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

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.

Preferring Lateral Video Endoscopic Inguinal Lymph Node Dissection Over Classic Video Endoscopic Inguinal Lymph Node Dissection in Squamous Cell Carcinoma of Penis: Lessons Learnt from Twenty-One Patients at a Single Center

OBJECTIVE

Inguinal lymphadenectomy is essential for staging and disease control. Minimally invasive techniques are recently replacing open techniques to reduce complications. We present our experience and lessons learnt from 21 patients who underwent lateral video endoscopic inguinal lymphadenectomy (L-VEIL) for penile malignancy.

METHODS

All patients above 18 years of age with histopathology-confirmed squamous cell carcinoma penis with stages ≥ T1b and T1a with persistent lymphadenopathy who underwent L-VEIL over a period of 2 years (2020-2022) were included. The data were analyzed on the basis of intraoperative and postoperative complications, lymph node yield, hospital stay, and histopathology report.

RESULTS

Forty-one lower limbs of 21 patients underwent L-VEIL during the abovementioned period. Median age was 52 years. Mean operative time (on 1 side) was 80 minutes. Median lymph node yield per side was 7.2. Intraoperatively, 1 patient had a vascular injury at the saphenofemoral junction, requiring conversion to open. Postoperative complications were superficial surgical site infection (n=4), lymphedema (n=1), and lymphocoele (n=3), one of which was drained by pigtail catheter. One patient required exploration on the second postoperative day because of vascular injury. Average duration of hospital stay was 3 days. The median time of drain removal was 13 days. Histopathology suggested seminoma in 1 patient and mature teratoma in 1 patient; the rest of the patients' reports were negative for malignancy.

CONCLUSION

The L-VEIL is safe and feasible, and there is a reduction (~30%) in complications; oncological outcomes are also not affected. It has better ergonomics, resulting in ease and comfort for surgeons when compared with classical VEIL.

Long-term oncological and surgical outcomes after Video Endoscopic Inguinal Lymphadenectomy (VEIL) in patients with penile cancer

OBJECTIVE

To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL).

MATERIALS AND METHODS

Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range.

RESULTS

From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively.

CONCLUSION

VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.

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.

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.

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.

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.

Minimal invasive approaches in lymph node management of carcinoma of penis: A review

INTRODUCTION

Inguinal lymph node dissection (ILND) is an integral part in the management of carcinoma penis. The concerns about the postoperative morbidity associated with open ILND led to modification in the template of dissection and adoption of minimally invasive techniques such as video endoscopic inguinal lymphadenectomy (VEIL) and robotic-assisted VEIL (R-VEIL). In this review, we aim to describe the techniques, case selection, perioperative outcomes, and oncological outcomes of VEIL and R-VEIL and to compare it with open ILND.

METHODS

Databases of PubMed, Embase, and Google Scholar were searched to identify the articles for VEIL and R-VEIL. Using PRISMA guidelines, literature search yielded 3783 articles, of which 32 full-text articles relevant to the topic were selected and reviewed, after consensus from authors.

RESULTS

After the first description of VEIL, various modifications in port placements and approaches were described. Several studies have shown, VEIL and R VEIL are safe and feasible in both node-negative and node-positive Ca penis patients. Compared to open ILND, VEIL had fewer wound infections and skin necrosis, minimal blood loss, shorter mean hospital stays, and reduced duration of drain kept. There is no difference in mean lymph node yield and recurrence rates between open ILND, VEIL, R-VEIL.

CONCLUSION

VEIL and R-VEIL are safe and have comparable oncological outcomes with open ILND.

Progress on Management of Penile Cancer in 2020

OPINION STATEMENT

Management of penile cancer represents a challenge to urologic oncologists due to the disease's rarity and sparse data in the literature. Squamous cell carcinoma represents the most common histologic subtype of penile cancer. Penile cancer has a disastrous effect on patients' psychological and physical health. Penile cancer accounts for approximately 1% of cancer deaths in the USA annually. However, in recent years, the management of penile cancer has achieved marked progress in both diagnostic and therapeutic approaches with the intent to avoid radical surgeries. The traditional total penile amputation has been replaced by penile preserving procedures in many patients. Nowadays, total penile amputation (total penectomy) is preserved only for patients with proximal lesions. The introduction of minimally invasive surgical techniques in the management of penile cancer-infiltrated lymph nodes has been reported. Given the dismal prognosis with conventional cytotoxic therapies, new systemic therapies have been investigated in patients with locally advanced or metastatic penile cancer. Multiple studies have shown promising outcomes. All these efforts have resulted in a remarkable improvement in patient quality of life. The objectives of our review are to update clinicians on the advances in the management of penile cancer and to summarize the recent guidelines and recommendations.

