Feasibility and Safety of Video Endoscopic Inguinal Lymphadenectomy in Vulvar Cancer: A Systematic Review

Accuracy of ICG compared with technetium-99 m for sentinel lymph node biopsy in vulvar cancer

PURPOSE

Sentinel lymph node biopsy with radioactive tracer is the standard-of-care in lymph node status assessment in vulvar cancer. Indocyanine green fluorescence-ICG is a promising detection method, due to its advantages over technetium-99 m. In vulvar cancer, the procedure is controversial due to study heterogeneity and the small sample size in previous studies. This study evaluates ICG sentinel lymph node detection compared with the criterion-standard with technetium (dual modality method).

METHODS

Preoperative technetium and intraoperative ICG for sentinel lymph node have been prospectively evaluated in early-stage vulvar cancer. The primary endpoint was to determine accuracy in the detection rate for ICG compared with technetium. Secondary objectives included tracer modality relationship with obesity, tumor size and location.

RESULTS

In total, 75 patients participated at 8 centers; 38 had lateral and 37 had midline vulvar tumors. The overall sentinel lymph node detection rate was 85.3 % for technetium and 82.7 % for ICG. For lateral tumors, the detection rate was 84.2 % vs. 89.5 %, while it was 86.5 % vs. 75.7 % for middle tumors, using technetium and ICG, respectively. The median sentinel node harvest was 1.7 (range 1-4), with 24 % metastatic involvement. The sensitivity and positive predictive value for ICG based on the standard technique with technetium was 91.08 % (95 % CI, 83.76-95.84) and 94.8 % (95 % CI, 84.84-96.48), respectively. No significant differences were found comparing the two tracers in patients with midline lesions, obesity (body mass index ≥ 30) and tumor size ≥ 2-4 cm.

CONCLUSION(S)

ICG shows comparable performance parameters to the gold-standard of radioisotope localization.

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.

Safety and feasibility of single-incision radical vulvectomy: a novel approach for the treatment of vulvar cancer

Background

In the process of decreasing the morbidity of wound-related complications after vulvectomy and IL for treating vulvar malignancy, we performed a novel surgical procedure—single-incision radical vulvectomy (SIRV). Here, we share our initial experience and report its safety and feasibility.

Methods

Patients with advanced local vulvar tumors were sequentially enrolled in this prospective cohort study to undergo SIRV. While performing SIRV, routine radical vulvectomies were performed first. Subsequently, the flaps of the bridge area between the vulvectomy incisions and femoral triangles were separated and the lymph nodes underneath were removed. Anterior working spaces (AWS) before the femoral triangle were then made. The saphenous vein was carefully identified and retained, while the superficial and deep inguinal lymph nodes were removed from the medial to the lateral sides. After careful hemostasis, the wounds were sutured. Patient demographics, clinical data, pathologic data, operation time, node count, and complications were recorded.

Results

Ten patients underwent SIRV for vulvar cancer. Average hospital stay was 11.70±3.16 (range, 9–13) days. The average number of harvested lymph nodes was 7.59±3.62 (range, 3–15) and 15.14±3.63 (range, 11–20) for per side or both sides of the groin. Blood loss was ≤35 mL. Three patients developed inguinal lymphoceles and underwent needle aspirations. Two patients had impaired wound healing and achieved healing after dressing change. No other postoperative complications were noted during follow-up.

Conclusions

Compared with conventional open inguinal lymphadenectomy (COIL) and video endoscopic inguinal lymphadenectomy (VEIL), SIRV is a more minimally invasive procedure. Our short-term observations showed that SIRV is safe and feasible and has good future application prospects for vulvar cancer. However, definitive conclusions cannot be made. Therefore, long-term oncologic outcomes and large-scale clinical trials are warranted.

Reduced morbidity by using LigaSure compared to conventional inguinofemoral lymphadenectomy in vulvar cancer patients: A randomized controlled trial

BACKGROUND

Inguinofemoral lymphadenectomy (IFL) is part of the surgical treatment of different malignancies of the genital tract and/or the lower limb including vulvar carcinoma, penile carcinoma and melanoma. IFL is associated with morbidity in up to 85% of the patients. The aims of this MAMBO-IC study (Morbidity And Measurement of the Body) are to study the feasibility of using LigaSure for IFL and to assess the differences in the incidence of short-term complications using LigaSure versus conventional IFL randomized within each individual patient.

METHODS

In this multicenter randomized controlled trial (RCT), women diagnosed with squamous cell carcinoma of the vulva with an indication for bilateral IFL were included. It was randomly assigned for which groin the LigaSure was used; the other groin was treated with conventional IFL (sharp/diathermia). We estimated the incidence of ≥1 complication(s) per groin using logistic regression and compared this between the two surgical methods, adjusting for possible confounders.

RESULTS

We included 40 groins of 20 patients. The estimated incidence of ≥1 complication(s) was 29% after LigaSure versus 70% after conventional IFL (risk difference 41% (95% CI 19-62), p < 0.001). Patients' reported restriction of daily living activities and maximum pain score were equal for both treatment methods. There were no differences in the surgeon reported workload scores.

