inguinal lymphadenectomy (RILND) technique for penile cancer patients with cN+ disease in the inguinal lymph nodes.

METHODS

Over a 10-year period, 660 fascial-sparing RILND procedures were performed in 421 patients across two specialist penile cancer centres. The technique used a subinguinal incision with an ellipse of skin excised over any palpable nodes. Identification and preservation of the Scarpa's and Camper's fascia was the first step. All superficial inguinal nodes were removed en bloc under this fascial layer with preservation of the subcutaneous veins and fascia lata. The saphenous vein was spared where possible. Patient characteristics, oncologic outcomes and perioperative morbidity were retrospectively collected and analysed. Kaplan-Meier curves estimated the cancer-specific survival (CSS) functions after the procedure.

RESULTS

Median (interquartile range, IQR) follow-up was 28 (14-90) months. A median (IQR) number of 8.0 (6.5-10.5) nodes were removed per groin. A total of 153 postoperative complications (36.1%) occurred, including 50 conservatively managed wound infections (11.9%), 21 cases of deep wound dehiscence (5.0%), 104 cases of lymphoedema (24.7%), 3 cases of deep vein thrombosis (0.7%), 1 case of pulmonary embolism (0.2%), and 1 case of postoperative sepsis (0.2%). The 3-year CSS was 86% (95%Confidence Interval [95% CI] 77-96), 83% (95% CI 72-92), 58% (95% CI 51-66), respectively, for the pN1, pN2 and pN3 patients (p < 0.001), compared to a 3-year CSS of 87% (95% CI 84-95) for the pN0 patients.

CONCLUSION

Fascial-sparing RILND offers excellent oncological outcomes whilst decreasing the morbidity rates. Patients with more advanced nodal involvement had poorer survival rates, emphasizing the need for adjuvant chemo-radiotherapy.

Assessment and Reporting of Perioperative Adverse Events and Complications in Patients Undergoing Inguinal Lymphadenectomy for Melanoma, Vulvar Cancer, and Penile Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Inguinal lymph node dissection (ILND) plays a crucial role in the oncological management of patients with melanoma, penile, and vulvar cancer. This study aims to systematically evaluate perioperative adverse events (AEs) in patients undergoing ILND and its reporting.

METHODS

A systematic review was conducted according to PRISMA. PubMed, MEDLINE, Scopus, and Embase were queried to identify studies discussing perioperative AEs in patients with melanoma, penile, and vulvar cancer following ILND.

RESULTS

Our search generated 3.469 publications, with 296 studies meeting the inclusion criteria. Details of 14.421 patients were analyzed. Of these studies, 58 (19.5%) described intraoperative AEs (iAEs) as an outcome of interest. Overall, 68 (2.9%) patients reported at least one iAE. Postoperative AEs were reported in 278 studies, combining data on 10.898 patients. Overall, 5.748 (52.7%) patients documented ≥1 postoperative AEs. The most reported ILND-related AEs were lymphatic AEs, with a total of 4.055 (38.8%) events. The pooled meta-analysis confirmed that high BMI (RR 1.09; p = 0.006), ≥1 comorbidities (RR 1.79; p = 0.01), and diabetes (RR 1.81; p =  < 0.00001) are independent predictors for any AEs after ILND. When assessing the quality of the AEs reporting, we found 25% of studies reported at least 50% of the required criteria.

CONCLUSION

ILND performed in melanoma, penile, and vulvar cancer patients is a morbid procedure. The quality of the AEs reporting is suboptimal. A more standardized AEs reporting system is needed to produce comparable data across studies for furthering the development of strategies to decrease AEs.

Combined Reporting of Surgical Quality and Cancer Control after Surgical Treatment for Penile Tumors with Inguinal Lymph Node Dissection: The Tetrafecta Achievement

BACKGROUND

To optimize results reporting after penile cancer (PC) surgery, we proposed a Tetrafecta and assessed its ability to predict overall survival (OS) probabilities.

METHODS

A purpose-built multicenter, multi-national database was queried for stage I-IIIB PC, requiring inguinal lymphadenectomy (ILND), from 2015 onwards. Kaplan-Meier (KM) method assessed differences in OS between patients achieving Tetrafecta or not. Univariable and multivariable regression analyses identified its predictors.

RESULTS

A total of 154 patients were included in the analysis. The 45 patients (29%) that achieved the Tetrafecta were younger (59 vs. 62 years; p = 0.01) and presented with fewer comorbidities (ASA score ≥ 3: 0% vs. 24%; p < 0.001). Although indicated, ILND was omitted in 8 cases (5%), while in 16, a modified template was properly used. Although median LNs yield was 17 (IQR: 11-27), 35% of the patients had <7 nodes retrieved from the groin. At Kaplan-Maier analysis, the Tetrafecta cohort displayed significantly higher OS probabilities (Log Rank = 0.01). Uni- and multivariable logistic regression analyses identified age as the only independent predictor of Tetrafecta achievement (OR: 0.97; 95%CI: 0.94-0.99; p = 0.04).

CONCLUSIONS

Our Tetrafecta is the first combined outcome to comprehensively report results after PC surgery. It is widely applicable, based on standardized and reproducible variables and it predicts all-cause mortality.

[Complications and their management following axillary, inguinal and iliac lymph node dissection]

Irrespective of numerous technical developments, lymphadenectomy remains a necessary component of surgical tumor therapy. Depending on the extent and anatomical localization, complications associated with the lymph vessels such as lymphoceles, lymphatic fistulas or secondary lymphedema can occur with varying frequency, despite a meticulous dissection technique. Chronic lymph fistulas or lymphoceles often require interventional or surgical procedures. Pedicled or free microsurgical flaps are often required in the case of coexisting wound healing disorders or skin soft tissue defects, especially in an irradiated area. For secondary lymphedema a number of conservative and surgical treatment methods have been established. Adequate guideline-based conservative treatment is the method of first choice. If this does not lead to the desired result, microsurgical reconstructive, deviating or resecting procedures are available.

Prophylactic inguinal lymphadenectomy for high-risk cN0 penile cancer: The optimal surgical timing

Background

Few reports have investigated the oncologically safe timing of prophylactic inguinal lymphadenectomy for penile cancer patients with clinically normal inguinal lymph nodes (cN0), particularly those who received delayed surgical treatment.

Methods

The study included pT1aG2, pT1b-3G1-3 cN0M0 patients with penile cancer who received prophylactic bilateral inguinal lymph nodes dissection (ILND) at the Department of Urology of Tangdu Hospital between October 2002 and August 2019. Patients who received simultaneous resection of primary tumor and inguinal lymph nodes were assigned to the immediate group, while the rest were assigned to the delayed group. The optimal timing of lymphadenectomy was determined based on the time-dependent ROC curves. The disease-specific survival (DSS) was estimated based on the Kaplan-Meier curve. Cox regression analysis was used to evaluate the associations between DSS and the timing of lymphadenectomy and tumor characteristics. The analyses were repeated after stabilized inverse probability of treatment weighting adjustment.

