Endoscopic inguinal lymph node dissection for penile carcinoma: the developing of a novel technique

A single-center comparison of our initial experiences in treating penile and urethral cancer with video-endoscopic inguinal lymphadenectomy (VEIL) and later experiences in melanoma cases

Background

Video-endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive approach that is increasingly indicated in oncological settings, with mounting evidence for its long-term oncological safety.

Objectives

To present our single-center experience of treating penile and urethral cancer with VEIL, as well as its more recent application in melanoma patients.

Methods

We prospectively recorded our experiences with VEIL from September 2010 to July 2018, registering the patient primary indication, surgical details, complications, and follow-up.

Results

Twenty-nine patients were operated in one (24) or both (5) groins; 18 had penile cancer, 1 had urethral cancer, and 10 had melanoma. A mean 8.62 ± 4.45 lymph nodes were removed using VEIL and of these, an average of 1.00 ± 2.87 were metastatic; 16 patients developed lymphocele and 10 presented some degree of lymphedema; there were no skin or other major complications. The median follow-up was 19.35 months; there were 3 penile cancer patient recurrences in the VEIL-operated side. None of the melanoma patients presented a lymphatic inguinal recurrence.

Conclusions

VEIL is a minimally invasive technique which appears to be oncologically safe showing fewer complications than open surgery. However, complications such as lymphorrhea, lymphocele, or lymphedema were not diminished by using VEIL.

Challenging the Contraindications of Minimally Invasive Inguinal Lymph Node Dissection: Report of 2 Cases

BACKGROUND

Endoscopic inguinal dissection is an emerging procedure utilizing minimally invasive technology to perform inguinal dissections aiming to avoid skin complications. Despite numerous reports there seems to be no consensus on inclusion and exclusion criteria, raising the question of when and when not to choose the minimally invasive technique. We compare the inclusion and exclusion criteria in published literature, and present our experience with 2 challenging cases; 1 with skin infiltration and the other with a previous lymphadenectomy scar.

MATERIALS AND METHODS

We present 2 cases where this procedure was performed, despite limited nodal skin infiltration in the first case, and presence of a fresh scar of a previous biopsy and recent history of chemotherapy treatment in the second case.

RESULTS

Despite skin infiltration by inguinal nodes, endoscopic inguinal dissection was performed and the attached skin was excised and delivered with the lymph nodes through the incision in the first case. Presence of a fresh scar and history of chemotherapy did not affect the outcomes in the second case, albeit fibrosis and adhesions.

CONCLUSIONS

Skin infiltration, previous lymphadenectomy, and previous groin therapy might not represent absolute contraindications in selected cases and in the hands of experienced surgeons.

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.

Efficacy and Safety of Lateral Approach-Video Endoscopic Inguinal Lymphadenectomy (L-VEIL) over Open Inguinal Block Dissection: a Retrospective Study

This retrospective study compared the immediate post-operative short-term outcomes of Lateral Approach-Video Endoscopic Inguinal Lymphadenectomy (L-VEIL) and open surgery approach in patients with TNM stage N0 and N1 tumors. Inguinal lymphadenectomies performed for various TNM stage N0 and N1 cancers between January 2011 and December 2015 at a single center were analyzed by collecting data from operation theater records and case files. Mean blood loss, operative time, drain output, nodal yield, nodal positivity, and complications were analyzed as post-procedural outcomes. Among the 116 surgeries performed, 92 were open surgery and 24 were L-VEIL. Compared with open surgery, L-VEIL led to significantly lower blood loss (64.8 mL vs. 23.3 mL; p = 0.002), mean nodal yield (11.04 vs. 8.38; p = 0.001), and mean hospital stay (3.08 vs. 8 days; p < 0.001). However, the operative time was similar for both the groups (94.5 vs. 68.1 min; p = 0.08). Complications that were significantly low in L-VEIL were flap necrosis [RR 1.29; 95% CI (1.03-1.72); p < 0.001], wound dehiscence [RR 1.25; 95% CI (1.19-1.51); p = 0.005), wound infection [RR 1.34; 95% CI (1.19-1.51); p = 0.003], readmission [RR 1.3; 95% CI (1.17-1.44); p = 0.005], and re-surgery [p = 0.014]. Occurrence of complications such as lymphocele [RR 1.25; 95% CI (0.33-4.78); p = 0.5], lymphorrhea [RR 1.27; 95% CI (1.15-1.40); p = 0.5], and pedal edema [p = 0.2] were similar for both the approaches. L-VEIL was effective and safe compared with open inguinal block dissection in treatment of various TNM stage N0 and N1 urogenital and skin cancers.