Minimally invasive inguinal lymph node dissection: initial experience and reproducibility in a limited resource setting-with technique video

BACKGROUND

Conventional inguinal lymph node dissection comes with a high wound complication rate which increases hospital stay and may delay adjuvant treatment. Minimally invasive lymph node dissection (MILND) is a novel endoscopic technique which aims to minimize complications of lymphadenectomy. Herein we present our technique and experience with MILND to examine safety, feasibility and reproducibility in a setting of limited resources.

METHODS

All patients undergoing MILND in the National Cancer Institute, Cairo were prospectively included following informed consent, IRB and ethical committee approval. Demographics, clinical, pathological data and postoperative complications according to Clavien-Dindo classification were recorded. Footage collected was used to create a step-by-step video demonstrating the technique.

RESULTS

Twenty-seven procedures were included in the study. The most common indications were vulval cancer (44%) and skin melanoma (19%). There were 5 (18%) conversions to open procedure, all of them in the first 10 cases of the learning curve. The median (range) operative time was 120 (45-240) min and there was a trend towards shorter operative time after the first 5 cases. Wound dehiscence occurred in 4 cases (15%). Three of them (11%) required reoperation (grade III). Grade I/II complications in the form of seroma and wound infection occurred in 34%. The median (range) postoperative hospital stay was 2 (1-14). The median (range) number of retrieved lymph nodes was 12 (3-19). No grade III/IV lymphedema was recorded at 90 days after surgery.

CONCLUSION

MILND is a safe, feasible technique associated with relatively low postoperative wound complications even when performed in a centre with relatively limited resources.

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.

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.

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.

Initial experience of video endoscopic inguinal Lymphadenectomy in a center located at northeast brazilian region

Introduction:

Video endoscopic inguinal lymphadenectomy – VEIL – has emerged as an alternative to reduce post-surgical complications (PSC) in patients with penile cancer submitted to inguinal lymphadenectomy (IL). In some series, these PSC are observed in more than 50% of patients. The objectives of the present study are to describe the initial experience of VEIL in a Hospital in Teresina, PI, Brazil, and to analyze PSC incidence.

Material and Methods:

Retrospective descriptive study of patients submitted to VEIL from March 2014 to November 2015. Data were collected regarding surgical time, bleeding, complications, lymph node number, conversion, global complications, drainage time, cellulitis, lymphocele, cutaneous necrosis, miocutaneous necrosis and hospitalization time.

Results:

20 lower limbs of 11 patients were operated. Mean age was 51.4 (24-72) years. Mean surgical time was 85 (60-120) minutes. No patient showed intrasurgical complications, bleeding > 50 mL or conversion. Three surgeries evolved with lower limb edema, 2 with lymphoceles and one patient had cutaneous necrosis and another bulging of surgical wound. Mean time of hospitalization was 4 (2-11) days. A mean of 5.8 (1-12) lymph nodes were dissected in each surgery.

Conclusion:

VEIL is a safe and easy technique with lower incidence of PSC that can be reproduced in small centers.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020: tumeurs du pénis French ccAFU guidelines — Update 2018—2020: Penile cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.008. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.008. That newer version of the text should be used when citing the article.

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.

Endoscopy-assisted inguinal lymphadenectomy in vulvar cancer

OBJECTIVE

To explore the feasibility and efficiency of video endoscopic inguinal lymphadenectomy (VEIL) for vulvar cancer.