Results

A total of 87 patients were enrolled in the study, 35 of them in the immediate group and 52 in the delayed group. The median (range) interval time between primary tumor resection and ILND of the delayed group was 85 (29-225) days. Multivariable Cox analysis demonstrated that immediate lymphadenectomy was associated with a significant survival benefit (HR, 0.11; 95% CI, 0.02-0.57; p = 0.009). An index of 3.5 months was determined as the optimal cut-point for dichotomization in the delayed group. In high-risk patients who received delayed surgical treatment, prophylactic inguinal lymphadenectomy within 3.5 months was associated with a significantly better DSS compared to dissection after 3.5months (77.8% and 0%, respectively; log-rank p<0.001).

Conclusions

Immediate and prophylactic inguinal lymphadenectomy in high-risk cN0 patients (pT1bG3 and all higher stage tumours) with penile cancer improves survival. For those patients at high risk who received delayed surgical treatment for any reason, within 3.5 months after resection of the primary tumor seems to be an oncologically safe window for prophylactic inguinal lymphadenectomy.

Inguinal lymph node dissection in the era of minimally invasive surgical technology

BACKGROUND

Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications.

METHODS

The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020.

FINDINGS

There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Modified Video Endoscopic Inguinal Lymphadenectomy: a deep-first approach

OBJECTIVES

To describe our modified technique of performing video endoscopic inguinal lymphadenectomy (VEIL) with the proposed benefits of a shallow learning curve and better ergonomics.

METHODS

We describe our modified VEIL technique: the deep first approach, in a squamous cell carcinoma penis patient with a pathological T3 disease and bilateral palpable, mobile inguinal lymph nodes post penectomy.

RESULTS

The surface markings and the port incision sites for the procedure were conventional. However, in contrast to the standard superficial dissection plane development below the Scarpa's fascia at the initial camera port site, our technique commenced with a deep dissection plane just above the fascia lata. The dissection limits were directly identified: the sartorius muscle laterally, the inguinal ligament superiorly, and the adductor longus muscle medially. The saphenous vein was identified early and close to the saphenofemoral junction, allowing undemanding dissection. The superficial flap dissection was done entirely under direct vision, with better ergonomics owing to a continuous counter-traction by the pressure of insufflated gas. Deep inguinal nodal dissection then concluded the procedure.

CONCLUSIONS

The described technique is surmised to be easier to perform, given the lack of ambiguity in the correct initial dissection plane, direct visualization of surgical landmarks early in the procedure, and early identification of the saphenous vein close to the SFJ. It may improve the learning curve allowing for a wider acceptance of VEIL.

Radioisotope-Guided Sentinel Lymph Node Biopsy in Penile Cancer: A Long-Term Follow-Up Study

Lymph node (LN) management is critical for survival in patients with penile cancer. However, radical inguinal lymphadenectomy carries a high risk of postoperative complications such as lymphedema, lymphocele, wound infection, and skin necrosis. The European Association of Urology guidelines therefore recommend invasive LN staging by modified inguinal lymphadenectomy or dynamic sentinel node biopsy (DSNB) in clinically node-negative patients (cN0) with intermediate- and high-risk tumors (≥ T1G2). However, the timing of DSNB (simultaneous vs. subsequent to partial or total penile resection) is controversial and the low incidence of penile cancer means that data on the long-term outcomes of DSNB are limited. The present study aimed to analyze the reliability and morbidity of DSNB in patients with penile cancer during long-term follow-up. This retrospective study included 41 patients (76 groins) who underwent radioisotope-guided DSNB simultaneously or secondarily after penile surgery from June 2004 to November 2018. In total, 193 sentinel LNs (SLNs) and 39 non-SLNs were removed. The median number of dissected LNs was 2.5 (interquartile range 2–4). Histopathological analysis showed that five of the 76 groins (6.6%) contained metastases. None of the non-SLNs were tumor-positive. In accordance with the guidelines, all inguinal regions with positive SLNs underwent secondary radical inguinal lymphadenectomy, which revealed three additional metastases in one groin. Regional LN recurrence was detected in three patients (four groins) during a median follow-up of 70 months, including two patients in whom DSNB had been performed secondarily after repetitive penile tumor resections. DSNB-related complications occurred in 15.8% of groins. Most complications were mild (Clavien–Dindo grade I; 50%) or moderate (II; 25%), and invasive intervention was only required in 3.9% of groins (IIIa: n = 1; IIIb: n = 2). In summary, this study suggests that the current radioisotope-guided DSNB procedure may reduce the complication rate of inguinal lymphadenectomy in patients with cN0 penile cancer. However, DSNB and penile surgery should be performed simultaneously to minimize the false-negative rate. Recent advances, such as new tracers and imaging techniques, may help to reduce the false-negative rate of DSNB further.

A laparoscopic radical inguinal lymphadenectomy approach partly preserving great saphenous vein branches can benefit for patients with penile carcinoma

Background

Inguinal lymphadenectomy (iLAD) is effective for penile carcinoma treatment, but usually results in many complications. This study aims to clinically evaluate the feasibility and clinical significance of a laparoscopic radical iLAD approach partly preserving great saphenous vein branches for penile carcinoma patients.

Methods

A total of 48 patients with penile cancer who underwent laparoscopic radical iLAD with retention of the great saphenous vein in Henan Cancer Hospital from 2012 Jan to 2020 Dec were included in this study. Sixteen penile carcinoma patients who underwent laparoscopic radical iLAD preserving parts of superficial branches of the great saphenous vein were identified as the sparing group, and the matched 32 patients who incised those branches were identified as control group. This new procedure was performed by laparoscopy, preserving parts of superficial branches of the great saphenous vein, superficial lateral and medial femoral veins. Clinicopathological features and perioperative variables were recorded. Postoperative complications, including skin flap necrosis, lymphorrhagia, and lower extremity edema were analyzed retrospectively.

Results

We found that the operative time of the sparing group is significantly longer than the control group (p = 0.011). There was no statistical difference in intraoperative blood loss, the lymph node number per side, average time to remove the drainage tube and postoperative hospital stay between the two groups. Compared to the control group, the sparing group showed a significantly decreased incidence of lower extremity edema (p = 0.018). The preservation of parts of superficial branches of the great saphenous vein was mainly decreased the incidence of edema below ankle (p = 0.034).

Conclusions

This study demonstrated that the iLAD with preserving parts of superficial branches of the great saphenous vein, with a decreased incidence of postoperative complications, is a safe and feasible approach for penile cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01582-3.

Pelvic and inguinal single-site approach: PISA technique. New minimally invasive technique for lymph node dissection in penile cancer

OBJECTIVES

To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique.

