Complications of inguinal and pelvic lymphadenectomy for squamous cell carcinoma of the penis: a contemporary series

PURPOSE: We examined complications in a contemporary population of patients with penile cancer undergoing inguinal lymphadenectomy with or without pelvic lymphadenectomy. MATERIALS AND METHODS: The records of all patients treated for squamous cell carcinoma of the penis from January 1992 to May 2003 were reviewed. Complications and length of stay were examined. Complications were divided into early (30 days or less after surgery) and late (greater than 30 days). RESULTS: A total of 41 men were diagnosed with squamous cell carcinoma of the penis, of whom 22 underwent a total of 40 inguinal lymphadenectomies (ILs). Of the patients 13 underwent unilateral IL, 9 underwent simultaneous bilateral ILs and 10 underwent pelvic lymphadenectomy. Mean followup was 34.2 months (range 9.2 to 69.3). Early complications were lymphedema in 4 of 40 cases (10%), minor wound infection in 3 (7.5%) and minor wound separation in 3 (7.5%). Additionally, 5 of 40 patients (12.5%) had lymphoceles, which 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. There was no significant difference in the complication rates in patients with unilateral dissection compared to bilateral or pelvic lymph node dissection. Median length of stay was 2 days (range 1 to 9). There was no significant difference in hospital stay for unilateral dissection compared to bilateral or pelvic lymph node dissection. CONCLUSIONS: These data demonstrate the relative safety of a contemporary lymphadenectomy. We believe that these results lend support to early lymphadenectomy, including simultaneous bilateral dissections, when clinically indicated. Furthermore, these results demonstrate the benefits of a standard postoperative pathway using compression stockings, sequential compression devices and early ambulation with restricted anticoagulant use.     

Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure for radical management of inguinal nodes in patients with penile squamous cell carcinoma

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.     

改良技术减少阴茎癌根治性腹股沟淋巴结清扫术后皮瓣坏死的效果分析

目的 探讨改良技术减少阴茎癌根治性腹股沟淋巴结清扫术后皮瓣坏死的方法与疗效. 方法 回顾性分析2002年6月至2010年6月63例阴茎癌126侧改良根治性腹股沟淋巴结清扫术患者资料,清扫范围按照经典的根治性腹股沟淋巴结清扫术方法,减少皮瓣坏死改良技术包括:S形切口,在膜性解剖标志引导下精确分离皮瓣层面. 结果 63例随访12～ 93个月,共发一并发症37侧次,其中轻度皮瓣坏死7侧次(5.6％),切口感染3侧次(2.4％),淋巴水肿19侧次(15.1％),血清肿2侧次(1.6％),淋巴囊肿5侧次(4.0％),下肢深静脉血栓形成1侧次(0.8％).未发生并发症106侧(84.1％),发生1次或2次轻度并发症20侧次(16.0％). 结论 改良根治腹股沟性淋巴结清扫术中采用S形切口和膜性解剖标志精确分离皮瓣层面技术,可减少术后皮瓣坏死发生率.     

阴茎癌腹腔镜下和开放式腹股沟淋巴结清扫术的对比研究

目的 比较阴茎癌腹腔镜下与开放式双侧腹股沟淋巴结清扫术的临床效果. 方法 回顾性分析2007年6月至2011年6月收治的23例阴茎癌患者的临床资料,年龄40～75岁,平均57岁.病程7d～9年,平均18.6个月.术前临床分期T1期10例,T2期7例,T3期6例.10例腹股沟淋巴结肿大,其中3例有2枚肿大淋巴结.根据腹股沟淋巴结清扫方式将患者分为腹腔镜手术(laparoscopic surgery,LS)组10例和开放式手术(open surgery,OS)组13例,两组患者的年龄、病程、肿瘤分期和淋巴结肿大情况等比较差异均无统计学意义(P＞0.05).比较两组患者的手术时间、术中出血量、术后引流管留置时间、平均住院时间、切除淋巴结数量及并发症等情况. 结果 LS组手术时间(103.6±15.2)min、术中出血量(56.5±6.8)ml、术后引流管留置时间(5.8±0.8)d、住院时间(8.5±1.1)d,OS组手术时间(156.8±18.3) min、术中出血量(88.5±9.5)ml、术后引流管留置时间(12.5±1.3)d、住院时间(15.7±1.9)d,两组比较差异均有统计学意义(P＜0.05).LS组切除淋巴结数量为(9.5±1.3)枚、OS组为(10.3±1.5)枚;LS组病理阳性淋巴结数量为5处6枚,OS组为5处7枚,两组比较差异均无统计学意义(P＞0.05).两组均无输血病例,无败血症等严重并发症发生,无死亡病例.随访12～48个月,OS组出现肺转移1例,其余患者无原位复发及转移. 结论 与开放手术比较,阴茎癌腹腔镜下双侧腹股沟淋巴结清扫术具有术中出血量少、术后恢复快、住院时间短、并发症少等优点,是一项安全有效的手术.     