Minimizing Post-operative Complications of Groin Dissection Using Modified Skin Bridge Technique: A Single-Centre Descriptive Study Showing Post-operative and Early Oncological Outcomes

INTRODUCTION

Historically, groin dissections are associated with high morbidity. Various modifications have been described in the literature with inconsistent outcomes. The aim of this paper is to highlight modified skin bridge technique to minimize all post-operative complications of groin dissection without compromising early oncological outcomes.

METHODS

A retrospective descriptive study of the computerized cancer database was performed to retrieve details of all the cancer patients who had undergone groin dissections during January 2012 to September 2016. Data pertaining to clinical profile including demographics, clinical and histopathological details, treatment profile, procedure-related morbidity and relapse patterns were extracted and analysed.

RESULTS

A total of 75 patients underwent 105 groin dissections during this period. Out of 105 groin dissections, 43 were inguinal lymph node dissection (ILND) and 62 were combined ilio-inguinal lymph node dissection (IILND). The most common diagnosis was carcinoma penis (25%) followed by malignant melanoma (14.6%) and squamous cell carcinoma (13.33%) of lower extremities. Overall, the most common complications were seroma (14.28%) and skin edge necrosis (7.61%) followed by surgical site infection (4.76%). After a median follow-up of 17.64 months (IQR 5-61.53), a total of 18 patients (24%) developed recurrence.

CONCLUSION

Groin dissection still remains an important diagnostic as well as therapeutic procedure justifying its potential of morbidity. Modified skin bridge technique is a very effective method to minimize all post-operative complications with optimal early oncological outcomes.

Risk Group Systems for Penile Cancer Management: A Study of 203 Patients With Invasive Squamous Cell Carcinoma

OBJECTIVE

To evaluate the accuracy of previously published risk group systems for predicting inguinal nodal metastases in patients with penile carcinoma.

MATERIALS AND METHODS

Two hundred three cases of invasive penile squamous cell carcinomas (SCC) were stratified using the following systems: Solsona et al (J Urol 2001;165:1509), Hungerhuber et al (Urology 2006;68:621), and the system proposed by the European Association of Urology (EAU; Eur Urol 2004;46:1). Receiver operating characteristic (ROC) analysis was carried out to compare accuracy in predicting final nodal status and cancer-related death.

RESULTS

Most of cases were pT2/pT3 high-grade tumors with a small percentage of low-grade pT1 carcinomas. The metastatic rates for the Solsona et al, EAU, and Hungerhuber et al systems in the high-risk category were 15 of 73 (21%), 16 of 103 (16%), and 10 of 35 (29%) in patients with clinically negative inguinal lymph nodes and 52 of 75 (69%), 55 of 93 (59%), and 34 of 47 (72%) in patients with palpable inguinal lymph nodes, respectively. Performance by ROC analysis showed a low accuracy for all stratification systems although the Solsona et al and the Hungerhuber et al systems performed better than the EAU system. Patients in intermediate-risk categories and with clinically palpable inguinal lymph nodes were more likely to have nodal metastasis than patients with clinically negative lymph nodes in the same category.

CONCLUSION

These stratification systems may be useful for patients with low-grade superficial tumors and less accurate for evaluating patients with high-grade locally advanced penile carcinomas. These data may be useful for therapeutic planning of patients with penile SCC.

Video endoscopic inguinal lymphadenectomy for lymph node metastasis from solid tumors

AIM

Inguinal lymphadenectomy (IL) is the standard treatment for inguinal lymph node (LN) metastases from genitourinary neoplasm and other cutaneous malignancies. Video endoscopic inguinal lymphadenectomy (VEIL) is emerging as a new modality for treating inguinal LN metastasis, with the aim of reducing post-operative complications. However, the safety and effectiveness of this new approach is still unclear.