MATERIAL AND METHODS

10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015-2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions.

VARIABLES

30-day PCs, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics.

RESULTS

Inguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120-170 min and median EBL was 66 (30-100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications-symptomatic inguinal lymphocele). Median LOS was 5.8 (3-10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25 (8-14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills.

CONCLUSIONS

PISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications.

Incidence and risk factor analysis of complications after sentinel node biopsy for penile cancer

BACKGROUND

Surgical staging is recommended in intermediate to high risk clinically node negative (cN0) penile cancer (PeCa). Because (modified) inguinal lymph node dissection (ILND) is associated with high morbidity, dynamic sentinel node biopsy (DSNB) was introduced with the aim to reduce morbidity while maintaining diagnostic accuracy.

OBJECTIVE

To determine the incidence and types of complications after DSNB and identify risk factors for the occurrence of postoperative complications.

PATIENTS AND METHODS

We evaluated 644 PeCa patients (1284 DSNB procedures) with at least one cN0 groin who underwent DSNB between 2011 and 2020 at a single high-volume centre. 30-day and 30-90-day postoperative complications were collected according to the modified Clavien Dindo classification and the standardized methodology proposed by the European Association of Urology panel. Univariable and multivariable generalized linear mixed models were used to identify risk factors for the occurrence of complications per groin.

RESULTS

A 30-day postoperative complication occurred in 14% of groins (n=186), of which 94% were mild to moderate. Wound infection and lymphocele formation were most common. 30-90-day postoperative complications occurred in 3.4% of the groins, all of which were mild or moderate (grade 1-2). The number of removed LNs per groin was the main independent predictor for any 30-day complications and grade≥2 complications (OR 1.40; p<0.001). An increase in the probability of postoperative complications with the number of LNs removed was observed after accounting for all confounders.

CONCLUSIONS

Despite being less morbid than (modified) ILND, DSNB is still associated with a considerable risk of mild to moderate postoperative complications. This risk increases with an increasing number of LNs removed. Further procedural refinement aimed at removing the true sentinel node(s) only, may help further reduce the morbidity of surgical staging in PeCa.

Microsurgical treatment of lower extremity lymphedema: A multidisciplinary approach to improve morbidity in advanced penile cancer patients

INTRODUCTION

Lower extremity lymphedema is a major source of morbidity in up to 70% of penile cancer patients. Lymphedema is often thought to be incurable, though surgical treatments have started to emerge. This study is the first to apply lymphovenous bypass specifically to penile cancer patients status post lymphadenectomy.

METHODS

We performed microsurgical lymphovenous bypass in 3 patients who underwent inguinal lymphadenectomy for advanced penile cancer, and later lymph node transplant in 1 patient.

RESULTS

The lymphovenous bypass was performed by a trained microsurgeon: Two patients were treated as outpatients for lymphedema, and 1 patient underwent prophylactic lymphovenous bypass simultaneously with initial lymphadenectomy. We saw significant improvement in patient's clinical lymphedema as well as lymphatic drainage on infared imaging for 2 of 3 patients at 12 months, however 1 of these patients did require later lymph node transfer at 24 months.

CONCLUSION

This early proof of concept study shows that these procedures should be considered and studied further in the treatment and prevention of debilitating lymphedema in the penile cancer population.

Comparison of different surgical methods and strategies for inguinal lymph node dissection in patients with penile cancer

To compare the clinical feasibility and oncological outcome of different surgical techniques for inguinal lymphadenectomy (ILND) in patients suffering from penile cancer. This study included data from 109 cN_0-2 patients diagnosed with penile cancer who received ILND. 80 laparoscopic ILND were performed on 40 patients, while 138 open surgeries were performed on 69 patients. Perioperative complications and prognosis were compared between different surgical techniques. Compared with the open surgery group, the laparoscopy group had a shorter hospital stay (8.88 ± 7.86 days vs. 13.94 ± 10.09 days, P = 0.004), and a lower wound healing delay rate (8.75% vs. 22.46%, P = 0.017), but also had longer drainage time (10.91 ± 9.66 vs. 8.70 ± 4.62, P = 0.002). There were no significant differences in terms of other intraoperative parameters, complications, and survival between open and laparoscopic group. Compared with saphenous vein ligated subgroup, preserved subgroup showed no significant reducing of complication rate. There was no significant difference among complication between different open surgery subgroup. Immediate ILND showed no prognostic advantage over delayed ILND regardless of clinical lymph node status. Compared with open surgery, the minimally invasive ILND technique has similar oncological efficiency and a lower complication rate. Saphenous vein preservation has limited value in reducing complications. Delayed lymphadenectomy might be a more reasonable option for ILND.

Saphenous-sparing Ascending Video Endoscopic Inguinal Lymph Node Dissection Using a Leg Approach: Surgical Technique and Perioperative and Pathological Outcomes

Background

Open inguinal lymph node dissection (oILND) has high morbidity. Ascending saphenous-sparing video endoscopic ILND (VEILND-AS+) represents a minimally invasive alternative with potential benefits.

Objective

To describe our VEILND-AS+ technique and compare outcomes to oILND.

Design, setting, and participants

This was a retrospective cohort study of penile cancer patients.

Surgical procedure

VEILND-AS+ was performed according to the technique described in the supplementary video.

Measurements

We compared perioperative and pathological outcomes between the two procedures.

Results and limitations

In the study cohort of 206 men we performed 40 VEILND-AS+ and 251 oILND procedures. In comparison to oILND, VEILND-AS+ had a longer operation time (185 vs 120 min; p < 0.01) but a shorter hospital stay (2 vs 4 d; p < 0.01). A median of eight resected lymph nodes with a median of one affected node per groin was observed in both groups. Extranodal extension was found in 30% of cases after VEILND-AS+ and 35% after oILND. In both groups the median drainage time was 13 d. Wound infections were observed in 38% of cases after VEILND-AS+ and 27% after oILND (p = 0.19). Skin necrosis or wound breakdown occurred in 0% and 6% of cases after VEILND-AS+ and oILND (p < 0.01), while lymphoceles were drained in 18% and 7% of cases, respectively(p = 0.03). Following VEILND-AS+ and oILND, 20% and 14% of patients, respectively, were referred to a lymph oedema clinic (p < 0.01).

Conclusions

VEILND-AS+ is a safe procedure and offers shorter hospital stays and possibly a lower risk of skin necrosis and wound breakdown in comparison to oILND. Further improvements in the VEILND-AS+ technique are required to reduce complications associated with dead space and injury to lymphatic vessels.

Patient summary

For patients undergoing surgery on lymph nodes in the groin, a minimally invasive approach instead of open surgery led to discharge 2 days earlier and may have lower rates of severe wound complications.