METHODS

We evaluated 46 patients with vulvar cancer. Treatment included VEIL using the hypogastric subcutaneous approach (VEIL-H, 17 patients), VEIL with the limb subcutaneous surgical approach (VEIL-L, 8 patients), and open inguinal lymphadenectomy (OIL, 21 patients). All patients underwent radical vulvectomy; we evaluated operative time, the amount of bleeding, SF score, recurrence rate, etc. RESULTS: The durations of VEIL-H and VEIL-L were 170.79 ± 18.92 and 180.12 ± 17.88 min, respectively, which were longer than that of OIL (100.68 ± 11.37 min; P = 0.028). Bleeding volumes in the VEIL-H and VEIL-L groups were 15.23 ± 2.17 and 17.16 ± 2.35 ml, respectively; there were significantly lower than that of the OIL group (36.68 ± 3.48 ml; P = 0.021). The numbers of unilateral lymph nodes harvested were similar in all groups. The duration of hospitalization in VEIL group was shorter than that of the OIL group. There were less skin and lymphatic complications after VEIL than after OIL. Total SF-36 scores were significantly higher in the VEIL group than that in the OIL group (P = 0.032). There were no statistically significant differences in local recurrence, distant metastasis, and mortality among the three groups.

CONCLUSION

VEIL for vulvar cancer treatment is effective, with the advantages of short hospitalization stay, less bleeding, and reduced postoperative complications comparing the OIL.

Robotic-Assisted Video Endoscopic Inguinal Lymphadenectomy in Carcinoma Vulva: Our Experiences and Intermediate Results

OBJECTIVES

To describe the technique of robotic-assisted video endoscopic inguinal lymphadenectomy (R-VEIL) in patients with carcinoma vulva and discuss the advantages of the technique and oncological outcome.

METHODS

Twelve patients of squamous cell cancer of vulva underwent 22 R-VEIL procedures from February 2011 to February 2015. Their preoperative, intraoperative, and postoperative data were retrospectively analysed.

RESULTS

The mean age of patients was 61 years (range, 32-78 years). The mean operative time was 69.3 minutes (range, 45-95 minutes). The mean blood loss was 30 mL (range, 15-50 mL). No intraoperative complication was observed. The mean drain output was 119 mL (range, 50-250 mL), and the drains were removed at a mean of 13.9 days (range, 8-38 days). The average number of superficial and deep inguinofemoral lymph nodes retrieved was 11 (range, 4-26). Two patients had positive lymph nodes on histopathology (16.67%). Postoperative complications were lymphocele (6 groins), chronic lower limb lymphedema (6 cases), prolonged lymphorrhea (1 groin), and cellulitis (2 groins). Over a follow-up period ranging from 7 to 67 months, 1 patient developed recurrence in the inguinal nodes and died 7 months after the recurrence.

CONCLUSIONS

The R-VEIL allows the removal of inguinal lymph nodes within the same limits as the open procedure for inguinal lymph node dissection and has a potential to reduce the surgical morbidity associated with the open procedure. Long-term oncological results are not available though our initial results appear promising. Prospective multi-institutional studies are required to prove its efficacy over open inguinal lymph node dissection.

Comparative Study of Video Endoscopic Inguinal Lymphadenectomy Through a Hypogastric vs Leg Subcutaneous Approach for Penile Cancer

OBJECTIVE

To compare the efficacy and safety of video endoscopic inguinal lymphadenectomy through a hypogastric subcutaneous approach (VEIL-H) with a leg subcutaneous approach (VEIL-L) in the surgical management of penile cancer.

MATERIALS AND METHODS

Between October 2012 and October 2016, 72 penile cancer patients who underwent VEIL-H (n = 37) or VEIL-L (n = 35) by one experienced surgeon in our hospital were retrospectively included. Data associated with demographic characteristics and perioperative outcomes were evaluated and compared between two groups.

RESULTS

No intraoperative complications occurred and no deaths were recorded. No difference was noted with respect to demographic and clinicopathological data, operative time, estimated blood loss, spare of the great saphenous vein, dissected inguinal lymph nodes, patients with inguinal lymph node metastasis, positive inguinal lymph nodes, duration of drain, postoperative hospital days, and postoperative complications between two groups (p > 0.05). Two patients of each group received a bilateral laparoscopic pelvic lymphadenectomy in one session. The pathological results of all dissected pelvic lymph nodes were negative. Median follow-up was 16.2 months, during which time three patients in VEIL-L group and two patients in VEIL-H group developed regional or distant metastases.

