Technical management of inguinal lymph-nodes in penile cancer: open versus minimal invasive

Robot-assisted inguinal lymphadenectomy to treat penile and vulvar cancers: a scoping review

INTRODUCTION

Inguinal lymph nodes dissection (ILND) is recommended in patients presenting with high-risk penile (PC) or vulvar cancers (VC). Though, this surgical procedure is underused because of its anticipated morbidity. Minimally invasive approaches were proposed to minimize complications associated with open surgery. In this review, we analyze current available data exploring intra and perioperative outcomes of robot-assisted ILND (RAIL).

EVIDENCE ACQUISITION

On April 9th, 2023, a literature search was conducted using the PubMed and Scopus databases. The search employed the combination of the following terms: ("robotic assisted" OR "robot-assisted" OR "robotic") AND ("inguinal lymph node dissection" OR "lymphadenectomy") AND ("penile cancer" OR "vulvar cancer"). Out of the 404 identified articles, 18 were used for the present scoping review and their results were reported according to the PRISMA statement.

EVIDENCE SYNTHESIS

Data on 171 patients, ranging in age from 32 to 85 years, were obtained. Most of them (90.6%) harbored a penile squamous cell carcinoma and presented with no palpable nodes (85%). Operation time (OT) ranged between 45 and 300 min. Estimated blood loss varied from 10 to 300 mL. One single intra-operative complication was reported and one conversion to open was recorded. The lymph nodes (LNs) count spanned from 3 to 26 per groin, with 17 studies reporting a median yield >7 nodes. Hospital stay was 1-7 days, while the duration of drainage ranged from 4 to 72 days. Post-operative complications included lymphocele (22.2%; 0-100%), lymphedema (13.4%; 0-40%), cellulitis (11.1%; 0-25%), skin necrosis (8.7%; 0-15.4%). seroma (3.5%; 0-20%) and wound breakdown/wound infection (2.9%; 0-10%). Out of the included studies, 7 provided at least a 12-month follow-up, with recurrence-free rates ranging from 50% to 100% in patients affected by penile cancer and from 92% to 100% in vulvar cancer patients.

CONCLUSIONS

The available evidence on RAIL for the treatment of PC and VC is limited. The approach appears to be safe and effective, as it provides an adequate lymph node yield while ensuring a minimally morbid postoperative course and a short hospital stay.

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.

Reply to May et al. The Goal of Achieving High-Quality Surgical First-Line Therapy in Patients with Penile Cancer Is Important; However, Some Collective Efforts Are Still Required in Order to Reach It. Comment on "Brassetti et al. Combined Reporting of Surgical Quality and Cancer Control after Surgical Treatment for Penile Tumors with Inguinal Lymph Node Dissection: The Tetrafecta Achievement. Curr. Oncol. 2023, 30, 1882-1892"

We have carefully read the comment by May et al. [...].

Combined Reporting of Surgical Quality and Cancer Control after Surgical Treatment for Penile Tumors with Inguinal Lymph Node Dissection: The Tetrafecta Achievement

BACKGROUND

To optimize results reporting after penile cancer (PC) surgery, we proposed a Tetrafecta and assessed its ability to predict overall survival (OS) probabilities.

METHODS

A purpose-built multicenter, multi-national database was queried for stage I-IIIB PC, requiring inguinal lymphadenectomy (ILND), from 2015 onwards. Kaplan-Meier (KM) method assessed differences in OS between patients achieving Tetrafecta or not. Univariable and multivariable regression analyses identified its predictors.

RESULTS

A total of 154 patients were included in the analysis. The 45 patients (29%) that achieved the Tetrafecta were younger (59 vs. 62 years; p = 0.01) and presented with fewer comorbidities (ASA score ≥ 3: 0% vs. 24%; p < 0.001). Although indicated, ILND was omitted in 8 cases (5%), while in 16, a modified template was properly used. Although median LNs yield was 17 (IQR: 11-27), 35% of the patients had <7 nodes retrieved from the groin. At Kaplan-Maier analysis, the Tetrafecta cohort displayed significantly higher OS probabilities (Log Rank = 0.01). Uni- and multivariable logistic regression analyses identified age as the only independent predictor of Tetrafecta achievement (OR: 0.97; 95%CI: 0.94-0.99; p = 0.04).