VEILND (Video Endoscopic Inguinal Lymph Node Dissection) with Florescence Indocyanine Green (ICG): A Novel Technique to Identify the Sentinel Lymph Node in Men with ≥pT1G2 and cN0 Penile Cancer

Introduction

In men with ≥pT1G2 cN0, penile cancer lymph node sampling is recommended with either (1) scintigraphically labelled Dynamic sentinel lymph node biopsy (DSLNB) or (2) modified inguinal lymph node dissection (MILND). Although DSLNB is a minimally invasive technique, the false negative rate can be about 10%, and a further operative procedure is required if positive. Open MILND is a diagnostic and therapeutic option but has a much higher morbidity. A potential compromise is the technique of LND-VEILND (video endoscopic inguinal LND) that can be combined with ICG florescence marking of sentinel lymph node (SLN). We present a pilot study of ICG-VEILND. The aim was to validate the applicability of a combination ICG marking of SLN in VEILND (to increase probability to excise SLN) and determine the optimal timing and dosage of ICG.

Materials and Methods

15 patients with VEILND (24 groins) underwent ICG application with fluorescence near-infrared (NIR 803⟶830 nm) detection. ICG is applied subcutaneously adjacent to the penile cancer or residual stump of penis or suprapubic region (in a history of total penectomy: 5 cases). The dose of 1.25 mg (ICG) was applied in one case with invisible SLN, the dose of 2.5 mg in 1 mL in 8 cases, and 5 mg in the remaining 6 patients (10 groins).

Results

Failure of marking SLN with ICG occurred in 25.0% of cases (6/24): due to application of 1.25 mg ICG, extensive metastasis to SLN, in 4 cases, the cause was unknown (16.7%, 4/24). In the short follow-up period, no local recurrence was seen in the pN0 ICG group.

Conclusion

Fluorescence infrared image with ICG dye increases the probability of removal of the SLN during VEILND. The dose of ICG is 2.5 (5) mg diluted in 1 ml and can be applied preoperatively even in the suprapubic region in men with a history of total penectomy, with an unexplainable failure of ICG marking in 16.7%.

Single-port robotic inguinal lymph node dissection: A safe and feasible option for penile cancer

INTRODUCTION

Inguinal lymph node dissection (ILND) is essential to the accurate staging of advanced penile cancer and in determining prognosis. Open ILND is associated with significant morbidity. The robotic-assisted approach has been described with comparable nodal yield with the advantage of decreased postoperative complications when studied with the multiport robotic platform. This video shows our approach for an ILND with the Intuitive single port (SP) robotic platform.

METHOD

A 54-year-old man underwent a partial penectomy for a penile mass that revealed squamous cell carcinoma invading the corpus spongiosum (pT2). Patient had non-palpable lymph nodes on physical examination. We proceeded with the bilateral inguinal lymph node dissection using the Intuitive da Vinci Single-Port Robot.

RESULTS

A standard template dissection was performed on both sides. Due to nodal enlargement noted on the pre-operative CT scan on the right side, superficial and deep ILND were performed on that side. Intra-operative frozen section pathologies of superficial lymph nodes were negative on the left side. Bilateral saphenous veins were preserved. Total procedure time was 4 hours and 51 minutes in duration with minimal blood loss noted (<30 mL). Pathology revealed one 4.5cm superficial positive node on the right with no extra-nodal extension and no other positive nodes. No complications were noted. He was discharged on post-operative day 1 with minimal pain or leg swelling.

CONCLUSIONS

We describe the technique and feasibility of ILND using the SP robotic platform. This approach has the potential to reduce morbidity with comparable nodal dissection as the open approach.

A single-centre experience of the management of inguinal lymph nodes associated with penile squamous-cell carcinoma

Background:

Twenty-two cases of penile carcinoma that were managed at our institution over a 5-year period were analysed on the basis of inguinal lymph node dissection (ILND), complications and follow-up.

Methods:

A total of 22 cases post penectomy were stratified into low risk (T1 G1 or G2 without lympho-vascular invasion and negative on fine-needle aspiration cytology (FNAC)) and high risk (T1 G3 and above and/or lympho-vascular invasion). Low-risk patients having palpable lymphadenopathy were given a course of antibiotics. If the lymph nodes were still palpable, FNAC was done, and patients then underwent superficial ILND (SILND) or even ILND in cases with positive frozen-section reports. In the high-risk group, all patients underwent SILND, and if required, underwent ILND. Two patients in the high-risk group were lost to follow-up after 9 months. Histopathology reports were noted, and patients were followed up for 2 years.

Results:

In the low-risk group, seven patients had palpable lymph nodes and underwent SILND. The remaining five patients were put on surveillance. Amongst the seven who underwent SILND, six were positive at frozen section, requiring ILND. Nine patients in the high-risk group underwent ILND. Four patients in the ILND group had a minor wound infection. Lymphoedema was seen in two patients which was managed conservatively, and lymphorrhoea was seen in one patient. Flap necrosis occurred in one patient. Recurrences were seen in three patients in the high-risk group. Two who had deep node involvement and who had early nodal recurrence underwent bilateral ILND. One patient in the high-risk group had late ipsilateral nodal recurrence and underwent ipsilateral ILND. There were no regional recurrences.

Conclusion:

Carcinoma of the penis has high morbidity because of delayed presentation, lack of awareness and poor compliance. This necessitates staging SILND in all high-risk cases for therapeutic and prognostic purposes.

Technical management of inguinal lymph-nodes in penile cancer: open versus minimal invasive

Inguinal lymphadenectomy (ILND) remains the standard of care for patients with invasive squamous cell carcinoma of the penis, dictating patient prognosis, adjuvant therapies, and surveillance strategies. Importantly the performance of an ILND has been shown to improve cancer-specific outcomes, providing a modifiable factor for patients with an aggressive malignancy. Surprisingly, the procedure remains underutilized, mainly due to the high surgical morbidity associated with the procedure. The open lymphadenectomy technique has undergone several modifications over the last 30 years to minimize its associated surgical morbidity, but wound-related complications remain significant. Minimally invasive surgery (MIS) techniques have been recently introduced to help mitigate wound-related complications associated with open lymphadenectomy, with promising results. In this review, we highlight the importance of ILND, present a detail review of the surgical and oncological outcomes associated with open, laparoscopic and robotic ILND for patients with penile cancer.

Current practice patterns of society of urologic oncology members in performing inguinal lymph node staging/therapy for penile cancer: A survey study

OBJECTIVES

Inguinal lymph node (ILN) staging and therapeutic procedures are important for the diagnosis and management of suspected Inguinal lymph node metastasis in the setting of penile cancer. Morbidity associated with inguinal lymph node dissection (ILND) and the lack of standardization in its perioperative management are both significant. In this study, we aimed to define current management approaches and potential opportunities for improving outcomes.