CONCLUSIONS

Hypogastric approach is as effective and safe as VEIL-L for penile cancer. Moreover, VEIL-H can avoid the operation on both the limb and abdomen if laparoscopic pelvic lymphadenectomy is required.

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.

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.

[CCAFU french national guidelines 2016-2018 on penile cancer]

INTRODUCTION

The aim of this work is to establish guidelines proposed by the external genital organ group of the CCAFU for the diagnosis, treatment and follow-up of penile cancer.

MATERIAL AND METHODS

The multidisciplinary working party studied 2013 guidelines exhaustively reviewed the literature, and evaluated references and their level of proof in order to attribute grades of recommandation.

RESULTS

The most common histological type is squamous cell carcinoma. Clinical examination of the penis is usually sufficient to access local extension. It can be completed by MRI to assess deeper extension. Physical examination of both groins must evaluate inguinal regional lymph nodes involvement. In the presence of palpable lymph nodes, abdomen and pelvis computed tomography and ¹⁸F-FDG PET-CT are recommended. Sentinel lymph node biopsy is recommended in the case of penile cancer with high risk of lymph node extension with no palpable lymph nodes. Treatment of the primary tumour is usually surgical. It must be as conservative as possible while ensuring negative surgical margins. Brachytherapy or local treatment can be proposed in some cases. Bilateral inguinal lymph node areas must be systematically treated. Inguinal lymphadenectomy alone has a curative role in patients with metastatic invasion of a single node (stage pN1). In the case of more extensive lymph node involvement, multimodal management combining chemotherapy, surgery, and possibly radiotherapy has to be considered.

CONCLUSIONS

The treatment of penile cancer is usually surgical possibly in combination with chemotherapy in the presence of lymph node extension. The main prognostic factor is lymph node involvement, requiring appropriate management at the time of diagnosis.x © 2016 Elsevier Masson SAS. All rights reserved.

Robot-Assisted Simultaneous Bilateral Radical Inguinal Lymphadenectomy Along with Robotic Bilateral Pelvic Lymphadenectomy: A Feasibility Study

INTRODUCTION

To report the surgical technique, procedure outcomes, and feasibility of robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy.

MATERIALS AND METHODS

Three consecutive patients of penile and urethral carcinoma with palpable inguinal lymphadenopathy who underwent robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy in our institution from May 2013 to October 2015 were included in the study. Surgical technique is described and feasibility of the procedure is assessed.

RESULTS

Three patients aged 58, 76, and 35 years underwent robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy with a mean operative duration of 453.33 minutes (range 420-490 minutes). Average blood loss was 66.66 mL (range 50-80 mL) and mean time to removal of last drain was 44.66 days (range 28-72 days). Mean lymph node yield in left inguinal region, right inguinal region, left pelvic region, and right pelvic region was 18, 14.6, 13.3, and 16.6, respectively. The perioperative period was uneventful. No skin flap-related complications were seen. One patient suffered lymphocele postoperatively, which was managed successfully with needle aspiration. One patient developed lung metastasis in follow-up and none of them had local recurrence.

CONCLUSION

Robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy is feasible, safe, and may result in decreased morbidity compared to conventional open lymphadenectomy.

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.

Prognostic factors in patients with penile carcinoma and inguinal lymph node metastasis

OBJECTIVES

To identify prognostic factors in patients with penile carcinoma and confirmed lymph node metastasis.

METHODS

Patients were selected from a historical series of patients with penile carcinoma. An experienced pathologist reviewed all cases. Information regarding the total number of lymph nodes excised, the number of positive lymph nodes and the presence of extranodal extension were used. Lymph node ratio was categorized as <0.15 and >0.15.

RESULTS

The 5-year recurrence-free survival and disease-specific survival rates were 55.3% and 64.1%, respectively. Lymphovascular invasion, lymph node ratio and pN status influenced survival rates in univariate analysis. Lymphovascular invasion and lymph node ratio remained as independent predictors of disease-specific survival and recurrence-free survival in the multivariate analysis. A risk stratification of death and tumor recurrence was observed when patients were grouped into three categories: absence of risk factors; the presence of one risk factor; and the presence of two or more risk factors.

