Laparoscopic and robotic video endoscopic inguinal lymphadenectomy by the lateral approach

Robot-Assisted Video Endoscopic Inguinal Lymph Node Dissection for Penile Cancer: An Indian Multicenter Experience

Objective: To report outcomes of multicenter series of penile cancer patients undergoing robot-assisted video endoscopic inguinal lymph node dissection (RA-VEIL). Materials and Methods: In this retrospective analysis from 3 tertiary care centers in India, consecutive intermediate-/high-risk carcinoma penis (CaP) patients with nonpalpable inguinal lymphadenopathy and/or nonbulky (<3 cm) mobile inguinal lymphadenopathy undergoing RA-VEIL were included. Patients with matted/bulky (>3 cm) and fixed lymphadenopathy were excluded. Demographic, clinical, and intraoperative data were recorded. Perioperative complications were graded by the Clavien-Dindo classification (CDC). The International Society of Lymphology (ISL) {0-III} grading was used for the assessment of lymphedema. Incidence and pattern of recurrences were assessed on follow-up. Results: From January 1, 2011, to September 30, 2023, 115 patients (230 groins) underwent bilateral RA-VEIL for CaP. The median age of the cohort was 60 (50-69) years. Clinically palpable (either unilateral or bilateral) inguinal lymphadenopathy was seen in 54 patients (47%). The "per groin" median operative time was 120 (100-140) minutes with median lymph node yield of 12 (9-16). No complications were recorded in 87.8% groins operated, with major complications (CDC 3) seen in 2.6% groins. At a median follow-up of 13.5 months, 13 patients had documented recurrences and there were 10 cancer-related deaths. No port-site recurrences were observed. No/minimal lymphedema (ISL 0/I) was seen in 94% legs. Conclusion: RA-VEIL demonstrates safety and oncologic efficacy in penile cancer patients presenting with clinically nonpalpable and/or nonbulky inguinal lymphadenopathy, with favorable functional outcomes.

Laparoscopic simultaneous anterograde inguinal and pelvic lymphadenectomy for penile cancer: two planses, three holes, and six steps

Objective

To assess the feasibility, safety, and efficiency of simultaneous anterograde video laparoscopic inguinal and pelvic lymphadenectomy for penile cancer.

Materials and methods

We reviewed retrospectively the records of 22 patients (44 lateral) who underwent inguinal lymph nodes dissection for penile cancer. The procedure was standardized as two planes, three holes, and six steps. Two Separate-planes: superior plane of eternal oblique aponeurosis/ / fascia lata; inferior plane of superficial camper fascia. Three holes: two artificial lateral boundary holes, the internal and external boundary holes, and the hole of oval fossa. Six steps: separate the first separate-plane; separate the second layer; separate two artificial lateral boundary holes; free great saphenous vein; separate the third hole and clean up the deep inguinal lymph nodes; pelvic lymphadenectomy.

Results

A total of 22 cases were included and 9 patients underwent simultaneous pelvic lymphadenectomy. The average operation time on both sides was 7.52 ± 3.29 h, which was 0.5-1 h/side after skilled. The average amount of bleeding was 93.18 ± 50.84 ml. A total of 8 patients had postoperative complications, accounting for 36.36%, and no complications great than Clavien-Dindo class III occurred.

Conclusion

This study demonstrated that the video laparoscopic simultaneous anterograde inguinal and pelvic lymphadenectomy is a feasible and safe technique. Indocyanine Green was helpful for lymph node identify.

Robot-Assisted Video Endoscopic Inguinal Lymph Node Dissection for Carcinoma Penis

Inguinal lymph node status is the single most important prognostic factor for survival in patients with carcinoma penis. Various modifications and alternatives to open inguinal lymph node dissection have been developed as the same is associated with high postoperative morbidity such as wound infection, skin flap necrosis, lymphorrhea, and lymphedema. Robot-assisted video endoscopic inguinal lymph node dissection (RA-VEIL) has the potential to accomplish thorough inguinal lymph node dissection with definitively reduced postoperative morbidity. In this video, we demonstrate our technique of RA-VEIL: The fascia lata first approach and highlight our technical modifications of the conventionally described procedure.

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.

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.