METHODS AND MATERIALS

A questionnaire was developed with 16 questions regarding pre, peri, and postoperative management of patients undergoing ILND. The questionnaire was approved by the Society of Urologic Oncology (SUO) Questionnaire Committee, which facilitated its dissemination through an initial email and a follow-up reminder to 1,003 members. The study was conducted from July to August, 2020.

RESULTS

Of the 1,003 SUO members invited to participate, 93 responded (9.3% response rate); 49% performed 1 to 2 ILNDs annually, and 60% chose open ILND for high-risk primary cancer cN0. For suspicious lymph nodes > 2 cm, 69% preferred ILND, 86% preoperative systemic neoadjuvant chemotherapy, followed by surgery for bulky inguinal metastasis, and 84% used perioperative antibiotics (ABX), 53% of whom discontinued ABX 24 hours after surgery. Prophylactic anticoagulation was used by 78% of respondents, and 60% stopped it after ambulation. Specific ligation of lymphatics (versus none) was used by 82% of respondents, 55% obtained frozen sections, and 94% used inguinal drains. A saphenous sparing technique was used by 75% of respondents. An incisional wound vacuum device was used by 17% of respondents. Compression stockings and/or referral to a lymphedema specialist were used to manage postoperative lymphedema by 61% of respondents.

CONCLUSIONS

Responses to a penile lymphadenectomy survey were relatively low and were primarily from the academic surgeon subset of the SUO. Significant consensus ( ≥ 70%) was noted for neoadjuvant chemotherapy for bulky nodal metastasis prior to surgery, perioperative antibiotic use, ligation of lymphatics, drain placement, and saphenous sparing dissection techniques. Other evidenced-based strategies that could decrease morbidity were rarely used, including dynamic sentinel node biopsy, incisional wound vacuums, and lymphedema prevention. Prospective trials are needed to validate and resolve existing treatment paradigms and to optimize perioperative pathways to reduce complications in penile cancer management.

Penile cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer with orphan disease designation and a prevalence of 0.1-1 per 100,000 men in high-income countries, but it constitutes up to 10% of malignancies in men in some African, Asian and South American regions. Risk factors for PSCC include the absence of childhood circumcision, phimosis, chronic inflammation, poor penile hygiene, smoking, immunosuppression and infection with human papillomavirus (HPV). Several different subtypes of HPV-related and non-HPV-related penile cancers have been described, which also have different prognostic profiles. Localized disease can be effectively managed by topical therapy, surgery or radiotherapy. As PSCC is characterized by early lymphatic spread and imaging is inadequate for the detection of micrometastatic disease, correct and upfront surgical staging of the inguinal lymph nodes is crucial in disease management. Advanced stages of disease require multimodal management. Optimal sequencing of treatments and patient selection are still being investigated. Cisplatin-based chemotherapy regimens are the mainstay of systemic therapy for advanced PSCC, but they have poor and non-durable responses and high rates of toxic effects, indicating a need for the development of more effective and less toxic therapeutic options. Localized and advanced penile cancers and their treatment have profound physical and psychosexual effects on the quality of life of patients and survivors by altering sexual and urinary function and causing lymphoedema.

DaPeCa-8: drawing the map of lymphatic drainage in patients with invasive penile cancer - evidence from SPECT/CT and sentinel node surgery

BACKGROUND

Anatomy of the lymphatic drainage guides the extent of inguinal lymph node dissection in penile cancer.

OBJECTIVE

To prospectively assess the lymphatic drainage of penile cancer with single-photon emission computed tomography CT (SPECT-CT) and implications for the extent of inguinal lymph node dissection.

METHODS

We assessed the lymphatic drainage of 62 patients with at least unilateral clinical lymph node-negative (cN0) status with SPECT-CT at our tertiary referral centre. We evaluated 122 cN0 inguinal basins and compared them to the histopathological outcome. The inguinal regions were divided into ten different Daseler zones on SPECT-CT. The surgical team filled in a corresponding scheme at sentinel node biopsy and sent lymph nodes from each Daseler zone individually for histopathological examination.

RESULTS

SPECT-CT successfully visualized lymphatic drainage in 116 of the 122 cN0 inguinal basins (95.1%). The vast majority of sentinel nodes and all metastatic nodes were located in central and superior inguinal zones, including six metastatic nodes in lateral superior zones. Minimal lymphatic drainage was seen to the inferior Daseler zones and no metastatic deposits were located here. No direct pelvic drainage was observed.

CONCLUSIONS

Penile cancer lymphatic drainage is primarily to sentinel in the superior and central zones of Daseler. Colleagues practicing a modified inguinal lymph node dissection as a standard in cN0 patients are encouraged to include all these zones, while the inferior zones can be omitted. This study confirms the absence of lymphatic drainage directly to the pelvic region and supports the practice of omitting pelvic nodes from sentinel node biopsy.

Modified Inguinal Lymph Node Dissection in Groin-Negative Patients of Penile Cancer: Our Experience

Cancer of the penis is an important health problem in India, causing significant morbidity. Involvement of locoregional lymph nodes is the most significant prognostic factor for patients with penile cancer. In this study, we reviewed clinical data of all patients who underwent modified inguinal lymph node dissection as a means to diagnose micro-metastasis in inguinal lymph nodes, and analysed the outcomes. We retrospectively reviewed the hospital clinical charts of patients treated for carcinoma of the penis. Inguinal and distant metastases were assessed by physical examination, ultrasound imaging of the inguinal region, computed tomography of the abdomen and pelvis and a chest radiograph. Patients with clinically negative inguinal lymph nodes underwent modified lymph node dissection (mILND) both to diagnose and stage the disease. Complications occurring during a 30-day period after surgery were defined as early and thereafter as late complications. A total of 40 patients with a mean age of 52.27±13.10 (range 25-73) years underwent mILND. Wedge biopsy from the primary lesion had revealed intermediate-risk disease in 22 (55%) patients and high-risk disease in 18 (45%) patients. Histopathological examination of the primary penile lesion revealed a pT1 lesion in 32 patients and a pT2 lesion in the remaining 8 patients. Fourteen (35%) of the 40 patients showed micro-metastases in the inguinal lymph nodes on frozen sections. The mean follow-up in these patients was 56.6±18.09 months. There were no instances of local or systemic recurrences seen in 38 (95%) patients within 5 years. Superficial lymph node dissection and where facilities are available DSLNB remain the standard of care in the management of patients with clinically groin-negative (cN0) intermediate- and high-risk groups. Modified inguinal lymph node dissection would be a safe and appropriate alternative to this in all centres that do not have access to newer modalities like DSLNB, video-endoscopic (VEIL) or robotic-assisted techniques.

