- Email: [email protected]
Modified endoscopic left inguinal lymphadenectomy
Actas Urol Esp. 2013;37(10):663---666
Actas Urológicas Españolas www.elsevier.es/actasuro
SKILL AND TALENT
Modified endoscopic left inguinal lymphadenectomy夽 M. Alvarez-Maestro ∗ , E. Rios Gonzalez, L. Martinez-Pi˜ neiro, F.J. Sanchez Gomez Departamento de Urología, Hospital Universitario Infanta Sofía, Madrid, Spain Received 24 November 2012; accepted 9 February 2013 Available online 27 November 2013
KEYWORDS Penile melanoma; Modified endoscopic inguinal lymphadenectomy; Surgical technique
PALABRAS CLAVE Melanoma de pene; Linfadenectomía inguinal endoscópica modificada; Técnica quirúrgica
Abstract Introduction: Endoscopic inguinal lymphadenectomy is an evolution of laparoscopic surgery thanks to background in these techniques. This is a new technique and the indications in the field of penile tumors today are expanding. The technique aims at reducing the morbidity of the procedure without compromising the cancer control or reducing the template of the dissection. Material and methods: We present the modified endoscopic inguinal lymphadenectomy in a 70year-old male patient with penile melanoma and positive sentinel lymph node in left inguinal limb. Intraoperative data, pathology, post operatory evolution and oncological follow-up are described. Results: Operative time was 120 min. Nine lymph nodes were retrieved and none of them showed positivity at pathology. There were no complications. The drain was kept for five days. After 12 months of follow up, no signs of disease progression were noted. Conclusion: The endoscopic inguinal lymphadenectomy is feasible in clinical practice. New studies with a greater number of patients and long-term follow-up may confirm the oncological efficacy and possible lower morbidity of this new approach. © 2012 AEU. Published by Elsevier España, S.L. All rights reserved.
Linfadenectomía inguinal izquierda endoscópica modificada Resumen Introducción: La linfadenectomía inguinal endoscópica es una evolución de la cirugía laparoscópica que resulta posible gracias a los conocimientos previos en este tipo de técnicas. Se trata de una nueva técnica y sus indicaciones en el campo de los tumores de pene están ampliándose hoy en día. La técnica busca reducir la morbilidad del procedimiento sin comprometer el control oncológico ni reducir el área de resección. Material y métodos: Presentamos la realización de linfadenectomía inguinal endoscópica modificada en un varón de 70 a˜ nos con diagnóstico de melanoma de pene y ganglio centinela positivo en la región inguinal izquierda. Se colocaron 3 trocares de trabajo sobre un triángulo femoral previamente dibujado sobre la región inguinal izquierda del paciente. Se describen los datos intraoperatorios, anatomopatológicos, postoperatorios y de seguimiento oncológico.
夽 Please cite this article as: Alvarez-Maestro M, Rios Gonzalez E, Martinez-Pi˜ neiro L, Sanchez Gomez FJ. Linfadenectomía inguinal izquierda endoscópica modificada. Actas Urol Esp. 2013;37:663---666. ∗ Corresponding author. E-mail address: [email protected] (M. Alvarez-Maestro).
2173-5786/$ – see front matter © 2012 AEU. Published by Elsevier España, S.L. All rights reserved.
664
M. Alvarez-Maestro et al. Resultados: El tiempo operatorio fue de 120 min. Se obtuvieron 9 ganglios, siendo todos negativos en el estudio anatomopatológico. El drenaje fue retirado al quinto día postoperatorio. No hubo complicaciones. Después de 12 meses de seguimiento no hay signos de progresión de la enfermedad. Conclusión: La linfadenectomía inguinal endoscópica es factible en la práctica clínica. Nuevos estudios con mayor número de pacientes y seguimiento a largo plazo pueden confirmar la eficacia y posible menor morbilidad de este nuevo abordaje. © 2012 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction Primary malignant melanoma (MM) of the penile is an extremely rare entity, reporting approximately 200 cases. The most common sites of malignant melanoma are head and neck (55%), female genital organs (18%), anorectal region (24%) and urinary tract (3%). Melanomas located in male genital tract represent less than 1% of the total cases. Among them, the main localization is glans (55%), followed by prepuce (28%) and distal urethra in which navicular fossa and urethral meatus are the predominant sites (8%). In the majority of the published cases penile MM patients are in the sixth and seventh decades of life.1 At the time of diagnosis, most of the melanomas are in vertical growth phase and its average thickness is 1.5 mm. Melanocytes derived from progenitor neural crest cells, migrating to the basal layer of the epidermis, give rise to tumoral cells that lead to cutaneous melanomas. For this reason mucosal melanomas are extremely rare. To date, papers about the use of endoscopic inguinal lymphadenectomy (EIL) in the treatment of penile cancer are scarce and, according our knowledge, the present publication is the first describing the use of EIL for the treatment of penile melanoma.
