Introduction

Penile cancer (PeC) is a disease that occurs rarely in northern countries. Inguinal dissemination is the most important prognostic factor in PeC. The number of lymph nodes removed and lymph node density are emerging prognostic factors in urologic cancers; however, evidence in PeC is provocative but poor. Patients with nonpalpable nodes with a risk for dissemination have about a 25% risk of metastatic dissemination; however, when lymph nodes are palpable, the incidence of metastasis rises above 50%.¹

Considering recent European Association of Urology guidelines, immediate inguinal lymph node dissection (ILND) after resection of the primary tumor is indicated in high-risk patients with nonpalpable nodes and for patients with palpable nodes and clinical stage < cN3 or skin invasion.² For patients with bulk inguinal disease, neoadjuvant chemotherapy with salvage surgery is the current recommendation. Pelvic lymphadenectomy is indicated in patients with more than 2 positive inguinal metastases without bulk pelvis disease.²

Due to the high morbidity reported in the open surgery era, few centers perform inguinal and prophylactic pelvic lymphadenectomy in the same operative act.³

Video endoscopic inguinal lymphadenectomy (VEIL) is becoming a popular option as it reduces surgical morbidity as compared to open ILND. There have been very few cases of severe morbidity when performing pelvic lymphadenectomy using laparoscopic or robotic approaches,^4,5 and severe morbidity appears to be associated with N stage disease.⁴

We explore the possibility of performing simultaneous video endoscopic inguinal and pelvic lymphadenectomies, evaluating the efficacy and morbidity of this procedure.

Case Report and Preparation

A 54-year-old male has been diagnosed with penile squamous cell carcinoma at an advanced stage (cT3). Initial examination showed the presence of 3 palpable nodes on 1 side of the groin, each measuring less than 2 cm in diameter (cN2). However, there were no adhesions to the skin and the nodes were mobile. A pelvic MRI scan was performed, which did not show any enlargement of the pelvic lymph nodes. Bilateral VEIL and simultaneous bilateral pelvic ILND (p-VEIL) were performed 1 month after partial penectomy (pT3 grade 3).

First-generation cephalosporin prophylactic intravenous antibiotics were administered routinely during hospital stays.

Relevant surgical steps of the p-VEIL procedure: one team is prepared for VEIL operation, and the other is prepared to perform laparoscopic pelvic lymphadenectomy (Figure 1).

Preoperative Workup

Palpable nodes were marked with ink on the skin. When nodes are difficult to find, such as in obese patients, the node is marked guided by ultrasound (Figure 1).

Patient Positioning and Lower Limb Preparation

VEIL: supine position with both lower limbs externally rotated, abduction of 45 degrees, and the knee joint slightly flexed. The video system must be placed on the opposite side of the limb under intervention at the level of the patient’s waist. The surgeon stood on the right side of the leg, and the assistant stood on the left (Figure 1, A).

Pelvic lymph node dissection (PLND): standard laparoscopic transperitoneal PLND with Trendelenburg position.

Trocar Placement

VEIL: a 3-trocar configuration distal to the femoral triangle (Figure 2, B).

PLND: standard W-shape trocar placement (Figure 2, B).

Lymph Node Dissection and Evaluation

All VEIL steps were performed according to a previously reported study.⁵ Superficial and deep inguinal node resection (zones 1 and 2) were performed simultaneously to ipsilateral PLND (zone 3; Figure 3). Vacuum drainage was left in each inguinal region and will be removed when output is less than 50 mL. The patient was recommended to start walking early after the procedure and to wear antiembolic socks. Postoperative antibiotics were not prescribed.

A uropathology expert assigned the staging according to the 17th American Joint Committee on Cancer tumor-node-metastasis cancer staging system.

Results and Follow-Up

The procedure had an operative time of 180 minutes and blood loss of 150 mL. The hospital stay lasted 20 hours with no complications. Drainage was removed on the seventh postoperative day.

A total of 40 lymph nodes were removed (Figure 4). The histopathological evaluation confirmed 2 positive nodes with extracapsular extension in 10 retrieved at the right inguinal, and 1 positive in 12 retrieved at the right pelvic. On the left side, only 1 out of 8 inguinal nodes were positive without extracapsular extension, and 0 out of 10 were positive in the pelvic area. The pathological stage was 3 (pT3N3M0). Evidence of lymphocele or inferior members lymphedema was not observed.

Thirty days after the primary treatment, taxane-based adjuvant chemotherapy was conducted. No radiation was applied.

Follow-ups were performed according to the European Association of Urology guidelines.² No progression was observed at 3 years of follow-up.

Discussion

Lymphatic spread to inguinal lymph nodes is the preferable dissemination route after local invasion and remains the most important prognostic factor in patients with penile cancer.⁶ Long-term survival worsens in superficial inguinal, deep inguinal, and pelvic involvement.

Lymph node dissection remains the gold standard staging and is potentially curative for lymphatic metastasis in PeC.²

The goal of lymphadenectomy is to remove the lymph nodes and achieve regional control staging, guide adjuvant treatment decisions, and improve survival. However, open ILND has a high incidence of complications, as high as 70%.^6-8 Most are wound-related or lymph-related complications. Reduced skin morbidity is the most robust advantage observed in VEIL compared to open surgery series,^7-10 followed by 3 times less lymphoedema.¹ Over the past few decades, endoscopic inguinal lymphadenectomy has shown similar oncological outcomes to the open approach, with reduced morbidity in patients with palpable and mobile lymph nodes.⁷

The evidence supporting pelvic lymphadenectomy for PeC is weak, given that PeC is a rare disease. Professor Horenblas from Germany conducted the only retrospective study measuring the impact of prophylactic pelvic lymphadenectomy on patients with palpable 2 or more inguinal lymph nodes due to a high risk of metastasis.⁵ The probability of pelvic metastasis is 44% in patients with palpable inguinal lymph nodes, whereas pT2-4 represent a likelihood of metastasis of 30.3%, 44.2%, and 58.2%, respectively.⁶

In the era of open surgery, inguinal and pelvic procedures were performed in sequential stages due to morbidity. In the era of minimally invasive surgery, morbidity reduction allows both procedures to be performed simultaneously with better lymph node staging and morbidity no higher than the procedures performed separately. It is worth noting that the present work does not bring any new information about the indication of pelvic lymphadenectomy. However, it suggests that both procedures, pelvic lymphadenectomy and VEIL, can be performed simultaneously. This approach can lead to better lymph node staging in patients who are often difficult to follow up with due to social and cultural reasons. Compared to the laparoscopic approach, the advantages of robotics are still in study, with very few studies in PeC.¹¹

Long-term survival for stage 3 PeC is dismal. Fast multimodality treatment with surgery, systemic medications, and radiation is the best chance to improve survival in these patients. The IMPACT trial is ongoing to help provide better decision-making in these complex advanced cases.³

This preliminary experience suggests that p-VEIL is feasible.

The potential advantages may include: (1) removing more nodes with better identification of metastatic disease, (2) standardizing positive nodes in different areas: zone 1 (superficial inguinal, above fascia lata), zone 2 (deep inguinal, under fascia lata), and zone 3 (pelvic) to estimate prognosis²; this approach is justified in patients with a high risk for pelvic lymph node disease risk, and (3) offering 1-shot nodal staging, good recovery, and faster application of adjuvant treatments, especially for noncompliant patients or in cases of difficult access to health services.