CONCLUSIONS

This RCT shows that LigaSure for IFL is feasible and associated with significantly less short-term surgical complications compared to conventional IFL. Further studies with a larger sample size are needed to validate our findings. ISRCTN15057626.

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.

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.

Fibrin-thrombin sealant does not reduce lymphocele formation in patients with inguinofemoral lymphadenectomy for vulvar cancer

Purpose: Inguinofemoral lymphadenectomy (IFLD) is associated with very high morbidity. Fibrin sealant patches are used in various surgical procedures to prevent hematomas and lymphoceles. Here, we report a single-institution experience of fibrin sealants after IFLD in vulvar cancer and give an overview of the current literature.

Patients and methods: We retrospectively analyzed outcome data on vulvar cancer patients who underwent bilateral IFLD between November 2014 and June 2016 at the University Hospital Basel. A fibrin sealant patch (Tachosil^®) was placed in one groin only. Postsurgical fluid collection and complications were compared between both groins; time courses of lymphocele formation were analyzed using a linear mixed-effects regression model.

Results: Postsurgical outcome of 11 consecutive patients with bilateral IFLD for vulvar cancer was assessed for a median follow-up of 32 days (range 12–77). Significantly larger lymphoceles were detected over time in the groin with the fibrin sealant patch (median 20 mL vs 5 mL without patch, p=0.002), and more punctures for symptomatic lymphocele were required on this side. The infection rate did not differ between sides.

Conclusion: Fibrin sealant patches should not routinely be used for prevention of lymphoceles after IFLD for vulvar cancer. They do not seem to reduce lymph collection, the need for puncture or the infection risk after lymphadenectomy in our experience and according to a general literature review.

A Comparative Study of Video Endoscopic Inguinal Lymphadenectomy and Conventional Open Inguinal Lymphadenectomy for Treating Vulvar Cancer

OBJECTIVE

This study aims to compare the complications, oncological outcomes, cosmetic satisfaction, and quality of life experienced by women with vulvar cancer undergoing video endoscopic inguinal lymphadenectomy (VEIL) versus conventional open inguinal lymphadenectomy (COIL).

PATIENTS AND METHODS

Forty-eight consecutive patients with vulvar cancer who underwent COIL (n = 27) or VEIL (n = 21) at the Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China between 2003 and 2016 were included in this retrospective cohort study. The perioperative data, postoperative complications, oncological outcomes, cosmetic satisfaction, and quality of life of the COIL and VEIL groups were compared.

RESULTS

Twenty patients (74.1%) in the COIL group and 19 patients (90.5%) in the VEIL group returned for follow-up after the operation. The median follow-up time was 73 months (8-162 months) for the COIL group and 28 months (8-58 months) for the VEIL group. The inguinal lymph node yield in the VEIL group was comparable with that in the COIL group (15 ± 5 vs 18 ± 6, P = 0.058). The VEIL and COIL groups had a similar 2-year recurrence rate (10.5% vs 10%, P = 0.957) and 2-year disease-specific survival rate (95.5% vs 93.3%, P = 0.724). The wound complication rate was significantly lower in the VEIL group than the COIL group (4.8% vs 55.6%, P = 0.000). The VEIL group had higher body image scores (16.27 ± 1.20 vs 13.16 ± 0.87, P < 0.0001) and cosmetic scores (20.13 ± 0.98 vs 16.92 ± 0.72, P < 0.0001) than the COIL group. The patients in the VEIL group had higher life quality scores on the Functional Assessment of Cancer Therapy-Vulvar questionnaire than those in the COIL group (165.9 ± 6.3 vs 160.5 ± 6.0, P = 0.026).

CONCLUSIONS

Compared with COIL, VEIL can effectively reduce postoperative wound complications and improve patients' cosmetic satisfaction and life quality without compromising therapeutic efficacy. Hence, we believe that VEIL is a good alternative to COIL for vulvar cancer patients when surgical expertise is available.

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.

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.

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.

Limiting the morbidity of inguinofemoral lymphadenectomy in vulvar cancer patients; a review

INTRODUCTION

Inguinofemoral lymphadenectomy (IFL) is performed in the treatment for vulvar cancer. One or more complications after IFL is reported in up to 85% of the patients. This review presents an overview of surgical techniques and peri- and post-operative care that has been studied in order to reduce the morbidity associated with IFL in vulvar cancer patients. Areas covered: Current knowledge on post-operative complications after different surgical techniques and peri- and post-operative protocols were discussed. A systematic literature review was conducted using MEDLINE, EMBASE and the Cochrane library on 20 February 2017. In order to be eligible for inclusion, studies must report the associated post-operative morbidity per surgical technique, or peri- or post-operative care given after IFL in vulvar cancer patients. Expert commentary: After the implementation of several new surgical techniques, the morbidity after IFL decreased but remains high and clinically meaningful. More research is needed on surgical techniques and peri-or post-operative care to further reduce the complication rates after IFL in vulvar cancer patients.