Material and methods Based upon our previous experience in laparoscopic surgery, EIL was carried out in an adult male diagnosed with penile melanoma and positive sentinel node in left inguinal limb. The patient was a 70-year-old male who consulted for purple nodular lesion on the distal end of prepuce (Fig. 1). After
biopsy, the diagnosis was: penile non-ulcerated melanoma ≤7.132 mm in thickness who had positive sentinel node. As consequence, the patient underwent modified EIL.
Surgical technique After general anesthesia, the patient was positioned supine with ipsilateral knee flexed and hip abducted. It is necessary to place a pad under knee in order to maintain this position during surgery. Before trocars were placed, a triangle was drawn, and its cranial limit was anterior superior iliac spine, the medial border was the adductor muscle and the lateral border of the sartorius muscle (Fig. 2A). The width of the emptying area was around 11---12 cm, its length descending through the medial side of the thigh was 15 cm and 20 cm through the lateral side. An incision in the lower vertex of the triangle was performed and virtual space was created with optics (12 trocar) (Fig. 2B) and with fingers. Afterwards, 2 trocars were placed: 10 mm trocar in the right side and 5 mm in the left side (Fig. 2C). After dissection of subcutaneous tissue and fascia of Scarpa, safena vein is the first vascular structure that appears medial. In our procedure, safena vein was preserved (Fig. 3). The dissection was continued cranially up to inguinal ligament (upper limit). Superficial femoral lymphadenectomy was carried out and biopsy scar tissue was removed. Abdominal subcutaneous vein and tributaries lymphatic vessels were clipped by Hemo-lok. Then, deep lymphadenectomy was performed. Safena vein was spared and regional lymph nodes, from safena vein to femoral ligament, were resected (Fig. 4A and B). Through 5 mm trocar pathway, aspirative drainage was placed and lymph nodes were removed in extraction bag. Regional pressure must not exceed 10 mm Hg in order to maintain the field of view and to prevent, simultaneously, a spontaneous infiltration beyond the limits of emptying. To reduce the incidence of lymphedema and lymphatic leakage, ultrasonic scalpel or electrocautery is required to cut most of the tissues.
Results
Figure 1
Penile melanoma.
There were no intraoperative complications. Surgery time was 120 min, and a total surgery blood loss of 35 cc. Surgical drainage was removed after 5 days post-op. Elastic compression stockings, legs slightly elevated, low molecular weight heparin and antibiotics during 7 days were used as postoperative maintenance treatment. Superficial inguinal lymphadenectomy revealed 5 nodes without neoplastic infiltration while deep ones revealed 4 nodes without
Modified endoscopic left inguinal lymphadenectomy
665
Figure 4 (A) Anatomical limits of modified endoscopic inguinal lymphadenectomy. (B) Final image after the surgical removal of lymph nodes.
neoplastic infiltration. One year after surgery, the patient is asymptomatic and there is no evidence of recurrence of melanoma.
Discussion Figure 2 (A) Patient positioning and drawing of the femoral triangle. (B) Development of the workspace. (C) Placement of optics and working trocars.
Figure 3 Preservation of Safena vein according to Catalona technique.