Inguinal lymph node dissection for penile cancer: a contemporary review

Penile cancer is an uncommon disease associated with significant psychological and physical morbidity. Penile cancer has an expectable pattern of spread in a stepwise fashion, from inguinal to pelvic lymph nodes (PLN) then distant spread. Patients with penile cancer have variable survival, with patients with a low burden of nodal metastatic disease having lasting survival with surgical management, however patients with a large amount of locoregional metastatic disease having a worse prognosis. The current management options for patients with metastatic lymph node disease in penile cancer aims to reduce the morbidity associated with radical inguinal lymph node (ILN) surgery with appropriate risk stratification to optimise oncological control of the disease. This article describes current challenges in managing the inguinal region in patients with penile squamous cell carcinoma (SCC).

Proposal for modified inguinofemoral lymphadenectomy derived from investigation of anatomic distribution of sentinel and metastatic nodes in vulvar cancer

OBJECTIVE

We aimed to develop a less invasive inguinofemoral lymphadenectomy (IFL) approach for vulvar cancer based on the investigation of the anatomic distribution of sentinel and metastatic nodes.

METHODS

Patients with vulvar cancer treated by surgery between 1995 and 2019 were retrospectively reviewed. A seven-field method was adopted to assign the anatomic locations for lymph nodes removed via IFL or sentinel node biopsy. Only patients with nodal metastasis or sentinel nodes were included.

RESULTS

A total of 102 patients with eligible data were analyzed. Nodal metastasis was confirmed in 118 groins undergoing IFL; sentinel node detection succeeded in 46 groins. The medial-inguinal field had the highest rate of nodal metastasis involvement (59.3%, 70/118) and sentinel nodes present (73.9%, 34/46). The inferior-femoral field was involved only in one groin with quadruple-field metastases. The lateral-inguinal field was not involved in any groin. Neither the lateral-inguinal nor the inferior-femoral field presented sentinel nodes.

CONCLUSION

The lateral-inguinal and inferior-femoral fields of the groins have a low risk of developing nodal metastasis. Therefore, a modified IFL preserving these fields can be established to reduce surgical morbidity without sacrificing its therapeutic effect.

Anatomical characterization of the inguinal lymph nodes using microcomputed tomography to inform radical inguinal lymph node dissections in penile cancer

BACKGROUND & OBJECTIVES

Radical inguinal lymph node dissections (rILND) for penile cancer risk significant postoperative lymphocele and lymphedema. However, reducing the risk of lymphatic complications is limited by our understanding of lymphatic anatomy. Therefore, this study aims to elucidate the lymphatic anatomy within the current surgical borders of a rILND.

METHODS

To visualize the position of the lymph nodes, tissue packets excised from the inguinal region of five fresh, male cadavers were imaged using microcomputed tomography (µCT). To standardize the position, rotation and size between specimens, each lymph node packet was aligned using a Generalized Procrustes analysis.

RESULTS

There was a median of 13.5 lymph nodes (range = 8-18) per packet, with the majority (99%) clustered within a 6 cm radius of the saphenofemoral junction; a region 39%-41% smaller than current surgical borders. No difference existed between the number of nodes between sides, or distribution around the saphenofemoral junction.

CONCLUSIONS

This study provides the first 3D, in situ, standardized characterization of lymph node anatomy in the inguinal region using µCT. By using knowledge of the normal lymphatic anatomy, this study can help inform the reduction in borders of rILND to limit disruption and ensure a complete lymphadenectomy.

Robot-assisted endoscopic inguinal lymphadenectomy: A review of current outcomes

Objective

To review the role of robot-assisted endoscopic inguinal lymphadenectomy (RAIL) in the management of penile cancer.

Methods

A PubMed search for all relevant publications regarding RAIL series up until August 2019 was performed using the keyword “robotic”, “inguinal lymph node dissection”, and “penile cancer”. Weighted mean was calculated in the largest series for all outcomes using the number of patients included in each study as the weighting factor.

Results

We identified 23 articles, of note the three largest series that included 102, 27, and 20 RAIL in 51, 14, and 10 patients, respectively. Saphenous vein was spared in 88.93% of RAIL cases in these series and node yield was 11.42 per groin; 35.28% of patients had positive pathological nodes. The weighted mean of operative time was 87.98 min per RAIL and the estimated blood loss was 37.08 mL per patient. The mean length of hospital stay was 1.29 days and the drain was kept in place for 17.02 days; the major complication rate was only 5.31% in these series. The mean follow-up was 33.46 months with a recurrence-free survival of 96.33%.

Conclusion

The literature regarding RAIL describes promising results, although it has shorter follow-up and higher costs when compared to historically series from the open approach. Initials series reported lower cutaneous complications compared to conventional approach, without compromising oncological outcomes. However, long-term results and larger trials are crucial to validate those findings.

Utility of Minimally Invasive Technology for Inguinal Lymph Node Dissection in Penile Cancer

Our aim is to review the benefits as well as techniques, surgical outcomes, and complications of minimally invasive inguinal lymph node dissection (ILND) for penile cancer. The PubMed, Wiley Online Library, and Science Direct databases were reviewed in March 2020 for relevant studies limited to those published in English and within 2000–2020. Thirty-one articles describing minimally invasive ILND were identified for review. ILND has an important role in both staging and treatment of penile cancer. Minimally invasive technologies have been utilized to perform ILND in penile cancer patients with non-palpable inguinal lymph nodes and intermediate to high-risk primary tumors or patients with unilateral palpable non-fixed inguinal lymph nodes measuring less than 4 cm, including videoscopic endoscopic inguinal lymphadenectomy (VEIL) and robotic videoscopic endoscopic inguinal lymphadenectomy (RVEIL). Current data suggest that VEIL and RVEIL are feasible and safe with minimal intra-operative complications. Perhaps the strongest appeal for the use of minimally-invasive approaches is their faster post-operative recovery and less post-operative complications. As a result, patients can tolerate this procedure better and surgeons can offer surgery to patients who otherwise would not be a candidate or personally willing to undergo surgery. When compared to open technique, VEIL and RVEIL have similar dissected nodal count, a surrogate metric for oncological adequacy, and a none-inferior inguinal recurrence rate. Larger randomized studies are encouraged to investigate long-term outcome and survival rates using these minimally-invasive techniques for ILND.

Management of clinically node-negative groin in patients with penile cancer

Malignant penile neoplasms are commonly squamous etiology, with the inguinal nodes being the first echelon of spread. The disease spreads to the pelvic lymph nodes only after metastases to the groin nodes, and this is the most important prognostic factor in penile carcinoma. While treatment of penile carcinoma with proven metastases to the inguinal lymph nodes mandates ilioinguinal lymph node dissection, the treatment of patients with impalpable nodes is more controversial. Overtreatment leads to excessive treatment-related morbidity in these patients, while a wait-and-see policy runs the risk of patients presenting with inguinal and distant metastases, which would have been curable at presentation. Unfortunately, no single imaging modality has been proved to be convincingly superior in the staging, and hence, management of the clinically negative groin has been subject to debate. While some high volume centers have promoted the use of dynamic sentinel lymph node biopsy, others advocate the use of the modified inguinal lymph node template to stage the groin adequately. Newer techniques such as video endoscopic inguinal lymph node dissection have been introduced as an alternative to the original radical inguinal lymphadenectomy to reduce morbidity.

