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

Long-term follow-up of comparative study of open and endoscopic lymphadenectomy in patients with penile carcinoma

BACKGROUND

Penile carcinoma is an uncommon cancer that develops in the penis tissue. The standard surgical method to manage regional lymph nodes after local excision is radical inguinal lymphadenectomy, but it has a high rate of complications. The objective of this retrospective study was to compare the long-term outcomes of endoscopic inguinal lymphadenectomy and open inguinal lymphadenectomy in patients with penile carcinoma.

METHODS

The study included patients diagnosed with penile carcinoma who underwent open inguinal lymphadenectomy (n = 23) or endoscopic inguinal lymphadenectomy (n = 27) at a single hospital between January 2013 and January 2021. Operation time, blood loss, drainage, hospital stay, postoperative complications, and survival rates were assessed and compared between the two groups.

RESULTS

The two groups were comparable in terms of age, tumor size and stage, inguinal lymph nodes, and follow-up. The endoscopic group had significantly lower blood loss (27.1 ± 1.5 ml vs 55.0 ± 2.7 ml, P < 0.05), shorter drainage time and hospital stay (4.7 ± 1.1 days vs 8.1 ± 2.2 days, and 13.4 ± 1.0 days vs 19 ± 2.0 days, respectively, P < 0.05), and longer operation time compared to the open group (82.2 ± 4.3 min in endoscopic group vs 53.1 ± 2.2 min in open group, P < 0.05). There were significant differences in the incidence of incisional infection, necrosis, and lymphorrhagia in both groups (4 vs 0, 4 vs 0, and 2 vs 0, respectively, P < 0.05). The inguinal lymph node harvested was comparable between the two groups. The mean follow-up time was similar for both groups (60.4 ± 7.7 m vs 59.8 ± 7.3 m), and the recurrence mortality rates were not significantly different.

CONCLUSIONS

The study shows that both open and endoscopic methods work well for controlling penile carcinoma in the long term. But the endoscopic approach is better because it has fewer severe complications. So, the choice of surgery method might depend on factors like the surgeon's experience, what they like, and what resources are available.

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.

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.

Robot-assisted laparoscopic antegrade versus open inguinal lymphadenectomy: a retrospective controlled study

BACKGROUND

To investigate the surgical methods and clinical results of robot-assisted laparoscopic antegrade inguinal lymphadenectomy.

METHODS

A retrospective study was performed on clinical data from 19 patients with penile cancer admitted from March 2013 to October 2017. Among them, nine patients underwent robot-assisted laparoscopic antegrade inguinal lymphadenectomy (robot-assisted group) and 10 patients underwent open inguinal lymphadenectomy (open group). In the robot-assisted group, preoperative preparation, patient position, robot placement, design of operating channel and establishment of operating space are described. Key surgical procedures and techniques are also summarized. In addition, the number of lymph nodes removed, postoperative complications and follow-up in both groups were statistically analyzed.

RESULTS

For the 9 patients in the robot-assisted group, surgery was successfully accomplished at 17 sides without intraoperative conversion to open surgery. The surgery time for each side was 45~90 min using laparoscope with an average of 68.5 ± 13.69 min/side. The intraoperative blood loss was estimated to be < 10 ml/side, and the number of removed lymph nodes was not significantly different from that of the open group (12 ± 4.2/side vs.11 ± 5.8/side, P = 0.84). There were no postoperative complications such as skin necrosis, delayed wound healing and cellulitis in the robot-assisted group. Skin-related complications occurred in 9 (45%) of the 20 sides in the open group. During a median follow-up of 25 months in robot-assisted group and 52.5 mouths in open group, was not significantly different there were no statistical differences in recurrence-free survival between the groups (75% vs 60%, p = 0.536).

CONCLUSION

Robot-assisted laparoscopic antegrade inguinal lymphadenectomy achieved the desired surgical outcomes with fewer intraoperative and postoperative complications. The robotic arms of the surgical system were placed between the lower limbs of each patient. There was no need to re-position the robotic arms during bilateral inguinal lymphadenectomy. This simplified the procedure and reduced the use of trocars. If necessary, pelvic lymphadenectomy could be performed simultaneously using the original trocar position.

