Radiology and Imaging Video-endoscopic Inguinal Lymphadenectomy Walter F Correa1 and Marcos Tobias-Machado2
1. Fellow, Urological Oncology and Laparoscopy; 2. Head, Urological Oncology Section, Department of Urology, ABC Medical School and Brazilian Institute of Cancer Control
Abstract
Penile carcinoma is a rare malignant disease with a significantly higher incidence in some areas of underdeveloped countries. Inguinal nodal involvement is found in 20–40% of cases at diagnosis and nodal metastasis is an important predictive factor for survival. Although recent data demonstrated a survival benefit with immediate resection of clinically occult lymph-node metastases, surgical morbidity is still high. Video- endoscopic inguinal lymphadenectomy (VEIL) was described in the clinical arena six years ago to duplicate the open template, reducing morbidity without compromising oncological control. All technical variations described for open surgery were safe and feasible using the endoscopic approach. In terms of reproducibility, preliminary results of a worldwide survey identified that 11 centres were already performing VEIL. Reduced morbidity and good midterm oncological results are important arguments for growing acceptance of this new minimally invasive option to manage inguinal lymph nodes in high-risk penile cancer patients.
Keywords Penile cancer, inguinal lymphadenectomy, laparoscopy, endoscopic procedures, surgery
Disclosure: The authors have no conflicts of interest to declare. Received: 14 March 2010 Accepted: 18 August 2010 Citation: European Oncology, 2010;6(2):80–4 Correspondence: Marcos Tobias-Machado, Urological Oncology Division, Department of Urology, ABC Medical School (FMABC), Rua Graúna 104 ap 131, 04514-000, Vila Liberabinha, São Paulo, Brazil. E:
tobias-machado@uol.com.br
After local invasion, inguinal lymph nodes are the first place prone to dissemination. In patients with impalpable nodes, 20–30% already have asymptomatic metastasis.2
Penile cancer is a rare disease in developed countries, but a recent epidemiological study showed that in some areas of Brazil this neoplasm is the second most common cause of malignant disease in men.1
When the dissemination is still at the inguinal nodes, the disease is potentially curable by radical inguinal surgery.3
Untreated
lymphonodal disease is either an important cause of morbidity or an important predictive factor for cancer-specific and overall survival.2,3 Despite the surgical benefits of prophylactic inguinal dissection at the time of diagnosis,4,5
lymphadenectomy surgical morbidity is more than 50%.6,7
contemporary series show that extended inguinal Over the last
20 years some alternatives have been proposed in an attempt to reduce surgical morbidity after inguinal lymphadenectomy based on limited lymph-node templates.8–10
Although potentially less invasive,
these options have some drawbacks concerning cancer control, and inguinal recurrence ranging from 5 to 15% at follow-up occurred with all of these techniques.11–13
Video-endoscopic inguinal
lymphadenectomy (VEIL) was first described in the clinical arena six years ago to duplicate the open template, reducing morbidity without compromising oncological control.14
Historical Aspects of the Development of Video-endoscopic Inguinal Lymphadenectomy The concept of endoscopic inguinal dissection was proposed by Bishoff et al., who showed its feasibility by dissecting two cadaveric
80
All patients had high-risk pathological factors for inguinal dissemination such as pathological stage >pT1, histological grade >1 or microvascular or lymphatic embolisation.2,15
Patients
underwent previous penectomy and, one month after the initial surgery, were selected for the inguinal procedure based on the pathology diagnosis of the specimen. The patients underwent bilateral inguinal lymphadenectomy following our protocol:
• •
classic open inguinal lymphadenectomy on one leg (standard procedure); or
VEIL on the other leg (study group). © TOUCH BRIEFINGS 2010
models in 2003.15–17
These authors attempted to operate on a patient, but they did not complete the operation due to lymph-node fixation to femoral vessels preventing a safe resection. Based on this report, our initial protocol did not include patients with palpable inguinal lymph nodes. VEIL was also based on other endoscopic surgeries described in cardiovascular,18
plastic19 and gynaecological surgery.20
After some modifications to Bishoff’s procedure, the first case in a clinical scenario was successfully operated on at ABC Medical School in São Paulo, Brazil in 2003.14,21
Our first study protocol was designed to test the feasibility of lymph-node resection and to evaluate surgical morbidity.22 Between 2003 and 2005, 10 patients were prospectively included in this study. They were diagnosed with penile carcinoma with no clinical inguinal lymphatic dissemination at the time of diagnosis.
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