Cannula-Assisted Port Placement during Video Endoscopic Inguinal Lymphadenectomy (VEIL)-a Novel and Safe Technique

To present our novel technique for subsequent port placement during video endoscopic inguinal lymphadenectomy (VEIL) surgery. VEIL has provided positive results in terms of reduction of pain, early recovery, and better cosmesis. Ten patients who underwent VEIL procedure during 2012-2015 were included in this study to assess feasibility, safety, and advantages of port placement by our new technique which include placement of subsequent ports with the help cannula of the first port. The size of incision, time taken for port placement, leakage of pneumo, any complication(s), and potential learning curve or special instrument requirements were noted in these patients. Median incision size was 10 mm and 5 mm for their respective sized ports with this new technique. Pneumo leakage was not seen in any patient. Median time taken for subsequent port placement was 2 min ± 15 s. No complication was noted to patients or the operating surgeon. The technique proved to be feasible and needed no special equipment or training. We report technical feasibility, safety, and advantages of a new technique for port placement during VEIL surgery emphasising its potential to become a standard technique in the near future.

Comparison of clinical feasibility and oncological outcomes between video endoscopic and open inguinal lymphadenectomy for penile cancer: A systematic review and meta-analysis

BACKGROUND

To compare the clinical feasibility and oncological outcomes of video endoscopic inguinal lymph node dissection (VE-ILND) and open inguinal lymph node dissection (O-ILND) in the management of penile cancer.

METHODS

We searched published articles in the PubMed, Embase, Cochrane Library, Web of science, China National Knowledge Infrastructure, and Wanfang databases. Data were extracted by 2 independent authors, and meta-analysis was performed by using Review Manager software version 5.3.

RESULTS

Ten studies were included. Compared with the O-ILND group, the VE-ILND group exhibited less intraoperative blood loss (standardized mean difference [SMD] = 3.12; 95% confidence intervals [95% CIs] [1.27, 4.98]; P = .001), shorter hospital stay (SMD = 1.77; 95% CIs [0.94, 2.60]; P < .001), shorter drainage time (SMD = 2.69; 95% CI [1.47, 3.91]; P < .001), reduced wound infection rate (odds ratio [OR] = 10.62; 95% CI [4.01, 28.10]; P < .001); reduced skin necrosis rate (OR = 7.48; 95% CI [2.79, 20.05]; P < .001), lower lymphedema rate (OR = 3.23; 95% CI [1.51, 6.88]; P = .002), equivalent lymphocele rate (OR = 0.83; 95% CI [0.31, 2.23]; P = .720), and parallel recurrence rate (OR = 1.54; 95% CI [0.41, 5.84]; P = 0.530). However, the number of dissected lymph nodes (OR = 0.25; 95% CI [0.03, 0.47]; P = .030) was slightly increased in the O-ILND group. GRADE recommendations of primary outcomes were shown in a summary of findings table.

CONCLUSIONS

For perioperative outcomes, VE-ILND is superior to O-ILND. For short-term oncological outcomes, VE-ILND is comparable to O-ILND. However, long-term oncological control still requires further verification.

Adherence to the EAU guidelines on Penile Cancer Treatment: European, multicentre, retrospective study

PURPOSE

The European Association of Urology (EAU) guidelines for penile cancer (PC) are exclusively based on retrospective studies and have low grades of recommendation. The aim of this study was to assess the adherence to guidelines by investigating the management strategies for primary tumours and inguinal lymph nodes.

METHODS

We retrospectively reviewed the clinical charts of 176 PC patients who underwent surgery in eight European centres from 2010 to 2016. The stage and grade were assessed according to the 2009 AJCC-UICC TNM classification system. To assess adherence rates, we compared theoretical and practical adherence to the EAU guidelines.

RESULTS

Overall, 176 patients were enrolled. Partial amputation was the most frequent surgical approach (39%). 53.7% of tumours were stage Tis-T1b and the remaining 46.3% were stage T2-T4. Palpable lymph nodes were detected in 30.1% of patients and 45.1% underwent lymphadenectomy (LY). A sizeable group of tumours (43.2%) were N0. For primary treatment, adherence to the EAU guidelines was good (66%). In non-adherent cases, reasons for discrepancy were patient's choice (17%), surgeon's preference (36%), and other causes (47%). For LY, the guideline adherence was 70%, with either patient's or surgeon's choice or other causes accounting for discrepancy in 28, 20, and 52% of non-adherent cases, respectively.

CONCLUSION

Adherence to the EAU guidelines for PC was quite high across the eight European centres involved in the study. This notwithstanding, strategies for further improvement should be developed and evenly adopted.

Zonal mapping of sentinel lymph nodes in penile cancer patients using fused SPECT/CT imaging and lymphoscintigraphy

PURPOSE

To define the anatomical location of sentinel lymph nodes (SLN) in penile cancer patients based on Daseler's original zonal description using a combination of single photon emission computed tomography-computed tomography (SPECT-CT), cross sectional imaging and lymphoscintigraphy and characterise the limits of Zone V.

MATERIALS AND METHODS

Patients with primary penile cancer ≥T1G2 were included in the study. A total of 113 groins with impalpable inguinal lymph nodes (cN0) underwent planar lymphoscintigraphy and SPECT-CT. The sentinel lymph nodes were mapped on cross sectional imaging according to Daseler's anatomical description. Using measurements from fixed anatomical landmarks, a custom-made software program mapped the SLNs. SLNs were mapped to the previously undefined Zone V using 3 approaches to avoid observational bias: (a) as perceived by the uroradiologist, (b) limiting Zone V to a 5 mm radius from the sapheno-femoral junction or (c) using a 10 mm radius from the sapheno-femoral junction.

RESULTS

Using SPECT-CT, drainage to the groins was seen in 109 of the 113 cN0 groins (96.5%). The majority of the SLNs were located in the central and superior quadrants with 38.2% lying within Zone I, 45% in Zone II and 13% in Zone V. More importantly, sentinel lymph nodes were still localised to the inferior zones with 3% located in Zone III and 0.8% in Zone IV.

CONCLUSIONS

Using a hybrid of SPECT-CT, cross sectional imaging and lymphoscintigraphy we have demonstrated that SLNs may be located in the inferior zones. We also define the limits of Zone V as an area of 5 mm radius from the sapheno-femoral junction.

