Author (year)
Patients skin
Necrosis skin (%)
Infection (%)
Seroma (%)
Lymphocele (%)
Lymphedema (%)
Ravi (1962–1990)
112
62
17
7
–
27
Ornellas et col. (1972–1987)
200
45
15
6
–
23
Ayyappan et col.
78
36
70
–
87
57
Lopes et col. (1953–1985)
145
15
22
60
–
30
Bevan-Thomaz et col.
53
8
10
10
–
23
Bouchot et col. (1989–2000)
88
12
7
19
–
22
Kroon et col. (1994–2003)
129
15
27
9
12
31
Pandey et col. (1987–1998)
128
20
17
16
–
19
Pompeo (1984–1997)
50
6
12
6
–
18
Spiess et col. (2008)
43
11
9
–
2
17
Two years later, Nelson et al. reported a retrospective analysis of 40 inguinal lymphadenectomies and demonstrated lymphedema in 4 of 40 cases (10%), minor wound infection in 3 (7.5%), and minor wound separation in 3 (7.5%), and 5 of 40 patients (12.5%) had a lymphocele, which was spontaneously resolved. Late complications were lymphedema in 2 of 40 patients (5%), flap necrosis in 1 (2.5%), and lymphocele in 1 (2.5%), requiring percutaneous drainage [24].
Other authors reported complications such as seroma or lymphocele in 0–26%, lymphorrhea in 9–10%, and wound infections or skin necrosis in 0–15% [21, 27–30].
Twenty-First Century: Minimally Invasive Surgical Era
Minimally invasive surgery, including the endoscopic and laparoscopic techniques, is widely accepted and performed in urology with proven benefits for morbidity reduction. Consequently, the concept of minimally invasive surgery is supported for ILND.
Bishoff et al. in 2003 reported the first endoscopic inguinal node dissection in two cadavers and one patient. The dissection was possible in the human cadavers, but it was not possible in the patient due to the adherence of the enlarged lymph nodes to the femoral vessels [29].
Tobias-Machado et al. in 2006 reported the first successful video-endoscopic inguinal lymphadenectomy (VEIL) in humans [30]. The idealized technique allows a superficial and deep excision of the inguinal lymph nodes, analogous to the radical conventional surgery utilizing laparoscopic instruments.
In a comparative study published in 2007 in the Journal of Urology, they performed, in the same patient, a standard open lymphadenectomy on one side and endoscopic on the other side. The initial impression, obtained in ten patients undergoing bilateral lymphadenectomy for non-palpable lymph nodes, was lower postoperative morbidity with no skin complications when compared to the conventional technique [31, 32]. No disease progression was described at 25 months follow-up.
In the same year, Sotelo et al. [33] reported in the Journal of Endourology the outcomes after 14 inguinal endoscopic lymphadenectomy (IEL) in eight patients with clinical stage T2 squamous cell penis carcinoma. Median operative time was 91 min, and the average node yield was nine. No wound-related groin complications occurred.
In 2009, Master and colleagues reported 25 endoscopic inguinal lymphadenectomies (LEG procedures) in 16 patients and 5% morbidity [24].
In 2011, Tobias-Machado et al. reported the feasibility of less applied to ILND [34].
In 2013, Pompeo et al. reported a bilateral simultaneous veil as an alternative to reduce operative time [35].
The complication rate of video-endoscopic surgery performed in series with more than ten groins is at least half the rate of conventional surgery (Table 1.2).
Table 1.2
Reported series performing video-endoscopic inguinal lymphadenectomy
Author | Cutaneous event (%) | Lymphatic event (%) | Morbidity (%) |
|---|---|---|---|
Sotelo et al. (2007) | 0 | 23 | 23 |
8 cases/14 VEIL | |||
Thyavihaly et al. (2008) | 0 | 15 | 15 |
10 cases/10 sides | |||
Tobias-Machado et al. (2009) | 5 | 10 | 15 |
20 cases/30 VEIL | |||
Master et al. (2009) | 0 | 5 | 5 |
16 cases / 25 sides | |||
Rawal Sudhir et al. (2012) | 2.5 | 10 | 12.5 |
22 cases/ 39 VEIL | |||
Romanelli and Tobias (2013) | 0 | 27.2 | 27.2 |
20 cases/33 VEIL |
Romanelli et al. advocated that long-term oncological results were exactly the same as those reported by open series [36].
With the advance of the robot-assisted surgery field in the twenty-first century, surgeons worldwide are using the laparoscopic technique to perform robotic inguinal lymphadenectomy for penile cancer.
In 2009, Josephson et al. [37] reported the first staged bilateral endoscopic operation performed robotically (RAVEIL) with no metastatic involvement in six superficial and four deep lymph nodes.
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