CONCLUSIONS

Our Tetrafecta is the first combined outcome to comprehensively report results after PC surgery. It is widely applicable, based on standardized and reproducible variables and it predicts all-cause mortality.

Global research trends in penile cancer: Bibliometric and visualized analysis

Background

Penile cancer is a malignant tumor of the genitourinary system that mostly occurs in middle-aged and elderly men aged 50-70 years, which can seriously affect physical, psychological, and sexual health. Hundreds of original articles and reviews on penile cancer are published each year. However, a bibliometric analysis of these publications has not been performed.

Objective

This study aimed to systematically analyze and visualize penile cancer-related publications through bibliometrics and reveal identified topics, hotspots, and knowledge gaps in related fields.

Methods

Based on the Web of Science core collection database, we first analyzed the quantity and quality of publications in the field of penile cancer. Second, we profiled the publishing groups in terms of country, institution, author's publication, and cooperation network. Then, we systematized and summarized the hot topics of research.

Results

This bibliometric analysis was conducted from 2001 to 2022. The analysis identified 1,687 articles and reviews, which were published in 432 journals. The number of publications and citations on penile cancer-related research has steadily increased over the last two decades. Furthermore, academic institutions in Europe and the United States play a leading role in penile cancer research. The country, institution, journal, and author with the most publications were the United States (507), H Lee Moffitt Cancer Research Center (96), Journal of Urology (83), and Spiess P (87), respectively. The most frequently used keywords were penile cancer (743), squamous-cell carcinoma (717), cancer (380), carcinoma (232), lymphadenectomy (229). 16 keyword clustering information was obtained, including #0 male circumcision, #1 lichen sclerosus, #2 chemotherapy, #3 penile neoplasms, #4 targeted therapy, #5 resection margin, #6 cervical cancer, #7 lymph node dissection, #8 prognostic factor, #9 prostate cancer, #10 inguinal lymph node dissection, #11 human papillomavirus DNA, #12 gene, #13 penile intraepithelial neoplasia, #14 male sexual function, and #15 penile cancer.

Conclusion

More and more scholars are devoted to the research on penile cancer. This bibliometric analysis revealed that the main research topics and hotspots in penile cancer included risk factors and surgical treatment plans.

“Light green up”: Indocyanine Green Fluorescence Imaging–guided Robotic Bilateral Inguinal Lymphadenectomy by the Hypogastric Subcutaneous Approach for Penile Cancer

Background

Inguinal lymphadenectomy is of great significance in the management of penile cancer, which aims to mitigate the progression of lymph node metastasis. It is important to improve the efficiency of lymph node dissection and reduce surgical complications.

Objective

To detail a novel technique for robotic bilateral inguinal lymphadenectomy through the hypogastric subcutaneous approach by indocyanine green (ICG) fluorescence imaging, which promotes the identification and dissection of inguinal lymph nodes with considerable safety.

Design, setting, and participants

Ten eligible penile cancer patients who underwent ICG fluorescence imaging–guided robotic bilateral inguinal lymphadenectomy were prospectively enrolled (ICG group). Sixteen patients who underwent the surgery without ICG were retrospectively set as the control (non-ICG) group. Follow-up records for at least 12 mo were required.

Surgical procedure

Inguinal lymphadenectomy was performed by the hypogastric subcutaneous approach. The ICG solution was subcutaneously injected into the prepuce at the beginning of surgery, and ICG fluorescence imaging–guided robotic-assisted bilateral inguinal lymphadenectomy was conducted.

Measurements

Clinical outcomes were collected. The primary study outcome measurement was the number of dissected inguinal lymph nodes.

Results and limitations

The numbers of inguinal overall, superficial, and deep lymph nodes retrieved were all higher in the ICG than in the non-ICG group (p < 0.05). No patients had severe perioperative complications. No difference was found in the overall complication rate and 12-mo survival between two groups (p > 0.05).

Conclusions

ICG fluorescence imaging–guided robotic inguinal lymphadenectomy via the hypogastric subcutaneous approach is feasible and safe for patients with penile cancer, which is beneficial for dissecting more inguinal lymph nodes with few surgical complications.

Patient summary

We developed a promising indocyanine green fluorescence imaging–guided technique to perform robotic bilateral inguinal lymphadenectomy on patients with penile cancer, which conduces to remove more inguinal lymph nodes with limited complications.