Current controversies and developments on the role of lymphadenectomy for penile cancer

Penile squamous cell carcinoma is a rare cancer in men. The main prognosticators of survival for penile cancer patients remain the presence and the extent of lymph node metastasis. While radical inguinal lymphadenectomy has been the cornerstone of regional lymph node management for many years, it is still associated with significant morbidity and psychological distress. Recent developments in penile squamous cell carcinoma management have been met with some controversy in the urologic oncology community. Herein, we review the current controversies and developments on the role of inguinal lymphadenectomy for penile cancer.

Sentinel lymph node imaging in urologic oncology

Lymph node (LN) metastases in urological malignancies correlate with poor oncological outcomes. Accurate LN staging is of great importance since patients can benefit from an optimal staging, accordingly aligned therapy and more radical treatments. Current conventional cross-sectional imaging modalities [e.g., computed tomography (CT) and magnetic resonance imaging (MRI)] are not accurate enough to reliably detect early LN metastases as they rely on size criteria. Radical lymphadenectomy, the surgical removal of regional LNs, is the gold standard of invasive LN staging. The LN dissection is guided by anatomic considerations of lymphatic drainage pathways of the primary tumor. Selection of patients for lymphadenectomy heavily relies on preoperative risk stratification and nomograms and, as a result a considerable number of patients unnecessarily undergo invasive staging with associated morbidity. On the other hand, due to individual variability in lymphatic drainage, LN metastases can occur outside of standard lymphadenectomy templates leading to potential understaging and undertreatment. In theory, metastases from the primary tumor need to pass through the chain of LNs, where the initial node is defined as the sentinel LN. In theory, identifying and removing this LN could lead to accurate assessment of metastatic status. Radiotracers and more recently fluorescent dyes and superparamagnetic iron oxide nanoparticles (SPION) are injected into the primary tumor or peritumoral and the sentinel LNs are identified intraoperatively by a gamma probe, fluorescent camera or a handheld magnetometer. Preoperative imaging [e.g., single-photon emission computed tomography (SPECT)/CT or MRI] after tracer injection can further improve preoperative planning of LN dissection. While sentinel LN biopsy is an accepted and widely used approach in melanoma and breast cancer staging, its use in urological malignancies is still limited. Most data published so far is in penile cancer staging since this cancer has a typical echelon-based lymphatic metastasizing pattern. More recent data is encouraging with low false-negative rates, but its use is limited to centers with high expertise. Current guidelines recommend sentinel LN biopsy as an accepted alternative to modified inguinal lymphadenectomy in patients with pT1G2 disease and non-palpable inguinal LNs. In prostate cancer, a high diagnostic accuracy could be demonstrated for the sentinel approach. Nevertheless, due to lack of data or high false-negative rates in other urological malignancies, sentinel LN biopsy is still considered experimental in other urological malignancies. More high-level evidence and longitudinal data is needed to determine its final value in those malignancies. In this manuscript, we will review sentinel node imaging for urologic malignancies.

Radical Videoscopic Inguinal Lymphadenectomies: A Matched Pair Analysis

OBJECTIVE

To evaluate the modifications and feasibility of radical videoscopic inguinal lymphadenectomy (VIL).

PATIENTS AND METHODS

From January 2010 to December 2017, more than 200 patients who have underwent bilateral radical inguinal lymphadenectomy for penile cancer in Sun Yat-Sen University Cancer Center. And there were 33 patients who received radical VIL and 174 patients who received open inguinal lymphadenectomy (OIL). According to similar factors of age, body mass index, T stage, and N stage, two matched groups were created with a rate of 1:2, one group received VIL, and another group received OIL. The numbers of harvested lymph nodes, operating times, and complications were compared between the two groups. Descriptive statistical analyses, t tests, chi-square tests, and rank sum tests were performed.

RESULTS

In total, 93 patients were selected, including 31 patients who underwent bilateral VIL and 62 who underwent OIL. The numbers of harvested lymph nodes did not differ significantly (p = 0.983), the operating time was longer for the VIL than the open lymphadenectomy (p < 0.01), and the morbidity was lower among the VIL than the open lymphadenectomy.

CONCLUSIONS

Modified radical VIL is feasible, practical, and results in reduced morbidity. The dissecting field and the defined plane were critical to these modifications.

[Lymph node management of cN0 penile cancer]

In penile cancer, lymph node metastasis is the main known prognostic factor affecting patients' survival. Early inguinal lymph node dissection or the resection of clinically occult lymph node metastases improves survival compared with removal when the metastases become clinically apparent. Micrometastatic lymph node involvement is undetectable by current imaging modalities. Nomograms based on clinical and histopathological tumor characteristics are unreliable in predicting lymph node involvement. Consequently, in penile cancer patients with clinically normal inguinal lymph nodes (cN0) and a tumor stage ≥pT1, G2 surgical lymph node exploration is recommended. Radical inguinal lymphadenectomy is no longer recommended because of its invasiveness and high complication rate. Modified lymphadenectomy and dynamic sentinel lymph node surgery allow the detection of lymph node-positive patients with sufficient certainty. Thereby, the sentinel lymph node approach offers the least invasiveness and high sensitivity. Extended inguinal lymphadenectomy is still recommended in the case of positive nodes.

Video Endoscopic Inguinal Lymphadenectomy vs Open Inguinal Lymphadenectomy for Carcinoma Penis: Expanding Role and Comparison of Outcomes

OBJECTIVE

To compare differences of morbidity profile, oncological yield, and efficacy between video endoscopic inguinal lymphadenectomy and open inguinal lymphadenectomy cases.

MATERIALS AND METHODS

A total of 29 patients with proven squamous cell carcinoma of the penis were selected for inguinal lymphadenectomy from August 2013 to January 2017. Video endoscopic lymphadenectomy was performed on 1 limb and open inguinal lymphadenectomy was performed on the contralateral side. Relevant outcome data such as operative time, complication rate, number of lymph nodes removed, number of positive nodes, and recurrence during the follow-up period were collected, analyzed, and compared.

RESULTS

The mean operative time was significantly longer for the video endoscopic inguinal lymphadenectomy group (mean = 162.83 minutes) as compared with the open group (mean = 92.35 minutes). However, the mean numbers of lymph nodes removed were 7.6 in the endoscopic group and 8.3 in the open group. Postoperative complications occurred in 10 limbs (34.48%) in the open group and in 3 limbs (10.34%) in the endoscopic group. In the follow-up period ranging from 7 to 28 (mean 14) months, 2 patients died because of either distant or visceral metastasis.

CONCLUSION

The present study clearly outlines the fact that video endoscopic inguinal lymphadenectomy can deliver an equivalent lymph node yield similar to open inguinal lymphadenectomy with significantly less morbidity and is not affected by either the palpability or the number of palpable nodes. Thus, we believe that this minimally invasive technique can provide a prudent alternative for the management of the inguinal region in carcinoma of the penis.