CONCLUSIONS

The presence of one or more of the following parameters is correlated with a significantly higher risk of death and tumor recurrence in patients with penile carcinoma and inguinal lymph node metastasis: extranodal extension, lymph node ratio >0.15 and lymphovascular invasion.

Preliminary experience of performing a video endoscopic inguinal lymphadenectomy using a hypogastric subcutaneous approach in patients with vulvar cancer

To evaluate the feasibility and surgical outcome of video endoscopic inguinal lymphadenectomy (VEIL) using a hypogastric subcutaneous approach, 21 patients with vulvar cancer who underwent this procedure were included in the present study. Between December 2010 and March 2013, 21 consecutive patients with vulvar cancer underwent radical vulvectomy and VEIL using a hypogastric subcutaneous approach. The intraoperative and post-operative results and follow-up data were retrospectively analyzed. No intraoperative complications occurred. The mean duration of surgery for the endoscopic inguinal lymphadenectomies was 130 min (range, 80–180 min), with a mean estimated blood loss of 103 ml (range, 30–350 ml). The mean lymph node yield was 15 (range, 10–22 lymph nodes). The suction drains were removed after a mean duration of 7 days (range, 5–11 days). No skin-related complications were observed in the groin region and a lymphocele was only observed in 1/21 (4.8%) patients. After a mean follow-up period of 17 months (range, 3–31 months), recurrence was found in only one patient. All the patients were alive at the time of publication. Based on our preliminary experience, performing VEIL using a hypogastric subcutaneous approach is a safe and feasible technique for patients with vulvar cancer. These results indicate that this surgical technique may decrease the post-operative morbidity of lymphadenectomy without compromising the therapeutic efficacy. Future prospective studies with a greater sample size and a longer duration of follow-up are required.

Lymphadenectomy for testicular, penile, upper tract urothelial and urethral cancers

PURPOSE OF REVIEW

The lymph node dissection (LND) is an integral component of many oncologic surgeries. Better understanding of each cancer's behaviour and improvements in surgical techniques necessitate a critical analysis of lymph node disease and the optimal LND template. This review will focus on updates in managing lymph node disease in testicular, penile, upper tract urothelial and urethral cancer.

RECENT FINDINGS

For testicular and penile cancer, advances have focused on reducing the morbidity associated with the standard templates of dissection while maintaining oncologic efficacy. For upper tract urothelial carcinoma, data continue to be mixed regarding the need for a LND, though it does seem to benefit patients with advanced tumours. Little is known regarding the optimal LND template for urethral cancer.

SUMMARY

A thorough LND has an established diagnostic and therapeutic role in testicular and penile cancer. For upper tract urothelial carcinoma, the role of an LND remains controversial, though emerging evidence points to an association with improved outcomes. Due to the rarity of urethral cancer, there are no standard LND templates, though excising clinically positive nodes is recommended. For all these cancers, more sophisticated risk stratification based upon clinical and pathologic factors has helped determine which patients require an LND and how to best manage these patients after surgery.

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.

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.

[Cervical, inguinal and abdominal lymphnode dissection]

Diagnostic lymph node dissections can be defined as a form of oncological service surgery. These procedures aim at clarification of differential diagnoses of local or systemic lymph node pathologies or contribute to tumor staging. Procedure implementation can either involve incisional biopsy, selective lymph node extirpation or regional systematic lymph node dissection. Sentinel lymph node lymphadenectomy is a focused form of selective lymphadenectomy. Both surgeon and oncologist must have a preoperative consensus and mutual understanding about the detailed purpose of the procedure in the individual patient setting. Terminology conventions must be considered in communication. Potential reasons to extend surgery should be strategically reflected prior to surgery. Interventional techniques and minimally invasive forms of surgical lymph node dissection must be technically taken into account in order to reduce procedural morbidity. Clinically indicative scenarios, pathophysiological concepts and technical options of surgical lymph node dissection are described and discussed for various anatomical regions.