A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma

PURPOSE: We determined the primary pathological features of clear cell renal cell carcinoma that are predictive of positive regional lymph nodes at radical nephrectomy (RN) and developed a protocol for the selective use of extended lymph node dissection. MATERIALS AND METHODS: We studied 1,652 patients who underwent RN for unilateral pM0 sporadic clear cell renal cell carcinoma between 1970 and 2000. A multivariate logistic regression model was used to determine the pathological features of the primary tumor that were associated with positive regional lymph nodes at RN. RESULTS: There were 887 (54%) patients with no positive nodes (pN0), 57 (3%) with 1 positive node (pN1), 11 (1%) with 2 or more positive nodes (pN2) and 697 (42%) who did not have any lymph nodes dissected (pNx). Nuclear grade 3 or 4 (p <0.001), presence of a sarcomatoid component (p <0.001), tumor size 10 cm or greater (p = 0.005), tumor stage pT3 or pT4 (p = 0.017) and histological tumor necrosis (p = 0.051) were significantly associated with positive regional lymph nodes in a multivariate setting. These features can be used to identify candidates for extended lymph node dissection at the time of RN. For example, only 6 (0.6%) of the 1,031 patients with 0 or 1 of these features had positive lymph nodes at RN compared with 62 (10%) of the 621 patients with at least 2 of these features. CONCLUSIONS: The primary tumor pathological features of nuclear grade, sarcomatoid component, tumor size, stage and presence of tumor necrosis can be used to predict patients at the greatest risk for regional lymph node involvement at RN.     

Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis

PURPOSE: Lymphadenectomy for prostate cancer is limited to obturator and external iliac lymph nodes, although the internal lymph nodes represent the primary landing zone of lymphatic drainage. We performed anatomically adequate extended pelvic lymphadenectomy to assess the incidence of lymph node metastasis in cases of clinically localized prostate cancer. MATERIALS AND METHODS: A total of 103 consecutive patients underwent extended pelvic lymphadenectomy at radical retropubic prostatectomy comprising 9 selective fields, namely the external iliac, internal iliac, obturator and common iliac lymph nodes bilaterally, and the presacral lymph nodes. Histopathological findings were compared with serum prostate specific antigen (PSA), histopathological stage, preoperative biopsy and postoperative prostatectomy Gleason score. Extended pelvic lymphadenectomy was compared with radical retropubic prostatectomy and standard lymphadenectomy in 100 consecutive patients in terms of complications, the number of lymph nodes dissected and operative time. RESULTS: There were no significant differences in age, preoperative PSA or mean biopsy Gleason score in patients who underwent extended pelvic and standard lymphadenectomy. Metastases were diagnosed in 27 of the 103 patients (26.2%) who underwent the extended procedure. A mean of 28 lymph nodes (range 21 to 42) were dissected. Metastases were identified in the internal iliac and presacral regions despite negative obturator lymph nodes. Of the 27 patients 1 to 3 lymph nodes involved with metastasis were detected in 15, 9 and 1, respectively. In 26 of the 27 patients (95.8%) with lymph node metastasis PSA was greater than 10.5 ng./ml. and preoperative biopsy Gleason sum was 7 or greater. A low risk of 2% for lymph node disease was noted in patients with serum PSA less than 10.5 ng./ml. and biopsy Gleason sum less than 7. There were no significant differences in regard to intraoperative and postoperative complications, lymphocele formation or blood loss in the 2 groups. CONCLUSIONS: Extended pelvic lymphadenectomy is associated with a high rate of lymph node metastasis outside of the fields of standard lymphadenectomy in cases of clinically localized prostate cancer. Lymphadenectomy including the internal iliac lymph nodes should be performed in all patients with prostate cancer who are at high risk for lymph node involvement, as indicated by PSA greater than 10.5 ng./ml. and biopsy Gleason sum 7 or greater. In the low risk group pelvic lymphadenectomy can be omitted.     

