Figure 1. A, Boundaries of dissection as well as area undermined to create anterior working space. B, Correct level for development of anterior plane dissection.

Inguinal lymph node dissection (ILND) is an important component both in staging and also in treatment of different malignancies including penile and vulvar cancers according to National Comprehensive Cancer Network guidelines.^1,2

Traditionally, a full template ILND was performed using a large open incision. The perioperative morbidities of this surgery include skin edge necrosis, wound dehiscence, infection, lymphocele, lymphorrhea, deep vein thrombosis, and chronic extremity lymphedema. The complication rates with open full template were historically high, and as a result it can dissuade patients and even physicians from prescribing this necessary surgery.^3,4 Adherence to guideline recommendations for ILND is unfortunately very low with only 1 out of every 4 patients who meet criteria eventually undergoing ILND.⁵ This low guideline adherence is concerning considering the oncologic and survival benefits of ILND in indicated cases. Therefore, there is a need to discuss approaches that surgeons can use to reduce the morbidities and complications of ILND and to inform the urologic oncology community about the improved outcomes using these approaches so that more patients can safely receive this operation.

Figure 2. Transillumination of skin flap delineates arterial supply.

Dynamic sentinel node biopsy (DSNB) is perhaps the least morbid method for excisional biopsy of clinically nonpalpable groin lymph nodes. While negative DSNB avoids the morbidity of a full ILND, a positive DSNB mandates proceeding with formal ILND. Additionally, this approach should be avoided in the setting of palpable inguinal nodes.

Another approach to decrease morbidity of ILND is to modify the dissection template and reduce the field of dissection. Standard open ILND template involves removal of the lymphatic tissue from the inguinal ligament superiorly to the apex of the femoral triangle inferiorly, and from the adductor longus muscle medially to the sartorius muscle laterally with mobilization of the sartorius muscle for coverage of the femoral vessels. The dissection involves ligation and excision of the proximal greater saphenous vein and complete dissection of the femoral vessels. There are different modified templates proposed to date. Catalona first described a modified ILND template preserving the greater saphenous vein and limiting the dissection to the lateral edge of the femoral artery and superficial to the fossa ovalis, and reported a diminished incidence of lymphedema and wound complications.⁶ Avoiding mobilization of the sartorius muscle has also been shown to reduce wound healing complications.⁷ Spiess et al report their own contemporary series of modified template with a minor and major complication rate of 19% and 27%, respectively, with superficial diagnostic ILND.³ While superficial and modified templates reduce the morbidity of ILND, they theoretically increase the risk of undersampling, and advantage is lost when histopathological examination reveals a positive node as radical dissection often becomes mandatory at that point.

Figure 3. A, Dissection is carried in caudal to cephalad direction. Assistant can lift the nodal packet and allow the surgeon to carry dissection above the vessels. B, All remaining attachments are freed in preparation for nodal retrieving.

Another approach to decrease the morbidity of ILND is to use minimally invasive surgical techniques such as videoscopic inguinal lymphadenectomy (VEIL) and robotic videoscopic inguinal lymphadenectomy (RVEIL).^8-10 Minimally invasive techniques have primarily been described in penile cancer patients with nonpalpable or small palpable lymphadenopathy. However, the use of these techniques in patients with significant palpable inguinal lymphadenopathy as well as following systemic treatment is also reported. In experienced hands VEIL and RVEIL have shown promising results.

Figure 1 shows the area of dissection and the correct level for development of anterior plane of dissection prior to port placement for VEIL or RVEIL. This plane is usually bluntly developed prior to placing the trocars and/or docking the robot. Surgeons are advised to take caution to not develop this plane too close to the epidermis so as not to compromise the vascular supply to the skin flap above the working field, which will often result to skin necrosis postoperatively. In most patients, skin flap should be about 5 mm in thickness. A well-dissected anterior plane should demonstrate arterial blood supply to the above skin with transillumination from the endoscopic camera (Figure 2). Figure 3 shows steps of the case as well as the surgical field after a complete dissection. The groin wounds below the inguinal ligament that are used for open incision are notorious for skin necrosis, wound breakdown, and infection. A major advantage of minimally invasive approaches, whether robotic-assisted or pure laparoscopic, is the transition of the wound (port sites and extraction site) from the groin area to distal to the apex of the femoral triangle (Figure 4). Although minimally invasive techniques use a smaller incision, the most benefit in this case perhaps comes from transitioning of the wound location, and not necessarily the cumulative relative size of the wound.

Figure 4. A, Robotic port sites. Camera port (12 mm for da Vinci Si and 8 mm for da Vinci Xi; A). Eight mm robotic arm ports (B and C). Assistant port (D). B, Lymph node packet is retrieved usually through one of the port sites, and a closed-suction drain is placed through another one.

We previously analyzed the outcomes and complications of reported retrospective case series comparing VEIL and RVEIL to open ILND.^8-10 In brief, estimated blood loss is low regardless of the approach. RVEIL and VEIL appear to be safe with rarely required conversion to open approach. They have a longer operative time but a shorter hospital stay and reduced perioperative complication rate. The nodal yield and rate of recurrence, a surrogate for oncologic adequacy, indicate that RVEIL and VEIL techniques perform comparable to open ILND. However, potential selection bias should be considered when it comes to interpreting outcomes and complications since most of the current data on minimally invasive approaches come from nonrandomized retrospective series. Currently, data indicate patients and surgeons may shy away from ILND, with only 25% of appropriate indication patients getting ILND.⁵ With these modifications showing significantly reduced morbidities and complications, hopefully more patients who meet criteria will get this important operation.