Video Endoscopic Inguinal Lymphadenectomy:
A New Minimally Invasive Procedure for Radical Management of
Inguinal Nodes in Patients With Penile Squamous Cell Carcinoma
Marcos Tobias-Machado, Alessandro Tavares, Antônio Augusto Ornellas, Wilson Rica Molina, Jr.,
Roberto Vaz Juliano* and Eric Roger Wroclawski
From the Section of Urologic Oncology, Discipline of Urology, ABC Medical School, São Paulo and Albert Einstein Jewish Hospital
Research Institute, National Institute of Cancer (AAO), Rio de Janeiro, Brazil
Purpose: Video endoscopic inguinal lymphadenectomy is a recently described lymphadenectomy with the same template of
the open technique but performed with laparoscopic instruments under video guidance. It was developed to decrease
procedure related morbidity while maintaining good oncological results. We report our initial results in a trial comparing
video endoscopic inguinal lymphadenectomy with standard inguinal lymphadenectomy.
Materials and Methods: From 2003 to 2005, 10 patients with penile carcinoma who were at high risk for inguinal
metastases underwent bilateral inguinal lymphadenectomy. We performed standard lymphadenectomy in 1 limb and video
endoscopic inguinal lymphadenectomy on the contralateral side. Perioperative results and followup data were compared.
Results: No intraoperative complications occurred. Mean operative time was 92 and 126 minutes for open and endoscopic
surgery, respectively (p ⫽ 0.00002). Despite the small number of patients we noted a decrease in cutaneous complications
with video endoscopic inguinal lymphadenectomy (0% vs 50%, p ⫽ 0.017) and a trend toward decreased overall morbidity with
this endoscopic technique (20% vs 70%, p ⫽ 0.059). The mean number of retrieved and positive lymph nodes were similar for
the 2 techniques. At a mean followup of 18.7 months (range 12 to 31) no signs of recurrence or disease progression were noted.
In the postoperative period 9 of the 10 patients identified video endoscopic inguinal lymphadenectomy as the preferred
technique in terms of surgical morbidity.
Conclusions: Video endoscopic inguinal lymphadenectomy is a safe and feasible technique in patients with penile carcinoma
and nonpalpable nodes. These preliminary results suggest that video endoscopic inguinal lymphadenectomy may decrease
postoperative morbidity without compromising oncological control. Future studies should include the bilateral procedure,
longer term followup and a greater number of patients.
Key Words: penis, penile neoplasms, lymph node excision, laparoscopy, urethral neoplasms
standard open procedure. VEIL is an emerging technique
recently reported in clinical settings, which was developed to
decrease morbidity and improve patient outcomes without
compromising oncological control.13 We report the initial
results of a trial comparing VEIL and open conventional
inguinal lymphadenectomy in terms of feasibility, surgical
morbidity and preliminary cancer control in patients with
penile cancer treated at our institution.
enile carcinoma is a rare malignant disease with a
significantly higher incidence in some areas of underdeveloped countries. Inguinal nodal involvement is
found in 20% to 40% of cases at diagnosis and nodal metastasis is an important predictive factor for survival.1–3 Although recent data demonstrated a survival benefit with
immediate resection of clinically occult lymph node metastases, surgical morbidity is still high.4,5 Contemporary series show that refinements of the technique during surgery
associated with adequate postoperative care can decrease
complication rates to approximately 50%.6,7
In recent years some alternatives were proposed targeting decreased surgical morbidity after inguinal lymphadenectomy based on templates with limited excision.8 –10 Although these options are potentially less invasive, they have
some drawbacks concerning cancer control and inguinal recurrence during followup.11,12
Minimally invasive techniques for ablative procedures
are accepted for a wide range of urological diseases because
morbidity is decreased compared with the corresponding
P
PATIENTS AND METHODS
From August 2003 to February 2005, 10 patients with penile
squamous cell carcinoma were selected at our institution.
They underwent penile amputation and 1 month after initial
surgery they underwent the inguinal procedure based on
specimen pathological features. They had no clinically palpable lymph nodes but they had high risk pathological factors for inguinal metastases, such as pathological stage
greater than pT1, histological grade greater than 1, or microvascular or lymphatic embolization.2,14 After they provided informed consent for the study, which was approved
by our Ethical Institutional Committee, they were included
in our prospective protocol.
Submitted for publication June 9, 2006.
Study received Ethical Institutional Committee approval.