阴茎癌切除同期行改良根治性腹股沟淋巴结清扫术的可行性研究

目的 探讨同期行阴茎癌原发病灶切除和改良根治性腹股沟淋巴结清扫术的可行性.方法 回顾性分析2002年6月至2010年6月55例同期行阴茎癌切除和改良根治性腹股沟淋巴结清扫术的患者资料.患者年龄27～73岁,平均49岁.行同期改良根治性腹股沟淋巴结清扫术107侧,1侧行腹股沟淋巴结清扫术之前曾行大隐静脉抽出术,2侧行同期经典根治性腹股沟淋巴结清扫术. 结果 107侧改良根治性腹股沟淋巴结清扫术后发生切口感染1侧次(0.9％),下肢淋巴水肿18侧次(16.8％),皮瓣坏死6侧次(5.6％).每侧切除淋巴结3 ～23枚,平均11枚.3年总生存率为84％. 结论 阴茎癌切除同期行改良根治性腹股沟淋巴结清扫术可保证控瘤效果,不增加手术后并发症,是适合阴茎癌患者的治疗策略.     

Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results

The controversy surrounding the management of patients with invasive carcinoma of the penis and clinically negative nodes is discussed. The rationale, technique and preliminary results of a modified inguinal lymphadenectomy in which the lateral and caudal extents of nodal excision are reduced, and the saphenous veins are preserved also are presented. This modified lymphadenectomy has been performed in 6 patients with invasive carcinoma of the penis or distal urethra without major or troublesome complications.     

Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study

PURPOSE: Previous studies demonstrate a positive correlation between postoperative survival and the extent of pelvic lymphadenectomies in patients with bladder cancer. However, the distribution of nodal metastases has not been examined in sufficient detail. Therefore, we conducted a comprehensive prospective analysis of lymph node metastases to obtain precise knowledge about the pattern of lymphatic tumor spread. MATERIALS AND METHODS: Between 1999 and 2002 we performed 290 radical cystectomies and extended lymphadenectomies. Cranial border of the lymphadenectomy was the level of the inferior mesenteric artery, lateral border was the genitofemoral nerve and caudal border was the pelvic floor. We made every effort to excise and examine microscopically all lymph nodes from 12 well-defined anatomical locations. RESULTS: Mean total number and standard deviation of lymph nodes removed was 43.1 +/- 16.1. Nodal metastases were present in 27.9% of patients. The percentage of metastases at different sites ranged from 14.1% (right obturator nodes) to 2.9% (right paracaval nodes above the aortic bifurcation). By studying cases of unilateral primary tumors or with only 1 metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we did not identify a well-defined sentinel lymph node. CONCLUSIONS: We strongly recommend extended radical lymphadenectomy to all patients undergoing radical cystectomy for bladder cancer to remove all metastatic tumor deposits completely. The operation can be conducted in routine clinical practice and our data may serve as a guideline for future standardization and quality control of the procedure.     

阴茎癌84例手术治疗分析

目的：探讨阴茎癌的手术方式与愈后的关系。方法：通过对84例阴茎癌的手术治疗及3--15a的随访。结果：随访76例，3a存活65．8％(50例)，5a存活38％(29例)，10a存活31．6％(24例)，15a存活率23．7％(18例)。结论：阴茎癌手术治疗时间与预后有密切关系；阴茎部分切除术应距肿瘤至少2cm以上断阴茎，淋巴结的清扫范围应根据临床和病理情况做具体处理。     

Long-term followup of penile carcinoma treated with penectomy and bilateral modified inguinal lymphadenectomy

PURPOSE: We evaluated modified inguinal lymphadenectomy in the treatment of penile carcinoma, analyzing the rate of complications compared to complete inguinal lymphadenectomy, the complications in performing lymphadenectomy and penectomy concomitantly, and the long-term locoregional recurrence rate. MATERIALS AND METHODS: A total of 26 patients with squamous cell carcinoma of the penis were clinically assessed, and underwent penectomy and bilateral modified inguinal lymphadenectomy at the same operative time. Frozen section analysis of lymph nodes was performed and if metastases were detected a complete ipsilateral inguinal dissection was performed. RESULTS: A total of 52 modified lymphadenectomies were performed. In 10 procedures lymph node metastasis was present. Clinical staging presented false-positive and false-negative rates of 50% and 7.9%, respectively. The complication rate for modified lymphadenectomy was 38.9% and for complete inguinal lymphadenectomy it was 87.5%. Followup ranged from 5 to 112 months and mean followup of recurrence-free cases was 78 months (range 38 to 112). A total of 18 patients underwent bilateral negative modified inguinal lymphadenectomy and 2 of these experienced locoregional recurrence within 2 years after surgery. CONCLUSIONS: Modified inguinal lymphadenectomy causes a lower complication rate than complete inguinal lymphadenectomy. Bilateral modified inguinal lymphadenectomy performed at the same time as penectomy does not increase the complication rate. When frozen section analysis is negative bilaterally, 5.5% of inguinal regions might still harbor occult metastasis. Modified inguinal lymphadenectomy is recommended as a staging procedure in all patients with T2-3 penile carcinoma. A straight followup is required for 2 years since all recurrence was within this period.     

