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.     

Pelvic lymph node dissection for penile carcinoma: extent of inguinal lymph node involvement as an indicator for pelvic lymph node involvement and survival

PURPOSE: We identified pathological parameters of inguinal lymph node involvement with the aim of predicting pelvic lymph node involvement and survival. MATERIALS AND METHODS: A total of 308 patients with penile carcinoma and adequate followup were included in this study. The outcome of 102 patients who underwent lymphadenectomy for lymph node metastases was analyzed further. Histopathological characteristics of the regional lymph nodes were reviewed including unilateral or bilateral involvement, the number of involved nodes, pathological tumor grade of the involved nodes, and the presence of extracapsular growth. RESULTS: Tumor grade of the involved inguinal lymph nodes (OR 6.0, 95% CI 1.2-30.3) and the number of involved nodes (2 or less vs more than 2) (OR 12.1, 95% CI 3.0-48.1) were independent prognostic factors for pelvic lymph node involvement. Extracapsular growth (OR 2.3, 95% CI 1.1-4.8), bilateral inguinal involvement OR 3.4, 95% CI 1.2-9.4) and pelvic lymph node involvement (OR 3.1, 95% CI 1.4-6.6) were independent prognostic factors for disease specific survival. CONCLUSIONS: Patients with only 1 or 2 inguinal lymph nodes involved without extracapsular growth and no poorly differentiated tumor within these nodes are at low risk of pelvic lymph node involvement and have a good prognosis with a 5-year survival rate of approximately 90%. Pelvic lymph node dissection seems to be unnecessary in these cases.     

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.     

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.     

Contemporary morbidity from lymphadenectomy for penile squamous cell carcinoma: the M.D. Anderson Cancer Center Experience

PURPOSE: Inguinal lymphadenectomy can be curative in patients with small volume inguinal metastases and those with more significant adenopathy responding to combination chemotherapy. However, several series collected for 15 to 40 years attest to the significant morbidity associated with lymphadenectomy. We reviewed our recent experience with lymphadenectomy in patients with invasive penile cancer who were judged to require inguinal staging and therapeutic procedures to assess the incidence and magnitude of complications caused by this procedure, especially in those with no palpable adenopathy (prophylactic group). MATERIALS AND METHODS: A total of 106 lymphadenectomy procedures were performed in 53 patients. The indications for dissection were prophylactic in 66 (62%) patients in whom a superficial dissection alone was completed on the ipsilateral side, therapeutic in 28 (26%) in whom superficial, deep and ipsilateral pelvic dissections were performed, and palliative in 12 (11%) undergoing extensive resection of inguinal and abdominal wall tissue after chemotherapy. Minor postoperative complications included those requiring local wound débridement in the clinic, mild to moderate leg edema, seroma formation not requiring aspiration and minimal skin edge necrosis requiring no therapy. Major complications included severe leg edema interfering with ambulation, skin flap necrosis requiring a skin graft, rehospitalization, deep venous thrombosis, death, or reexploration or other invasive procedures performed in the operating room. The incidence and magnitude of complications were compared with prior reports from our center and other series. RESULTS: A total of 41 (68%) minor and 19 (32%) major complications occurred with the 106 dissections (31 of 53 patients, 58%). Prophylactic and therapeutic dissections were associated with a lower incidence of complications compared with palliative dissections (p = 0.017 to 0.049). The incidence of major complications also trended lower in the prophylactic group compared with other indications (p = 0.05). One patient in the palliative group died of sepsis on postoperative day 15. When compared with 3 prior series, the incidence of skin edge necrosis in our series was significantly lower (8% versus 45% to 62%, p <0.0001). Similarly, the incidence and severity of edema in our series were significantly lower than in a prior report from our institution (23% versus 50%, p <0.0001). CONCLUSIONS: For select patients undergoing prophylactic inguinal dissection to detect the presence of microscopic metastases, the incidence and magnitude of complications appeared acceptable in our contemporary experience. Similarly the morbidity of therapeutic lymphadenectomy appeared acceptable, considering the potential therapeutic benefit. However, significant complications, including death, can be associated with palliative groin dissection. Optimal candidates are those having a significant response to systemic chemotherapy whose groins are grossly uninfected.     

影响阴茎癌患者预后的危险因素分析

目的：分析影响阴茎癌患者预后的危险因素。方法：回顾性分析SEER数据库中2004～2009年诊断为阴茎癌的1090例患者的临床资料,用Kaplan—Meier生存分析法计算出总体死亡率及肿瘤特异性死亡率,对随访数据进行单因素及Cox多因素回归分析,分析因素包括患者年龄、种族、婚姻状况、原发部位、TNM分期、组织病理学分级。采用Logistic回归模型分析影响阴茎癌区域淋巴结转移的相关因素。结果：阴茎癌患者的5年总体死亡率为51．2％,5年肿瘤特异性死亡率为24．5％。Cox多因素回归分析得出区域淋巴结转移及远处转移是影响阴茎癌预后的独立影响因素。Logistic回归分析显示组织病理学分级是影响阴茎癌区域淋巴结转移的重要因素。结论：区域淋巴结转移及远处转移是影响阴茎癌预后的独立影响因素,组织病理分级通过影响阴茎癌区域淋巴结转移而影响患者预后。     