* Financial interest and/or other relationship with Mentor.
0022-5347/07/1773-0953/0
THE JOURNAL OF UROLOGY®
Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
953
Vol. 177, 953-958, March 2007
Printed in U.S.A.
DOI:10.1016/j.juro.2006.10.075
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VIDEO ENDOSCOPIC VERSUS STANDARD INGUINAL LYMPHADENECTOMY
In each patient classic open inguinal lymphadenectomy
was performed in 1 limb (standard procedure) and VEIL was
performed in the other limb (study group). The choice of
which side to use for each technique was randomized. A
pathologist blinded to the technique used for each side and
to patient outcomes examined the specimens.
Parameters analyzed were operative time per side, number of dissected lymph nodes, intraoperative complications,
incision aspect, drain output, postoperative patient outcomes, histologically positive lymph nodes and cancer control after at least 1 year of followup. Subjective pain evaluation was determined during postoperative days 1 to 3. Patient
satisfaction was evaluated at discharge from the hospital. All
patients with positive inguinal lymph nodes subsequently underwent extended pelvic laparoscopic lymphadenectomy and
they received no further surgical treatment.
A conventional radical procedure was performed using an
oblique inguinal incision, as previously described.5 Briefly, superficial and deep lymph nodes were dissected at the femoral
triangle medially to the femoral artery without saphenous vein
preservation. At the end of resection the sartorius muscle was
rotated to cover the artery and femoral vein.5
VEIL was performed with the patient supine with thigh
abduction. The video system was placed at the opposite side
next to the patient waist. A 2 cm incision was made 2 cm distal
to the lower vertex of the femoral triangle. Scissors and digital
maneuvers were used to develop a dissection plane deep to
Scarpa’s fascia. After digital elevation of the skin through the
first incision a second 1.0 cm incision was made 6 cm medial to
the apex of the triangle to place a 10 mm trocar. The last 5 mm
port was placed in an analogous manner 6 cm lateral to the
apex of the triangle. A 10 mm Hassan trocar was inserted in
the first incision. The first port accommodated 0-degree optics.
The medial port accepted the harmonic scalpel or the clip
applier and the lateral port accepted the grasper, scissors or a
dissection device (fig. 1).
The surgical team was positioned lateral to the patient leg,
so that surgery could be performed ergonomically. The working
space was insufflated with CO2 at 15 mm Hg. CO2 pressure
was kept as low as 5 to 10 mm Hg during all procedures.
Transillumination allowed good orientation and control of the
progression of dissection toward the cavity (fig. 2).
So that all superficial lymphatic tissue can be removed, it
is imperative to perform dissection with a harmonic scalpel
FIG. 1. Disposition of trocars in right thigh for VEIL. Pentagons
represent 10 mm trocars. Circle represents 5 mm trocar.
FIG. 2. Transillumination and external reference points to monitor
working space development.
in the plane just below Scarpa’s fascia (fig. 3). The main
landmarks are the adductor longus muscle medial, the sartorius muscle lateral and the inguinal ligament superior. At
this point we could identify the saphenous vein medial, and the
spermatic cord and external inguinal ring superomedial. The
femoral nerve branches, which could be preserved, were
present laterally. Identification and dissection of the saphenous vein was made cranially up to the fossa ovalis. The femoral artery was identified at the femoral triangle at the lateral
edge of the dissection limit. Distal lymphatic tissue was ligated
at the femoral triangle vertex and dissected with a harmonic
scalpel with final control achieved using clips (fig. 4). Lymphatic tissue dissection reached the femoral vessels above the
femoral ring. Distal saphenous ligation was performed with
metallic or polymeric clips. Control of the saphenous branches
was performed and proximal ligation of the saphenous vein at
the femoral vein was done with metallic or polymeric clips.
At the end of dissection the specimen was freed after
ligation of the proximal portion of the lymphatic tissue at
the deep portion of the femoral channel (fig. 5). The specimen was removed through the first 20 mm incision after
being placed in a plastic retrieval bag. A suction drain was
inserted through the 5 mm port incision.
Prophylactic intravenous cephalothin was done routinely.