METHOD

A systematic literature review was performed. Patient characteristics, selection criteria, intra-operative data, number of excised LNs and post-operative outcomes were extracted and described for each study.

RESULTS

Ten series that encompassed data of 236 procedures performed in 168 patients were reviewed. The conversion to traditional IL rates ranged between 0 and 7.7%. Median/mean operation time varied between 60 and 245 min. Wound-related complications and lymphatic collection/seroma ranged between 0 and 13.3% and 4 and 38.4%, respectively. The median/mean number of excised inguinal LNs ranged between 7 and 16. Although only four studies reported a follow-up time longer then 2 years, local recurrence rate was up to 6.6%.

CONCLUSIONS

VEIL is safe and feasible for experienced surgeons with advanced laparoscopic skills and familiarity with groin anatomy. The post-operative morbidity appears lower compared to the open procedure, mainly for wound/skin related complications. The number of harvested LN and the regional recurrence rate is comparable to that of conventional groin dissection. Before VEIL technique can be considered suitable for routine clinical practice, comparable oncological outcomes and lower post-operative morbidity should be assessed in a randomized controlled trial.

Modified endoscopic left inguinal lymphadenectomy

INTRODUCTION

Endoscopic Inguinal Lymphadenectomy is an evolution of laparoscopic surgery thanks to background in these techniques. This is a new technique and the indications in the field of penile tumors today are expanding. The technique aims at reducing the morbidity of the procedure without compromising the cancer control or reducing the template of the dissection.

MATERIAL AND METHODS

We present the modified endoscopic inguinal lymphadenectomy in a 70 years-old male patient with penile melanoma and positive sentinel lymph node in left inguinal limb. Intraoperative data, pathology, post operatory evolution and oncological follow-up is described

RESULTS

Operative time was 120 min. Nine lymph nodes were retrieved and none of then showed positivity at pathology. There were no complications. The drain was kept for five days. After 12 months of follow up, no signs of disease progression were noted.

CONCLUSION

The endoscopic inguinal lymphadenectomy is feasible in clinical practice. New studies with a greater number of patients and long-term follow-up may confirm the oncological efficacy and possible lower morbidity of these new approach.

Endoscopic inguinal lymphadenectomy for penile carcinoma and genital malignancy: a preliminary report

BACKGROUND AND PURPOSE

Open radical inguinal lymphadenectomy is reported to have morbidity as high as 50%. We describe our endoscopic inguinal lymphadenectomy that aims at decreasing the morbidity of the procedure without compromising the oncologic outcomes.

PATIENTS AND METHODS

Eleven groin dissections were undertaken in seven male patients. The procedure was performed via three ports. The first one was a 10-mm incision 3 mm distal to the apex of the femoral triangle. Two additional trocars (10 mm and 5 mm) were positioned 6 cm medially and laterally to the apex of the triangle, respectively. Taking the great saphenous vein as a landmark, the superficial and deep components were dissected. The boundaries of dissection were the same as those of radical inguinal lymphadenectomy. The numbers of lymph nodes harvested were recorded. The morbidity was retrospectively analyzed.

RESULTS

The mean operative time was 126 minutes. The mean number of lymph nodes was 12.3. The averaged output of drainage per leg was 50.8 mL each day. There were only three minor complications: One patient had hypercarbia and pneumoderm, and another had 50 mL of seroma; the third had 180 mL of lymphocele. Follow-up ranged from 4 to 27 months (mean 16.3); there was no evidence of recurrence and other sequelae.

CONCLUSIONS

Endoscopic inguinal lymphadenectomy is feasible for patients with penile cancer and genital malignancy. The technique reduces the risk of complication rate, and the oncologic outcome is highly promising. Larger studies, longer term follow-up are needed to assess the oncologic control and possible morbidity.

Video Endoscopic Inguinal Lymphadenectomy (VEIL)--a prospective critical perioperative assessment of feasibility and morbidity with points of technique in penile carcinoma

Background

Inguinal lymph node involvement is an important prognostic factor in penile cancer. Inguinal lymph node dissection allows staging and treatment of inguinal nodal disease. However, it causes morbidity and is associated with complications, such as lymphocele, skin loss and infection. Video Endoscopic Inguinal Lymphadenectomy (VEIL) is an endoscopic procedure, and it seems to be a new and attractive approach duplicating the standard open procedure with less morbidity. We present here a critical perioperative assessment with points of technique.