External validation of nomogram to predict inguinal lymph node metastasis in patients with penile cancer and clinically negative lymph nodes

INTRODUCTION

Penile cancer (PC) occurs less frequently in Europe and in the United States than in South America and parts of Africa. Lymph node (LN) involvement is the most important prognostic factor, and inguinal LN (ILN) dissection can be curative; however, ILN dissection has high morbidity. A nomogram was previously developed based on clinicopathological features of PC to predict ILN metastases. Our objective was to conduct an external validation of the previously developed nomogram based on our population.

MATERIALS AND METHODS

We included men with cN0 ILNs who underwent ILN dissection for penile carcinoma between 2000 and 2014. We performed external validation of the nomogram considering three different external validation methods: k-fold, leave-oneout, and bootstrap. We also analyzed prognostic variables. Performance was quantified in terms of calibration and discrimination (receiver operator characteristic curve). A logistic regression model for positive ILNs was developed based on clinicopathological features of PC.

RESULTS

We analyzed 65 men who underwent ILN dissection (cN0). The mean age was 56.8 years. Of 65 men, 24 (36.9%) presented with positive LNs. A median 21 ILNs were removed. Considering the three different methods used, we concluded that the previously developed nomogram was not suitable for our sample.

CONCLUSIONS

In our study, the previously developed nomogram that was applied to our population had low accuracy and low precision for correctly identifying patients with PC who have positive ILNs.

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.

Video Endoscopic Inguinal Lymphadenectomy via 3-Incision Lateral Approach for Vulvar Cancers: Our Preliminary Outcome of 37 Cases

OBJECTIVE

The purpose of this study was to build a video endoscopic inguinal lymphadenectomy (VEIL) via the 3-incision superolateral inguinal approach and explore the feasibility and significance of this method for vulvar cancer.

METHODS

Thirty-seven patients with vulvar cancer who underwent VEIL via the 3-incision superolateral inguinal approach were enrolled and followed up. The number of excised lymph nodes, intraoperative complications, inguinal wound healing, and the prognosis were retrospectively analyzed.

RESULTS

The average number of excised lymph nodes per side is 8.8 ± 3.7 (4-18) among the 37 patients and after the new method was more mature, is 9.6 ± 3.6 among the 34 patients treated. Primary healing was found in 36 cases, whereas delayed healing occurred in 1 case complicated with diabetes. The lymph node-positive patients (6 cases) were supplemented with postoperative radiochemotherapy (RCT). All patients survived during the follow-up. Of the 2 recurrent patients, one patient who received surgery again and RCT survived without tumor. The other patient undergoing RCT survived with tumor.

CONCLUSIONS

Compared with open lymphadenectomy, VEIL via the 3-incision lateral approach provides a feasible, but more cosmetic, and promising minimally invasive modality in clinic for treating patients with vulvar cancer.

Technical considerations to minimize complications of inguinal lymph node dissection

Penile cancer is a rare malignancy with a high propensity for regional dissemination. Current guidelines recommend inguinal lymphadenectomy in patients with penile cancer for palpable inguinal lymph nodes or in certain cases of nonpalpable inguinal lymph nodes. For many years, this procedure was performed with a traditional open approach and carried significant morbidity due to severe lymphedema, flap necrosis, wound infections, and seroma formation. The evolution of inguinal lymphadenectomy surgery for patients with penile cancer to a more minimally invasive approach has greatly reduced the morbidity of the procedure. Complications of inguinal lymphadenectomy can be minimized with modifications in surgical approach with the use of endoscopic, robotic, and various reconstructive methods. This review focuses on various intraoperative techniques to reduce morbidity in inguinal lymphadenectomies for penile cancer.

Minimally Invasive Inguinal Lymphadenectomy in the Management of Penile Carcinoma

OBJECTIVE

To report and analyze the outcomes of endoscopic inguinal lymph node dissection (E-ILND), inclusive of video endoscopic ILND (VEIL) and robotic-assisted ILND (RAIL) approaches, in the largest reported series to date.

MATERIALS AND METHODS

We retrospectively identified men with penile cancer who underwent E-ILND. Nodal resection volume, perioperative parameters, and postoperative complications were assessed and analyzed. A subset analysis of complications by tumor and operative characteristics was performed to determine the impact of these variables on complication rates.

RESULTS

A total of 34 E-ILND, comprising 7 VEIL and 27 RAIL limbs, were performed. Median nodal yield was 10.0 (interquartile range [IQR] 6.0-12.5) in all E-ILND limbs and 8.0 (IQR 13.0-23.0) in RAIL limbs. Median length of stay was 1 day (range 1-3) following E-ILND and RAIL procedures. The saphenous vein was spared in 57% (4/7) of VEIL and 100% (27/27) of RAIL limbs. Postoperative complications occurred in 33% (6/18) of E-ILND, including 21% (3/14) of RAIL patients. Median follow-up was 5.5 months (IQR 3.0-10.8), during which time 3 patients developed regional or distant metastases at a median duration of 1.7 months (IQR 0.9-3.9).