In the postoperative period patients were encouraged to
FIG. 3. Dissection deep to Scarpa’s fascia with harmonic scalpel
VIDEO ENDOSCOPIC VERSUS STANDARD INGUINAL LYMPHADENECTOMY
955
specimens using the endoscopic technique. Pathological examination of positive lymph nodes did not demonstrate any
capsular rupture. These 3 patients underwent additional
laparoscopic pelvic lymphadenectomy posteriorly, which
showed no additional positive nodes. Based on patient subjective evaluation 9 patients preferred the endoscopic technique in terms of surgical morbidity and 1 could not identify
which technique was best for him.
DISCUSSION
FIG. 4. Specimen after control of venous and lymphatic branches
with clips.
ambulate early and none received anticoagulants. Oral intake was started 12 hours after the procedure.
The suction drain was removed with an output of 50 ml or
less. All patients were followed with clinical evaluation on
postoperative days 7, 14, 30 and 60, and every 3 months
thereafter. Followup was 12 to 31 months (mean 18.7).
Statistical analysis was performed using the chi-square t
and Fisher’s exact tests for comparative parameters. The
confidence level was 95%.
RESULTS
Patient age was 39 to 60 years (mean 47). Table 1 shows
patient characteristics, including local pathological stage,
histological grade and associated vascular or lymphatic invasion before bilateral lymphadenectomy.
No intraoperative complications were observed and all
procedures were performed successfully. Mean operative
time was 92 minutes (range 80 to 110) for open surgery and
126 minutes (range 90 to 130) for VEIL (p ⫽ 0.00002). The
mean number of nodes removed was 9.7 (range 6 to 14) and
10 (range 6 to 16) for open surgery and VEIL, respectively
(p ⫽ 0.52).
Regarding postoperative complications, we observed a
20% incidence of complications related to VEIL vs 70% for
open surgery (p ⫽ 0.059). With VEIL the frequency of skin
related events was 0%, while with the conventional technique the frequency was 50% (p ⫽ 0.017, tables 1 and 2).
Complications in the open group were skin necrosis in a
small area in 3 cases, wound infection in 1, an area of
cellulitis in 1, chronic lymphedema in 1 and lymphocele with
spontaneous regression 2 months after lymphadenectomy in
1. In the endoscopic group there was 1 case of local hematoma with clinical resolution 10 days after surgery and 1 of
lymphorrhea through the drain orifice, which lasted for 12
days. Concerning pain evaluation during the first 3 postoperative days, 9 patients reported less pain in the limb that
underwent the endoscopic procedure and 1 reported no difference regarding pain between the 2 limbs. Mean time to
drain removal (output less than 50 ml) was 6.4 days for open
surgery and 4.9 days for VEIL.
Positive lymph nodes were found in 3 patients (30%)
(table 2). One positive lymph node was found on a specimen
obtained through the open technique and 2 were obtained in
There are some controversial issues concerning prophylactic
inguinal lymphadenectomy in patients with penile cancer.
While some groups reported data justifying immediate
lymphadenectomy because of survival advantages,3,4 others
recommended a watchful waiting policy and salvage surgery
when the inguinal lymph nodes become clinically positive.15
Although the survival benefits of lymphadenectomy in
patients with impalpable lymph nodes have been demonstrated, surgical morbidity is still high.3,5,6,15 Conventional
surgery is frequently performed with a large inguinal incision and it can result in skin complications, such as skin
necrosis and wound infection. Depending on the extent of
ganglionic resection chronic lymphedema, lymphorrhea and
lymphocele can occur. More recent studies suggest that the
application of some intraoperative and postoperative measures can decrease complication rates.7 During the last 2
decades treatment in patients with penile carcinoma and
impalpable regional lymph nodes has improved, making the
procedure considerably less morbid.
There are some explanations for these improvements. 1)
Patient selection has improved and surgery has been avoided
in patients at low risk for lymphatic disease.2,14 2) Some surgeons perform limited dissection with preservation of the saphenous vein.8 –11 Although morbidity decreased, all of these
techniques still did not achieve optimal oncological control.
More recently d’Ancona et al reported fewer complications with simplified staged lymphadenectomy compared
with radical dissection.9 On the other hand, 5.5% of patients
with negative simplified dissection had inguinal metastatic
disease during followup.
Another strategy that is accepted worldwide is lymphoscintigraphy to detect the functional sentinel lymph node.10
FIG. 5. Inspection after lymphadenectomy confirmed complete removal of superficial and deep lymph nodes within dissection template.