Size of metastasis in the sentinel node predicts additional nodal involvement in penile carcinoma

PURPOSE: The majority of patients with penile cancer with a tumor positive sentinel node do not benefit from complementary lymph node dissection because of absent additional involved nodes. We analyzed factors that may determine the involvement of additional nodes. MATERIALS AND METHODS: A total of 158 patients with clinically node negative penile carcinoma underwent sentinel node biopsy. Complementary inguinal lymph node dissection was performed when the sentinel node was tumor positive. The size of the sentinel node metastasis was measured and classified as micrometastasis--2 mm or less, or macrometastasis--more than 2 mm. Sentinel and dissection specimen nodes were step-sectioned. Factors were analyzed for their association with additional nodal involvement, including stage, diameter, grade, absence or presence of vascular invasion of the primary tumor, and sentinel node metastasis size. RESULTS: Tumor positive sentinel nodes were found in 46 groins and complementary lymph node dissection was performed. Nine of these 46 groins (20%) contained additional involved lymph nodes. On univariate and multivariate analyses the size of the sentinel node metastasis proved to be the only significant prognostic variable for additional lymph node involvement (each p = 0.02). None of the 15 groins with only micrometastasis in the sentinel node contained additional involved nodes. CONCLUSIONS: In penile carcinoma additional nodal involvement was related to the size of the metastasis in the sentinel node. Sentinel node micrometastasis was not associated with other involved lymph nodes. This finding suggests that these patients can be spared complementary lymph node dissection.     

Template‐based lymphadenectomy in urothelial carcinoma of the upper urinary tract: Impact on patient survival

Objectives: The benefit of lymphadenectomy (LND) in patients with urothelial carcinoma of the upper urinary tract (UCUUT) has remained controversial. The aim of this study was to examine the influence of the LND template and the total number of lymph nodes (LN) when increasing the number of patients undergoing complete dissection of regional nodes (CompLND). Methods: A total of 109 UCUUT patients with clinically negative nodes underwent nephroureterectomy with concomitant lymphadenectomy at our center. Patients' survival was examined according to the type of LND and the number of removed LN. Univariate analysis was performed to find the cut‐off value of LN influencing survival. Results: Seventy‐eight patients underwent CompLND. Incomplete lymphadenectomy was performed in an additional 41 patients. In the patients with pT2 or higher who were clinically negative for nodal metastasis, any cut‐off value for the total number of LN removed showed no statistical significance. In contrast, CompLND had a significant impact on patient survival. The Cox proportional hazard model showed that CompLND was a significant factor after adjusting for adjuvant chemotherapy. The total number of removed LN was not significant. Conclusions: In patients with muscle‐invasive clinical node‐negative UCUUT, the number of LN removed shows minimal influence on their survival. In contrast, the influence of the particular type of lymphadenectomy is statistically significant. These findings suggest that the extent of lymphadenectomy should be determined by the template and not by the number of removed LN.     

Reproducibility of lymphoscintigraphy for lymphatic mapping in patients with penile carcinoma

PURPOSE: We evaluated the reproducibility of lymphoscintigraphy in the assessment of the location and number of sentinel nodes in patients with penile carcinoma. MATERIALS AND METHODS: A total of 20 patients were prospectively included in analysis. Lymphoscintigraphy was performed after intradermal injection of technetium nanocolloid around the tumor or excision scar. We performed 10-minute anterior dynamic imaging, and static anterior and lateral images were obtained at 30 minutes and 2 hours. The following day scintigraphy was repeated after a second injection of the radiolabeled colloid given in an identical fashion, preceded by acquisition of a starting image. An observer evaluated the paired images and count rates were calculated from the images. RESULTS: At least 1 sentinel node was visualized in all patients on the first lymphoscintigram. A total of 56 sentinel nodes were seen in 38 basins. Drainage to both groins was seen in 18 patients. In 1 of these patients drainage to the prepubic area was also observed. There were 2 patients with drainage to 1 groin. The second lymphoscintigram revealed the same drainage pattern in all patients- the same number of nodal basins and number of sentinel nodes were visualized at identical locations. All hotspots that were visualized during the first lymphoscintigram showed an unequivocal increase in radioactivity after repeat injection. Thus, the reproducibility of penile lymphoscintigraphy was 100% (95% CI 85%-100%). The Pearson correlation coefficient of the paired count rates was 0.69 (p <0.0001). CONCLUSIONS: Results of lymphoscintigraphy in patients with penile carcinoma are highly reproducible for assessment of the number and location of sentinel nodes.     