The major prognostic factors of survival in patients with penile cancer are the presence and extent of lymph node metastases. For staging penile cancer, inguinal lymphadenectomy is usually required. Moreover, this surgical procedure could be a curative measure in patients with cancer affecting only penile and regional nodes. Surgical management is complex, but early inguinal lymphadenectomy remains an integral part of treatment because it improves the prognosis of patients.2 Traditional procedure has been replaced by modified inguinal lymphadenectomy by Catalona3 because cutaneous incision is shorter, nodal excision is reduced to lymph nodes medial to femoral vein, saphenous vein is preserved and it avoids the transposition of the Sartorius. Open lymphadenectomy may be associated with severe complications impairing the quality of life. For this reason, the first case of modified EIL for epidermoid carcinoma of the penis (T3N1M0) was published in 2003 by Bishoff et al.,4 reporting lower morbidity than open surgery because with this technique the lymphatic and vascular supply to the overlying skin are maintained. Later, in 2005, Machado et al.5 published the results of comparative study between endoscopic inguinal lymphadenectomy and contralateral open lymphadenectomy in 3 patients treated
666 with bilateral inguinal lymphadenectomy. The authors have reported flap necrosis and lymphedema in 2 of 3 sides in which open technique was used. However, with endoscopic procedure, no complications in lower extremities were reported. Recently, laparoscopic and robotic procedures have been described for the excision of inguinal nodes.6---10 TobiasMachado et al.11,12 compared the outcomes of laparoscopic and open surgery in two studies carried out respectively in 20 and 10 groins with no palpable lymph nodes: mean surgery time in laparoscopic group was 120 min and 92 min in open surgery group. Between both, no statistical differences in nodes number were observed; however complications rate was 70% in open surgery vs 20% in laparoscopic procedure. With a mean follow-up of 33 months, recurrences have not been reported. Patients with non-palpable-mobile or small (shorter than 1 cm) adenopathies, with a high risk of nodal involvement are considered good candidates for this type of endoscopic approach. EIL is a relative contraindication in patients with bulky immovable inguinal nodes.13 These patients are better candidates for traditional open surgery because the dissection of upper side of immovable-adhered lymph nodes is difficult. In superficial inguinal lymphadenectomy, the ideal mean number of lymph nodes to be harvested is from 8 to 10 and in radical inguinal lymphadenectomy this number is from 10 to 11. The total number of nodes resulting from the sum of inguinal and pelvic lymphadenectomy varies from 22 to 25.14 In our case, the number of lymph nodes harvested was 9 and lymphorrhea, the only complication observed, was similar to those reported in the literature. Drainage was removed 5 days after surgery. This surgical procedure has lower risk of cutaneous complications, but the incidence of lymphocele (23%) is higher than in open approach. The sentinel node concept was introduced by Cabanas in 197715 ; since then, it has been used in the breast cancer and melanoma staging. Although it has been used since 30 years ago to penile carcinoma staging, its relevance in these tumors remains much debated. The technique of dynamic sentinel node biopsy was conceived and adapted for penile squamous cell carcinoma, according to the concept of an orderly progression of metastatic cells from the primary site through the lymphatics to first drainage lymph node (sentinel node). Its sensitivity is 95% and complication rate is 10% in patients with melanoma.
Conclusions EIL is a safe and feasible technique in patients with penile tumors and with palpable and non-palpable nodes. Published cases suggest that EIL could reduce postoperative morbidity and would not jeopardize oncological control. However, the number of nodes removed by this procedure is lower than by open surgery; therefore, patients must be selected
M. Alvarez-Maestro et al. carefully. We consider that new studies with a greater number of patients and long-term follow-up should be performed.
Conflict of interest The authors declare that they have no conflict of interest.