Methods

Ten patients with moderate to high grade penile carcinoma with clinically negative inguinal lymph nodes were subjected to elective VEIL. VEIL was done in standard surgical steps. Perioperative parameters were assessed that is - duration of the surgery, lymph-related complications, time until drain removal, lymph node yield, surgical emphysema and histopathological positivity of lymph nodes.

Results

Operative time for VEIL was 120 to180 minutes. Lymph node yield was 7 to 12 lymph nodes. No skin related complications were seen with VEIL. Lymph related complications, that is, lymphocele, were seen in only two patients. The suction drain was removed after four to eight days (mean 5.1). Overall morbidity was 20% with VEIL.

Conclusion

In our early experience, VEIL was a safe and feasible technique in patients with penile carcinoma with non palpable inguinal lymph nodes. It allows the removal of inguinal lymph nodes within the same limits as in conventional surgical dissection and potentially reduces surgical morbidity.

Minimally invasive inguinal lymph node dissection (MILND) for melanoma: experience from two academic centers

BACKGROUND AND AIM

Regional lymph nodes are the most frequent site of spread of metastatic melanoma. Operative intervention remains the only potential for cure, but the reported morbidity rate associated with inguinal lymphadenectomy is approximately 50%. Minimally invasive lymph node dissection (MILND) is an alternative approach to traditional, open inguinal lymph node dissection (OILND). The aim of this study is to evaluate our early experience with MILND and compare this with our OILND experience.

METHODS

We conducted a prospective study of 13 MILND cases performed for melanoma from 2010 to 2012 at two tertiary academic centers. We compared our outcomes with retrospective data collected on 28 OILND cases performed at the same institutions, by the same surgeons, between 2002 and 2011. Patient characteristics, operative outcomes, and 30-day morbidity were evaluated.

RESULTS

Patient characteristics were similar in the two cohorts with no statistically significant differences in patient age, gender, body mass index, or smoking status. MILND required longer operative time (245 vs 138 min, p=0.0003). The wound dehiscence rate (0 vs 14%, p=0.07), hospital readmission rate (7 vs 21%, p=0.25), and hospital length of stay (1 vs 2 days, p=0.01) were all lower in the MILND group. The lymph node count was significantly higher (11 vs 8, p=0.03) for MILND compared with OILND.

CONCLUSIONS

MILND for melanoma is a novel alternative to OILND, and our preliminary data suggest that MILND provides an equivalent lymphadenectomy while minimizing the severity of postoperative complications. Further research will need to be conducted to determine if the oncologic outcomes are similar.

[Penile squamous cell carcinoma]

Penile squamous cell carcinoma (SCC) is uncommon in Europe, where it accounts for approximately 0.7% of all malignant tumors in men. The main risk factors are poor hygiene, lack of circumcision, human papillomavirus (HPV) infection, and certain chronic inflammatory skin diseases. HPV infection is detected in 70% to 100% of all penile in situ SCCs and in 30% to 50% of invasive forms of the disease, mainly basaloid and warty SCCs. In situ tumors can be treated conservatively, but close monitoring is essential as they become invasive in between 1% and 30% of cases. The treatment of choice for penile SCC is surgery. Inguinal lymph node irradiation is no longer recommended as a prophylactic measure, and it appears that selective lymph node biopsy might be useful for reducing the morbidity associated with prophylactic inguinal lymph node dissection. Survival is directly related to lymph node involvement. Improving our knowledge of underlying molecular changes and their associated genotypes will open up new therapeutic pathways.

Endoscopic inguinal lymphadenectomy with a novel abdominal approach to vulvar cancer: description of technique and surgical outcome

STUDY OBJECTIVE

To evaluate the feasibility and surgical outcome of a novel technique of endoscopic inguinal lymphadenectomy to treat vulvar cancer.

DESIGN

Retrospective analysis performed by a single center over 2 years (Canadian Task Force classification II-2).