Nomogram predictive of pathological inguinal lymph node involvement in patients with squamous cell carcinoma of the penis

PURPOSE: In penile cancer the therapeutic benefits of early inguinal lymphadenectomy must be counterbalanced by the high rates of morbidity, postoperative complications and mortality. A relevant aim is optimizing the selection of the patients who could really have the highest survival advantage from inguinal lymphadenectomy, limiting the cases in which this surgery might be considered over treatment with a risk of severe complications. We generated a nomogram estimating the risk of pathological inguinal lymph node involvement according to clinical lymph node stage and pathological findings of the primary tumor. MATERIALS AND METHODS: We retrospectively collected the clinical and pathological data of 175 patients who had undergone surgical therapy for squamous cell carcinoma of the penis from 1980 to 2002 at 11 urological centers in northeastern Italy. A logistic regression model was used to construct the nomogram. RESULTS: The presence of palpable groin lymph nodes and the histological findings of vascular and/or lymphatic embolization were important predictors of metastatic inguinal lymph node involvement. The nomogram predicting the risk of metastatic lymph node involvement showed a good concordance index (0.876) and good calibration. CONCLUSIONS: The clinical stage of groin lymph nodes and pathological findings of penectomy specimens allowed us to generate a nomogram to predict the probability of metastatic lymph node involvement in patients with squamous cell carcinoma of the penis. The statistical model showed an excellent ability to identify the patients with lymph node metastases and good calibration.     

Evaluation of dynamic sentinel lymph node biopsy in patients with squamous cell carcinoma of the penis and palpable inguinal nodes

OBJECTIVE

To evaluate dynamic sentinel lymph node biopsy (DSLNB) in patients with squamous cell carcinoma (SCC) of the penis and palpable inguinal lymph nodes, using inguinal lymph node dissection (ILND) as the reference standard to assess the reliability of DSLNB, as using radioscintigraphy and colloidal blue‐dye injection to locate the SLN was reported to be a useful technique to avoid ILND in men with SCC of the penis and clinically impalpable nodes.

PATIENTS AND METHODS

The study included 23 consecutive men with SCC of the penis and clinically palpable inguinal nodes treated between August 1999 and July 2006. On the day before surgery the patient had the SLN located by subcutaneous injection of 60 MBq ^99mTc‐nanocolloid 2 cm proximal to the penile tumour. The following day the patient was taken to the operating room for DSLNB, resection of the penile tumour and simultaneous ILND, if considered indicated (G2‐3 and/or T3‐4 primary tumour). During surgery 2 mL of colloidal blue dye was injected in the same area as the previous ^99mTc‐nanocolloid injection. The SLNs were located during surgery using a γ‐probe and visualization of blue dye in the node(s), which were then surgically removed. After partial or total penectomy, selected patients had ILND through a 10‐cm subinguinal incision. The primary tumour, SLNs and ILND specimens were assessed histopathologically, using haematoxylin and eosin staining only.

RESULTS

Biopsy of the primary tumour showed SCC grade 1 in six, grade 2 in 13 and grade 3 in two patients. The clinical T stage was T1 in two, T2 in seven, T3 in 13 and T4 in one. There were clinically palpable inguinal lymph nodes bilaterally in 19 and unilaterally in four men. Scintigraphy before surgery showed inguinal nodes bilaterally in 12 and unilaterally in eight patients, while there were no nodes in three. Surgery comprised partial penectomy in 14, radical penectomy in eight and circumcision alone in one patient. Simultaneous bilateral ILND was done in 15 patients. Inguinal node metastases were present in four of the 23 (17%) patients; the SLN was falsely negative in three (13%), one of whom had a small focus of cancer in the SLN that was missed on initial histopathological examination, and in two the dynamically located SLN contained no cancer, but node metastases were found in the ILND specimen.

CONCLUSION

The relatively high false‐negative rate of DSLNB indicates that it is not sufficiently reliable to replace complete ILND in men with a high suspicion of nodal metastases, i.e. a high‐grade or high‐stage primary lesion with clinically palpable inguinal nodes.