References 1. Oxley JD, Corbishley C, Down L, Watkin N, Dickerson D, Wong NA. Clinicopathological and molecular study of penile melanoma. J Clin Pathol. 2012;65:228---31. 2. Heyns CF, Fleshner N, Sangar V, Schlenker B, Yuvaraja TB, van Poppel H. Management of the lymph nodes in penile cancer. Urology. 2010;76 Suppl. 1:S43---57. 3. Catalona WJ. Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous vein: technique and preliminary results. J Urol. 1988;140:306---10. 4. Bishoff JT, Basler JW, Teichman JM, Thompson IM. Endoscopic subcutaneous modified inguinal lymph node dissection (ESMIL) for squamous cell carcinoma of the penis. J Urol. 2003;189:78. 5. Machado MT, Tavares A, Molina WR. Comparative study between videoendoscopic radical inguinal lymphadenectomy and standard open lymphadenectomy for penile cancer: preliminary surgical and oncological results. J Urol. 2005;173:226. 6. Britto CA, Rebouc ¸as RB, Lopes TR, Silva da Costa T, Leite Rde C, de Carvalho PS. Video-assisted left inguinal lymphadenectomy for penile cancer. Int Braz J Urol. 2012;38:289---90. 7. Tobias-Machado M, Correa WF, Reis LO, Starling ES, de Castro Neves O, Juliano R, et al. Single-site video endoscopic inguinal lymphadenectomy: initial report. J Endourol. 2011;25:607---10. 8. Sotelo R, Sanchez-Salas R, Clavijo R. Endoscopic inguinal lymph node dissection for penile carcinoma: the developing of a novel technique. World J Urol. 2009;27:213---9. 9. Josephson DY, Jacobsohn KM, Link BA, Wilson TG. Roboticassisted endoscopic inguinal lymphadenectomy. Urology. 2009;73:167---70. 10. Sotelo R, Sánchez-Salas R, Carmona O, Garcia A, Mariano M, Neiva G, et al. Endoscopic lymphadenectomy for penile carcinoma. J Endourol. 2007;21:364---7. 11. Tobias-Machado M, Tavares A, Molina Jr WR, Forseto Jr PH, Juliano RV, Wroclawski ER. Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes. Int Braz J Urol. 2006;32:316---21. 12. Tobias-Machado M, Tavares A, Ornellas AA, Molina Jr WR, Juliano RV, Wroclawski ER. Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure for radical management of inguinal nodes in patients with penile squamous cell carcinoma. J Urol. 2007;177:953---7. 13. Romanelli P, Nishimoto R, Suarez R, Decia R, Abreu D, Machado M, et al. Linfadenectomía inguinal video endoscópica (VEIL): resultados quirúrgicos y oncológicos, incluido pacientes con ganglios linfáticos palpables. Actas Urol Esp. 2013;37:305---10. 14. Master V, Organ K, Kooby D, Hsiao W, Delman K. Leg endoscopic groin lymphadenectomy (LEG procedure): stepby-step approach to a straightforward technique. Eur Urol. 2009;56:821---8. 15. Cabanas RM. An approach for the treatment of penile carcinoma. Cancer. 1977;39:456---66.
Actas Urológicas Españolas www.elsevier.es/actasuro
SKILL AND TALENT
Modified endoscopic left inguinal lymphadenectomy夽 M. Alvarez-Maestro ∗ , E. Rios Gonzalez, L. Martinez-Pi˜ neiro, F.J. Sanchez Gomez Departamento de Urología, Hospital Universitario Infanta Sofía, Madrid, Spain Received 24 November 2012; accepted 9 February 2013 Available online 27 November 2013
KEYWORDS Penile melanoma; Modified endoscopic inguinal lymphadenectomy; Surgical technique
PALABRAS CLAVE Melanoma de pene; Linfadenectomía inguinal endoscópica modificada; Técnica quirúrgica
Abstract Introduction: Endoscopic inguinal lymphadenectomy is an evolution of laparoscopic surgery thanks to background in these techniques. This is a new technique and the indications in the field of penile tumors today are expanding. The technique aims at reducing the morbidity of the procedure without compromising the cancer control or reducing the template of the dissection. Material and methods: We present the modified endoscopic inguinal lymphadenectomy in a 70year-old male patient with penile melanoma and positive sentinel lymph node in left inguinal limb. Intraoperative data, pathology, post operatory evolution and oncological follow-up are described. Results: Operative time was 120 min. Nine lymph nodes were retrieved and none of them showed positivity at pathology. There were no complications. The drain was kept for five days. After 12 months of follow up, no signs of disease progression were noted. Conclusion: The endoscopic inguinal lymphadenectomy is feasible in clinical practice. New studies with a greater number of patients and long-term follow-up may confirm the oncological efficacy and possible lower morbidity of this new approach. © 2012 AEU. Published by Elsevier España, S.L. All rights reserved.