CONCLUSION

E-ILND is feasible from a technical standpoint, and our results demonstrate that lymph node counts are comparable with an open approach. Importantly, E-ILND has the potential to reduce complication rates and time to convalescence when compared with open ILND.

Endoscopic inguinal lymphadenectomy in penile cancer: case report and literature review

Objectives

The objective was to submit our first experience in endoscopic inguinal lymphadenectomy (EIL), evaluate the feasibility of the procedure and carry out a review of the literature.

Material and methods

A 41-year-old patient was diagnosed with penile cancer with squamous cell carcinoma pT2G1 pathology, with no palpable inguinal lymph nodes. A bilateral inguinal lymphadenectomy was performed with preservation of the saphenous vein, conventional left and endoscopic right procedures. The perioperative data is presented and that obtained is discussed in the literature.

Results

The total time was 270 minutes, 180 for endoscopic and 90 for conventional procedures. Blood loss was minimal in both cases. Fifteen lymph nodes were dissected on the endoscopic side, and 17 in the conventional side, the latter with more pain and devitalised skin flap.

Conclusions

EIL for penile cancer is feasible and there is less morbidity with an early recovery. The literature is not conclusive on the indication of EIL.

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.

Clinical application of endoscopic inguinal lymph node resection after lipolysis and liposuction for vulvar cancer

AIM

To examine lymph nodes obtained after lipolysis and liposuction of subcutaneous fat of the inguinal region of female vulvar cancer patients to explore the feasibility of clinical application.

METHODS

The field of operation was on the basis of the range of the conventional resection of inguinal lymph nodes. We injected lipolysis liquid fanwise, started liposuction after 15-20 minutes; then the subcutaneous fatty tissue was sucked out clearly by suction tube. We selected the first puncture holes located on 2-3 cm part below anterior superior spine, the others respectively being located 3cm and 6cm below the first for puncturing into the skin, imbedding a trocar to intorduce CO2 gas and the specular body, and excise the lymph nodes by ultrasonic scalpel. The surgical field chamber was set with negative pressure drainage and was pressured with a soft saline bag after surgery.

RESULTS

A lacuna emerged from subcutaneous of the inguinal region after lipolysis and liposuction, with a wide fascia easily exposed at the bottom where lymph nodes could be readily excised. The number of lymph nodes of ten patients excised within the inguinal region on each side was 4-18. The excised average number of lymph nodes was 11 when we had mature technology.

CONCLUSION

Most of adipose tissue was removed after lipolysis and liposuction of subcutaneous tissue of inguinal region, so that the included lymph nodes were exposed and easy to excise by endoscope. This surgery avoided the large incision of regular surgery of inguinal region, the results indicating that this approach is feasible and safe for used as an alternative technology.

Robotic bilateral inguinal lymphadenectomy in penile cancer, development of a technique without robot repositioning: a case report

Introduction

Inguinal lymphadenectomy is the treatment of choice for patients with penile cancer and inguinal lymph node metastases. We describe the performance of the robotic bilateral inguinal lymphadenectomy technique without repositioning the robot in a patient with penile carcinoma and high risk for nodal metastases and no palpable lymph nodes.

Materials and methods

A 64-year-old male patient was diagnosed with penile cancer (TNM: T3 N 0 M 0) and underwent a total penectomy with perineal urethrostomy. We performed a robotic bilateral inguinal lymphadenectomy four weeks after the penectomy.

Results

The entire procedure was performed with the robot-assisted technique. The operative time, median estimated blood loss, and hospital stay was 360 min, 100 ml (50 ml in the right side and 150 ml in the left side), and three days, respectively. Metastatic nodes were present in both inguinal regions, with a yield of 19 lymph nodes on the right and 14 on the left. The patient presented with a left-side lymphocele that was drained at follow-up. No other complications were reported.

Conclusion

Robotic bilateral inguinal lymphadenectomy secondary to penile cancer is feasible, safe, and provides a good performance. Prospective studies are required to include a larger number of patients and long-term monitoring to assess the results of this procedure in comparison with open and laparoscopic techniques.