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VIDEO ENDOSCOPIC VERSUS STANDARD INGUINAL LYMPHADENECTOMY
TABLE 1. Demographic data and surgical results in 10 patients with bilateral inguinal lymphadenectomy by open and VEIL techniques
Pt No.—Age
1—40
2—52
3—43
4—50
5—39
6—60
7—45
8—55
9—41
10—45
Operative Time
(mins)
Local TNM
Pathological
Stage/Grade
Vascular or
Lymphatic
Invasion
Open
Surgery
T2/G3
T1/G2
T2/G2
T3/G3
T2/G2
T3/G2
T2/G2
T2/G2
T2/G3
T1/G2
No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
90
80
100
80
90
110
100
90
100
80
Complications
Drainage (days)*
VEIL
Open
Surgery
VEIL
Open
Surgery
VEIL
Pt Preferred
Technique
130
110
120
100
130
130
120
120
120
90
Cutaneous necrosis
None
Lymphedema
Epidermolysis
None
Lymphocele
Epidermolysis
Cellulitis
Incision infection
None
None
None
None
Lymphorrhea
None
None
Hematoma
None
None
None
6
6
6
7
5
10
7
4
7
6
5
4
3
6
5
8
3
4
5
6
VEIL
VEIL
VEIL
VEIL
None
VEIL
VEIL
VEIL
VEIL
VEIL
* Less than 50 ml/24 hours.
Although this produces excellent results in decreasing surgical morbidity, Kroon et al recently reported that this type of
procedure resulted in a 15% incidence of late inguinal recurrence, which can possibly compromise patient prognosis.12
In 2003 Bishoff et al described endoscopic subcutaneous
modified inguinal lymphadenectomy in 2 cadaveric models
and in 1 patient with stage T3N1M0 penile carcinoma.16
They reported the feasibility of the approach in the models
but dissection could not progress in the patient because of a
large lymph node in close contact with the femoral vessels.
Based on this initial report our initial protocol did not include patients with palpable inguinal lymph nodes. After
some modifications to the procedure we reported the first
successful experience in 3 patients.13
VEIL was also based on other endoscopic techniques for
vascular and axillary lymph node dissection.17,18 Notably as
we were finishing our report we found an electronic publication via Google™ that was not indexed in Medline®, which
was our initial database, showing preliminary experience of
a group in Lyon, France with endoscopic inguinal lymphadenectomy in 28 cases of vulvar or distal vaginal cancer.19
This technique (inguinoscopy) was similar to the VEIL technique except it is a gasless procedure and the group preserves the greater saphenous vein and some of its branches.
They observed minimal procedure related morbidity with
only 1 vascular lesion, which required opening of the skin for
suturing, and 7 lymphoceles (25%), which required needle
aspiration. No wound breakdowns or lymphedema were ob-
TABLE 2. Pathology results and oncological followup in 10
patients with bilateral inguinal lymphadenectomy by open and
VEIL techniques
No. Nodes Retrieved
No. Pos Nodes
Pt
No.
Open Surgery
VEIL
Open Surgery
VEIL
Followup
(mos)
1
2
3
4
5
6
7
8
9
10
7
6
8
14
12
10
6
8
12
14
8
6
10
16
10
10
7
9
10
14
0
0
1
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
1
0
31
26
21
20
18
17
15
14
13
12
No patients had recurrence.
served. Although median followup was not stated, only 1
recurrence was noted.
Concerning complications, our preliminary results are encouraging, suggesting that the VEIL technique has the potential to decrease postoperative morbidity. Cutaneous, lymphatic
and overall morbidity was less frequent for the VEIL procedure. There was a statistically significant difference in cutaneous morbidity favoring VEIL and in cases of lymphatic and
overall morbidity the difference approached significance. We
speculate that if our sample was greater, we would also observe a decrease in lymphatic and overall morbidity.
We believe that the decreased morbidity observed in
these initial patients may be explained by the fulfillment of
several principles. The procedure was performed using
small incisions, allowing better preservation of the skin
blood supply and lymphatic drainage with minimal use of
electrocautery and mechanical retraction. Incisions were
made away from the great vessels, making a sartorius muscle flap rotation unnecessary. Small lymphatic vessels were
identified under magnification and controlled with a harmonic scalpel. Larger branches were controlled with clips,
minimizing lymphatic leakage and lymphocele formation.