Linfadenectomía inguinal izquierda endoscópica modificada Resumen Introducción: La linfadenectomía inguinal endoscópica es una evolución de la cirugía laparoscópica que resulta posible gracias a los conocimientos previos en este tipo de técnicas. Se trata de una nueva técnica y sus indicaciones en el campo de los tumores de pene están ampliándose hoy en día. La técnica busca reducir la morbilidad del procedimiento sin comprometer el control oncológico ni reducir el área de resección. Material y métodos: Presentamos la realización de linfadenectomía inguinal endoscópica modificada en un varón de 70 a˜ nos con diagnóstico de melanoma de pene y ganglio centinela positivo en la región inguinal izquierda. Se colocaron 3 trocares de trabajo sobre un triángulo femoral previamente dibujado sobre la región inguinal izquierda del paciente. Se describen los datos intraoperatorios, anatomopatológicos, postoperatorios y de seguimiento oncológico.
夽 Please cite this article as: Alvarez-Maestro M, Rios Gonzalez E, Martinez-Pi˜ neiro L, Sanchez Gomez FJ. Linfadenectomía inguinal izquierda endoscópica modificada. Actas Urol Esp. 2013;37:663---666. ∗ Corresponding author. E-mail address: [email protected] (M. Alvarez-Maestro).
2173-5786/$ – see front matter © 2012 AEU. Published by Elsevier España, S.L. All rights reserved.
664
M. Alvarez-Maestro et al. Resultados: El tiempo operatorio fue de 120 min. Se obtuvieron 9 ganglios, siendo todos negativos en el estudio anatomopatológico. El drenaje fue retirado al quinto día postoperatorio. No hubo complicaciones. Después de 12 meses de seguimiento no hay signos de progresión de la enfermedad. Conclusión: La linfadenectomía inguinal endoscópica es factible en la práctica clínica. Nuevos estudios con mayor número de pacientes y seguimiento a largo plazo pueden confirmar la eficacia y posible menor morbilidad de este nuevo abordaje. © 2012 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction Primary malignant melanoma (MM) of the penile is an extremely rare entity, reporting approximately 200 cases. The most common sites of malignant melanoma are head and neck (55%), female genital organs (18%), anorectal region (24%) and urinary tract (3%). Melanomas located in male genital tract represent less than 1% of the total cases. Among them, the main localization is glans (55%), followed by prepuce (28%) and distal urethra in which navicular fossa and urethral meatus are the predominant sites (8%). In the majority of the published cases penile MM patients are in the sixth and seventh decades of life.1 At the time of diagnosis, most of the melanomas are in vertical growth phase and its average thickness is 1.5 mm. Melanocytes derived from progenitor neural crest cells, migrating to the basal layer of the epidermis, give rise to tumoral cells that lead to cutaneous melanomas. For this reason mucosal melanomas are extremely rare. To date, papers about the use of endoscopic inguinal lymphadenectomy (EIL) in the treatment of penile cancer are scarce and, according our knowledge, the present publication is the first describing the use of EIL for the treatment of penile melanoma.
Material and methods Based upon our previous experience in laparoscopic surgery, EIL was carried out in an adult male diagnosed with penile melanoma and positive sentinel node in left inguinal limb. The patient was a 70-year-old male who consulted for purple nodular lesion on the distal end of prepuce (Fig. 1). After
biopsy, the diagnosis was: penile non-ulcerated melanoma ≤7.132 mm in thickness who had positive sentinel node. As consequence, the patient underwent modified EIL.
Surgical technique After general anesthesia, the patient was positioned supine with ipsilateral knee flexed and hip abducted. It is necessary to place a pad under knee in order to maintain this position during surgery. Before trocars were placed, a triangle was drawn, and its cranial limit was anterior superior iliac spine, the medial border was the adductor muscle and the lateral border of the sartorius muscle (Fig. 2A). The width of the emptying area was around 11---12 cm, its length descending through the medial side of the thigh was 15 cm and 20 cm through the lateral side. An incision in the lower vertex of the triangle was performed and virtual space was created with optics (12 trocar) (Fig. 2B) and with fingers. Afterwards, 2 trocars were placed: 10 mm trocar in the right side and 5 mm in the left side (Fig. 2C). After dissection of subcutaneous tissue and fascia of Scarpa, safena vein is the first vascular structure that appears medial. In our procedure, safena vein was preserved (Fig. 3). The dissection was continued cranially up to inguinal ligament (upper limit). Superficial femoral lymphadenectomy was carried out and biopsy scar tissue was removed. Abdominal subcutaneous vein and tributaries lymphatic vessels were clipped by Hemo-lok. Then, deep lymphadenectomy was performed. Safena vein was spared and regional lymph nodes, from safena vein to femoral ligament, were resected (Fig. 4A and B). Through 5 mm trocar pathway, aspirative drainage was placed and lymph nodes were removed in extraction bag. Regional pressure must not exceed 10 mm Hg in order to maintain the field of view and to prevent, simultaneously, a spontaneous infiltration beyond the limits of emptying. To reduce the incidence of lymphedema and lymphatic leakage, ultrasonic scalpel or electrocautery is required to cut most of the tissues.