Assessing retroperitoneal lymphadenectomy experience in United States urological residency programs

PURPOSE: Surgical experience is important for the mastery of operative procedures. We evaluated the current United States urological surgical resident training in performing retroperitoneal lymph node dissection. MATERIALS AND METHODS: The Accreditation Council for Graduate Medical Education Residency Review Committee for Urology operative log reports from 2000 through 2004 were reviewed. We analyzed resident retroperitoneal lymph node dissection experience as surgeon and first assistant by examining CPT codes for retroperitoneal lymph node dissection (CPT codes 38780, 38570 and 38572). RESULTS: The overall number of retroperitoneal lymph node dissections performed at urological residency training programs has increased from 2000 to 2004 (781 to 924). The average number of retroperitoneal lymph node dissections performed by graduating residents in 2001 and 2004 did not change significantly (3.5 vs 4.0). Half of all graduating urology residents in 2004 had performed 2 or fewer retroperitoneal lymph node dissections as the primary surgeon and 1 or none as the first assistant during their training program. However, a small percentage (10%) of graduating residents completed their respective programs with 9 or more retroperitoneal lymph node dissections as primary surgeon and 4 as first assistant. There were no laparoscopic retroperitoneal lymph node dissections logged by graduating residents from 2001 through 2004. CONCLUSIONS: Accreditation Council for Graduate Medical Education data suggest that many urology residents have minimal surgical exposure and training in retroperitoneal lymphadenectomy. These results indicate that alternative strategies should be explored not only to improve the residency training experience but also to determine minimum training criteria.     

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.     

Modified radical inguinal lymphadenectomy for carcinoma of the penis: technique and results

PURPOSE: Modified radical inguinal lymphadenectomy for carcinoma of the penis is presented that satisfies the requirement for complete groin dissection, while significantly decreasing postoperative complications. MATERIALS AND METHODS: Eight patients with squamous cell carcinoma and 2 with leiomyosarcoma of the penis underwent bilateral modified inguinal lymphadenectomy, including removal of the superficial and deep inguinal lymph nodes. To avoid damage to the vessels of the groin region that run parallel to the inguinal ligament and lie in the fat of the superficial layer of the superficial fascia dissection is done beneath this layer. The proper cleavage plane is just above the membranous layer of the superficial fascia, beneath which the superficial inguinal lymph nodes are located. The saphenous vein is preserved and the sartorius muscle is left in situ, so as not to disturb collateral lymphatic drainage. RESULTS: At a followup of 6 to 104 months no skin necrosis, infection or deep venous thrombosis occurred. In 2 patients early moderate lymphedema of the lower extremities resolved with time, 2 had scrotal edema and 3 had a transient lymphocele. CONCLUSIONS: As described, modified radical inguinal lymphadenectomy decreases the morbidity associated with groin dissection, while removing superficial and deep inguinal lymph nodes.     

腹腔镜腹股沟淋巴结清扫术治疗阴茎癌及生殖肿瘤的初步临床体会

目的:总结腹腔镜腹股沟淋巴结清扫术术后并发症及控瘤效果。方法:回顾分析为10例男性患者(14侧)行腹腔镜腹股沟淋巴结清扫术的临床资料。股三角尖部下约3 cm处做10 mm观察孔,另两个切口分别位于距第一切口约6 cm的股三角外侧及内侧(10 mm、5 mm)。分离皮瓣后,以大隐静脉为解剖标志,清扫浅组及深组淋巴脂肪组织,手术清扫范围同开放根治术。记录手术清扫的淋巴结,分析并发症发生原因。结果:手术时间每侧平均(130±24.9)min,每侧平均清扫淋巴结(12.1±1.2)枚,每天每侧引流量平均(60.3±37.3)ml。3例患者发生轻微并发症,1例术中出现高碳酸血症及皮下气肿,1例术后发生50 ml的血清肿,1例手术部位出现180 ml的淋巴液肿。平均随访(24±11.7)个月,无肿瘤复发及其他并发症发生。结论:腹腔镜腹股沟淋巴结清扫术治疗转移性阴茎癌及恶性生殖肿瘤是可行的,不仅可明显减少术后并发症,而且控瘤效果令人满意。但应进行大宗病例的研究,并长期随访以评价其控瘤效果及潜在并发症。     

淋巴结比率在淋巴结阳性阴茎癌预后中的价值

目的探讨淋巴结比率在淋巴结阳性阴茎癌中的预后价值。方法分析1990年至2008年间复旦大学附属肿瘤医院诊治的60例淋巴结转移性阴茎鳞状细胞癌患者的临床资料。所有患者均接受了区域淋巴结清扫手术。阳性淋巴结数和淋巴结比率都转化为分类变量加以分析。无复发生存曲线通过Kaplan-Meier方法绘制并通过Log-rank检验加以分析。结果本组患者的阳性淋巴结数中位数为2个（1～27）,淋巴结比率的中位数为0.0896（0.031～0.406）。随着淋巴结清扫总数的增多,阳性淋巴结数目也逐渐增多。Log-rank成对比较的结果显示淋巴结比率比阳性淋巴结数能更好地区分各组间的生存差异。结论淋巴结比率是比阳性淋巴结数目更好的预后指标,更进一步的大宗病例研究有助于确定淋巴结比率的界值来具体界定低危和高危患者。