SETTING

Major university teaching hospital.

PATIENTS

The medical records for 17 consecutive patients who underwent endoscopic inguinal lymphadenectomy because of invasive vulvar cancer were retrospectively reviewed.

INTERVENTION

Endoscopic inguinal lymphadenectomy was performed using a novel abdominal approach.

MEASUREMENTS AND MAIN RESULTS

All patients underwent abdominal endoscopic inguinal lymphadenectomy without intraoperative complications. Median (range) operative time for the endoscopic procedure was 94 minutes, with estimated blood loss of approximately 137 mL (80-170 mL). A mean (range) of 16 (11-23) nodes were retrieved. In an additional 5 patients, pelvic node dissection was performed, with retrieval of 6 (3-11) nodes. Of the 17 patients, 2 demonstrated vulvar wound necrosis, and 1 exhibited lymphorrhea through the drain orifice. No other inguinal wound-related complications were observed. Mean postoperative hospital stay was 11 (8-19) days. All patients were followed up for more than 13 months, with no recurrence of cancer.

CONCLUSIONS

Endoscopic inguinal lymph node dissection using this novel abdominal approach in patients with vulvar cancer is a safe and feasible technique that may diminish the wound-related complications associated with the standard open approach.

Update in the surgical principles and therapeutic outcomes of inguinal lymph node dissection for penile cancer

OBJECTIVES

Inguinal lymph node dissection (ILND) for the treatment of metastatic penile squamous cell carcinoma (SCC) has historically been associated with significant morbidity. This review addresses the surgical principles and techniques to decrease its perioperative morbidity, while optimizing its oncologic outcomes.

MATERIALS AND METHODS

A review of the English scientific literature from 1966 to present was conducted using the PubMed search engine as well as of additional cited works not initially noted in the search using as keywords penile cancer, inguinal lymph node dissection, inguinal lymph node metastasis, morbidity, and complications.

RESULTS

The contemporary outcomes of ILND in the context of penile cancer have built on the significant contributions made by surgeons and scientists worldwide. In this review, we provide a comprehensive overview of the principles of ILND optimizing oncological outcomes, while minimizing its attributable morbidity. It is hoped this review will serve as a benchmark for clinicians to approach this often highly aggressive tumor phenotype.

CONCLUSIONS

ILND remains an important diagnostic and therapeutic procedure for patients with penile SCC, as contemporary ILND series have reported a decrease in its associated morbidity, with the potential for further treatment outcomes in years to come. ILND can in appropriately selected patients render them disease-free, thus justifying its associated morbidity.

Controversies in ilioinguinal lymphadenectomy

Patients with penile cancer who are proven to have negative inguinal lymph nodes have an excellent prognosis. Furthermore, patients with small-volume inguinal node involvement can often be cured by surgery alone. Lymphadenectomy has clear survival benefits for patients when applied to those with lymph node metastasis. However, the current morbidity of the standard technique of lymphadenectomy is an impediment to its universal application, and innovative strategies to reduce the morbidity of staging/treatment that do not compromise oncologic control must be developed and standardized. The optimal integration of multimodality therapy to improve survival in advanced disease will occur only through collaborative studies between centers with significant patient volume, which would be facilitated through the development of regional referral centers.

Penile cancer: management of regional lymphatic drainage

Presence and magnitude of the inguinal nodal metastases are the most important determinants of oncologic outcome in patients with squamous carcinoma of the penis (SCP). Surgical removal of the inguinal lymph nodes provides an important staging and therapeutic benefit to SCP patients, while the methodology of appropriate patient selection for lymph node dissection continues to evolve. Compliant, motivated, and reliable patients with low risk of harboring metastatic inguinal lymph nodes can be managed with careful inguinal surveillance. In SCP patients whose primary tumors demonstrate pathologic features of aggressive disease, modified bilateral inguinal lymph node dissection should be performed and converted to classic ilioinguinal lymph node dissection if metastatic disease is confirmed on frozen sections. Patients with bulky inguinal metastases are unlikely to be cured by surgery alone. Integration of systemic therapy, especially in a presurgical setting, is an attractive strategy for management of patients with advanced SCP, and is currently being studied prospectively.