Results
Figure 1
Penile melanoma.
There were no intraoperative complications. Surgery time was 120 min, and a total surgery blood loss of 35 cc. Surgical drainage was removed after 5 days post-op. Elastic compression stockings, legs slightly elevated, low molecular weight heparin and antibiotics during 7 days were used as postoperative maintenance treatment. Superficial inguinal lymphadenectomy revealed 5 nodes without neoplastic infiltration while deep ones revealed 4 nodes without
Modified endoscopic left inguinal lymphadenectomy
665
Figure 4 (A) Anatomical limits of modified endoscopic inguinal lymphadenectomy. (B) Final image after the surgical removal of lymph nodes.
neoplastic infiltration. One year after surgery, the patient is asymptomatic and there is no evidence of recurrence of melanoma.
Discussion Figure 2 (A) Patient positioning and drawing of the femoral triangle. (B) Development of the workspace. (C) Placement of optics and working trocars.
Figure 3 Preservation of Safena vein according to Catalona technique.
The major prognostic factors of survival in patients with penile cancer are the presence and extent of lymph node metastases. For staging penile cancer, inguinal lymphadenectomy is usually required. Moreover, this surgical procedure could be a curative measure in patients with cancer affecting only penile and regional nodes. Surgical management is complex, but early inguinal lymphadenectomy remains an integral part of treatment because it improves the prognosis of patients.2 Traditional procedure has been replaced by modified inguinal lymphadenectomy by Catalona3 because cutaneous incision is shorter, nodal excision is reduced to lymph nodes medial to femoral vein, saphenous vein is preserved and it avoids the transposition of the Sartorius. Open lymphadenectomy may be associated with severe complications impairing the quality of life. For this reason, the first case of modified EIL for epidermoid carcinoma of the penis (T3N1M0) was published in 2003 by Bishoff et al.,4 reporting lower morbidity than open surgery because with this technique the lymphatic and vascular supply to the overlying skin are maintained. Later, in 2005, Machado et al.5 published the results of comparative study between endoscopic inguinal lymphadenectomy and contralateral open lymphadenectomy in 3 patients treated
666 with bilateral inguinal lymphadenectomy. The authors have reported flap necrosis and lymphedema in 2 of 3 sides in which open technique was used. However, with endoscopic procedure, no complications in lower extremities were reported. Recently, laparoscopic and robotic procedures have been described for the excision of inguinal nodes.6---10 TobiasMachado et al.11,12 compared the outcomes of laparoscopic and open surgery in two studies carried out respectively in 20 and 10 groins with no palpable lymph nodes: mean surgery time in laparoscopic group was 120 min and 92 min in open surgery group. Between both, no statistical differences in nodes number were observed; however complications rate was 70% in open surgery vs 20% in laparoscopic procedure. With a mean follow-up of 33 months, recurrences have not been reported. Patients with non-palpable-mobile or small (shorter than 1 cm) adenopathies, with a high risk of nodal involvement are considered good candidates for this type of endoscopic approach. EIL is a relative contraindication in patients with bulky immovable inguinal nodes.13 These patients are better candidates for traditional open surgery because the dissection of upper side of immovable-adhered lymph nodes is difficult. In superficial inguinal lymphadenectomy, the ideal mean number of lymph nodes to be harvested is from 8 to 10 and in radical inguinal lymphadenectomy this number is from 10 to 11. The total number of nodes resulting from the sum of inguinal and pelvic lymphadenectomy varies from 22 to 25.14 In our case, the number of lymph nodes harvested was 9 and lymphorrhea, the only complication observed, was similar to those reported in the literature. Drainage was removed 5 days after surgery. This surgical procedure has lower risk of cutaneous complications, but the incidence of lymphocele (23%) is higher than in open approach. The sentinel node concept was introduced by Cabanas in 197715 ; since then, it has been used in the breast cancer and melanoma staging. Although it has been used since 30 years ago to penile carcinoma staging, its relevance in these tumors remains much debated. The technique of dynamic sentinel node biopsy was conceived and adapted for penile squamous cell carcinoma, according to the concept of an orderly progression of metastatic cells from the primary site through the lymphatics to first drainage lymph node (sentinel node). Its sensitivity is 95% and complication rate is 10% in patients with melanoma.