If this is the surgeon preference, saphenous vein preservation, which is implied by some groups to lead to less
postoperative edema, or simplified dissection with intraoperative frozen sections can be done via the endoscopic technique.8,19 We understand that if frozen sections are positive,
extension of the limits of dissection leads to an important
increase in morbidity when performed via an open approach.9
Since all anatomical landmarks must be perfectly identified so
that oncological control can be optimal, we think that VEIL
should only be performed by surgeons with relatively good
expertise in laparoscopic techniques who are familiar with the
open inguinal lymphadenectomy. Although operative time was
longer in relation to the open procedure, we believe that it will
decrease as we gain more experience.19 Hypercarbia can occur
but it is easily managed by hyperventilation and hyperhydration without any clinical repercussions.
Postoperative pain seemed to be less on the endoscopic
side. Patient subjective preferences confirmed that VEIL is
an attractive technique. The length of the larger VEIL incision was 2 cm compared to 10 cm for open surgery with
improved cosmesis (fig. 6). The possible benefits regarding
rapid hospital discharge were not assessed because of protocol design. The smaller drain output on the endoscopic side
VIDEO ENDOSCOPIC VERSUS STANDARD INGUINAL LYMPHADENECTOMY
3.
4.
5.
6.
7.
FIG. 6. Postoperative view of VEIL incisions in left limb and standard lymphadenectomy in right limb.
8.
allows us to suppose that we would have removed the drain
and discharged the patient home earlier if the endoscopic
technique had been performed on the 2 limbs. This hypothesis can be confirmed in a future study.
The similar number of nodes removed on the 2 sides of the
same patient is an indirect sign that VEIL can be as effective
as the open approach. The aerosol phenomenon related to
CO2 in malignant lymph nodes in this operation must be
observed with caution and its clinical significance in this
type of procedure awaits future long-term results. Our followup is still short for evaluating oncological control but the
lack of progression, recurrence or port implants after 12
months in patients with positive nodes is encouraging.
CONCLUSIONS
VEIL is a safe and feasible technique in patients with penile
carcinoma. Preliminary results suggest that VEIL allows
decreased postoperative morbidity without compromising
oncological control. Based on our data VEIL could become
the chosen minimally invasive procedure for prophylactic
inguinal lymphadenectomy in patients with penile cancer.
Its experimental application can be expanded to treat lymph
nodes in urethral, vulvar or skin cancer. New studies with
more patients and longer followup are necessary to obtain
more consistent data, although our results seem promising.
Abbreviations and Acronyms
9.
10.
11.
12.
13.
14.
15.
16.
VEIL ⫽ video endoscopic inguinal
lymphadenectomy
17.
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957
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VIDEO ENDOSCOPIC VERSUS STANDARD INGUINAL LYMPHADENECTOMY
EDITORIAL COMMENT
REPLY BY AUTHORS
These authors present a prospective analysis of a novel technique of inguinal lymph node dissection for penile carcinoma.
They not only present their new technique, but also compare it
to standard radical inguinal lymphadenectomy in the contralateral groin. This novel approach of VEIL may decrease the
surgical morbidity that is often attributable to conventional
open surgery, such as skin necrosis, wound infections and
lymphedema. With any new procedure caution and judgment
should be exercised but the authors provide evidence for the
safety and feasibility of this technique. In addition, oncological
principles appear to be maintained. As with many technological discoveries in the field of urology, this is also an adaptation
from other fields. In this case endoscopic techniques described
for vascular and axillary lymph nodes are applied to the VEIL
technique. This reiterates the fact that we can continue to
learn from our colleagues in other disciplines and we should
keep an open mind that surgery is a multidisciplinary field.
High risk penile cancer can result in high mortality due to
inadequate lymph node treatment or serious morbidity
due to lymph node dissection. This difficult situation requires creative solutions and may benefit from incorporation of new technologies. A promising new option to consider is magnetic resonance imaging with lymphotropic
nanoparticles. This technique may help improve patient
selection for inguinal lymphadenectomy, preventing unnecessary procedures or indicating earlier surgery when
lymph nodes are not yet palpable.1 Use of minimally invasive techniques, respecting the oncological and anatomical principles outlined for the VEIL procedure, may
further reduce complications and sequelae of surgical treatment.
1.
Michael A. Palese
Minimally Invasive Urologic Surgery
Mount Sinai Medical Center
New York, New York
Tabatabaei S, Harisinghani M and McDougal WS: Regional
lymph node staging using lymphotropic nanoparticle
enhanced magnetic resonance imaging with ferumoxtran-10 in patients with penile cancer. J Urol 2005; 174:
923.