Conclusions EIL is a safe and feasible technique in patients with penile tumors and with palpable and non-palpable nodes. Published cases suggest that EIL could reduce postoperative morbidity and would not jeopardize oncological control. However, the number of nodes removed by this procedure is lower than by open surgery; therefore, patients must be selected
M. Alvarez-Maestro et al. carefully. We consider that new studies with a greater number of patients and long-term follow-up should be performed.
Conflict of interest The authors declare that they have no conflict of interest.
References 1. Oxley JD, Corbishley C, Down L, Watkin N, Dickerson D, Wong NA. Clinicopathological and molecular study of penile melanoma. J Clin Pathol. 2012;65:228---31. 2. Heyns CF, Fleshner N, Sangar V, Schlenker B, Yuvaraja TB, van Poppel H. Management of the lymph nodes in penile cancer. Urology. 2010;76 Suppl. 1:S43---57. 3. Catalona WJ. Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous vein: technique and preliminary results. J Urol. 1988;140:306---10. 4. Bishoff JT, Basler JW, Teichman JM, Thompson IM. Endoscopic subcutaneous modified inguinal lymph node dissection (ESMIL) for squamous cell carcinoma of the penis. J Urol. 2003;189:78. 5. Machado MT, Tavares A, Molina WR. Comparative study between videoendoscopic radical inguinal lymphadenectomy and standard open lymphadenectomy for penile cancer: preliminary surgical and oncological results. J Urol. 2005;173:226. 6. Britto CA, Rebouc ¸as RB, Lopes TR, Silva da Costa T, Leite Rde C, de Carvalho PS. Video-assisted left inguinal lymphadenectomy for penile cancer. Int Braz J Urol. 2012;38:289---90. 7. Tobias-Machado M, Correa WF, Reis LO, Starling ES, de Castro Neves O, Juliano R, et al. Single-site video endoscopic inguinal lymphadenectomy: initial report. J Endourol. 2011;25:607---10. 8. Sotelo R, Sanchez-Salas R, Clavijo R. Endoscopic inguinal lymph node dissection for penile carcinoma: the developing of a novel technique. World J Urol. 2009;27:213---9. 9. Josephson DY, Jacobsohn KM, Link BA, Wilson TG. Roboticassisted endoscopic inguinal lymphadenectomy. Urology. 2009;73:167---70. 10. Sotelo R, Sánchez-Salas R, Carmona O, Garcia A, Mariano M, Neiva G, et al. Endoscopic lymphadenectomy for penile carcinoma. J Endourol. 2007;21:364---7. 11. Tobias-Machado M, Tavares A, Molina Jr WR, Forseto Jr PH, Juliano RV, Wroclawski ER. Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes. Int Braz J Urol. 2006;32:316---21. 12. Tobias-Machado M, Tavares A, Ornellas AA, Molina Jr WR, Juliano RV, Wroclawski ER. Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure for radical management of inguinal nodes in patients with penile squamous cell carcinoma. J Urol. 2007;177:953---7. 13. Romanelli P, Nishimoto R, Suarez R, Decia R, Abreu D, Machado M, et al. Linfadenectomía inguinal video endoscópica (VEIL): resultados quirúrgicos y oncológicos, incluido pacientes con ganglios linfáticos palpables. Actas Urol Esp. 2013;37:305---10. 14. Master V, Organ K, Kooby D, Hsiao W, Delman K. Leg endoscopic groin lymphadenectomy (LEG procedure): stepby-step approach to a straightforward technique. Eur Urol. 2009;56:821---8. 15. Cabanas RM. An approach for the treatment of penile carcinoma. Cancer. 1977;39:456---66.