Extending boundaries in minimally invasive procedures with simultaneous bilateral video endoscopic inguinal lymphadenectomy ( veil ) for penile cancer : initial Denver health medical center and ABC school of medicine experience and surgical considerations

ARTICLE INFO _________________________________________________________ ___________________ Vol. 39 (4): 587-592, July August, 2013 doi: 10.1590/S1677-5538.IBJU.2013.04.18 IBJU | EXTENDING BOUNDARIES IN MINIMALLY INVASIVE PROCEDURES WITH SIMULTANEOUS BILATERAL VIDEO ENDOSCOPIC INGUINAL LYMPHADENECTOMY (VEIL) FOR PENILE CANCER 588 lymphadenectomy (VEIL) was established as a new approach. However, reducing the field of dissection in the endoscopic method increased the potential for false-negative histopathological results and thus, possibly compromised the oncological effectiveness of the procedure. Although clinical experience is still limited in endoscopic inguinal dissection, there appears to be less morbidity and the early oncologic results are encouraging (1). However, these results are still investigational and require longer follow-up. Currently there are no reports of a simultaneous inguinal lymphadenectomy procedure. This procedure may reduce operative and anesthesia time and further decrease the morbidity of surgery. Our objective is to report the surgical technique, procedural outcomes, and feasibility of simultaneous bilateral lymph node resssection in the management of patients with indication for inguinal lymphadenectomy. Statistical analysis Three patients initially underwent partial penectomy for penile cancer. Due to the high risk of developing inguinal metastasis, lymphadenectomy was further indicated. Two patients underwent simultaneous bilateral VEIL while another underwent simultaneous bilateral surgery with VEIL on the right and open lypmhadenectomy on the left side due to palpable 3 cm node. Patient positioning and trocar placement The patient was placed in supine frog leg position. Two surgeons simultaneously performed the procedure from the lateral sides with their respective laparoscopic monitors on the opposite side of the table (Figure-1). A 1.5 cm incision was made 2 cm distally to the lower vertex of the femoral triangle. Scissors were employed to develop a plane of dissection deep to Scarpa’s fascia. A second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions and the working space was insufflated with CO2 at 5-15 mmHg. The final trocar was placed 2 cm proximally and 6 cm laterally from the first port (Figure-2). Dissection Video endoscopic inguinal lymphadenectomy with the same template of open surgery was performed bilaterally simultaneously. The main landmarks the adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly -were well visualized (2). The Figure 1 Simultaneous bilateral VEIL. IBJU | EXTENDING BOUNDARIES IN MINIMALLY INVASIVE PROCEDURES WITH SIMULTANEOUS BILATERAL VIDEO ENDOSCOPIC INGUINAL LYMPHADENECTOMY (VEIL) FOR PENILE CANCER 589 retrograde dissection with minimal use of the ultrasonic scalpel was initiated distally near the vertex of the femoral triangle towards the fossa ovalis. The safena vein was identified, clipped, and divided towards the femoral artery laterally. After the procedure, the skeletonized femoral vessels and the empty femoral channel could be identified, confirming the lymphatic tissue in this region was completely resected. Specimen retrieval and closure of ports The surgical specimen was removed through the first port incision. A suction drain was placed to prevent lymphocele development. Patients were discharged and drains were removed when output was < 50 mL.


INTRODuCTION
In patients with penile cancer, lymph node metastasis is the most important factor affecting survival.However, open radical inguinal lymphadenectomy is associated with high morbidity.To reduce morbidity, video endoscopic inguinal Extending boundaries in minimally invasive procedures with simultaneous bilateral video endoscopic inguinal lymphadenectomy (veil) for penile cancer: initial Denver health medical center and ABC school of medicine experience and surgical considerations _______________________________________________ lymphadenectomy (VEIL) was established as a new approach.However, reducing the field of dissection in the endoscopic method increased the potential for false-negative histopathological results and thus, possibly compromised the oncological effectiveness of the procedure.Although clinical experience is still limited in endoscopic inguinal dissection, there appears to be less morbidity and the early oncologic results are encouraging (1).However, these results are still investigational and require longer follow-up.Currently there are no reports of a simultaneous inguinal lymphadenectomy procedure.This procedure may reduce operative and anesthesia time and further decrease the morbidity of surgery.Our objective is to report the surgical technique, procedural outcomes, and feasibility of simultaneous bilateral lymph node resssection in the management of patients with indication for inguinal lymphadenectomy.

Statistical analysis
Three patients initially underwent partial penectomy for penile cancer.Due to the high risk of developing inguinal metastasis, lymphadenectomy was further indicated.Two patients underwent simultaneous bilateral VEIL while ano-ther underwent simultaneous bilateral surgery with VEIL on the right and open lypmhadenectomy on the left side due to palpable 3 cm node.

Patient positioning and trocar placement
The patient was placed in supine frog leg position.Two surgeons simultaneously performed the procedure from the lateral sides with their respective laparoscopic monitors on the opposite side of the table (Figure -1).A 1.5 cm incision was made 2 cm distally to the lower vertex of the femoral triangle.Scissors were employed to develop a plane of dissection deep to Scarpa's fascia.A second incision was made 2 cm proximally and 6 cm medially.Two 10 mm Hasson trocars were inserted in these incisions and the working space was insufflated with CO 2 at 5-15 mmHg.The final trocar was placed 2 cm proximally and 6 cm laterally from the first port (Figure -2).

Dissection
Video endoscopic inguinal lymphadenectomy with the same template of open surgery was performed bilaterally simultaneously.The main landmarks -the adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly -were well visualized (2).The retrograde dissection with minimal use of the ultrasonic scalpel was initiated distally near the vertex of the femoral triangle towards the fossa ovalis.The safena vein was identified, clipped, and divided towards the femoral artery laterally.After the procedure, the skeletonized femoral vessels and the empty femoral channel could be identified, confirming the lymphatic tissue in this region was completely resected.

Specimen retrieval and closure of ports
The surgical specimen was removed through the first port incision.A suction drain was placed to prevent lymphocele development.Patients were discharged and drains were removed when output was < 50 mL.

COMMENTS
Cancer of the penis is a rare malignant disease and treatment causes devastating effects on patients' physical and psychological health.The low incidence of this disease in developed countries in contrast with the high incidence in developing countries clearly indicates the disease's association with local economic conditions (3).Brazil has one of the highest incidences of penile cancer in the World.An epidemiological study published by Favorito et al. demonstrated that in some regions of Brazil, this mutilating disease is endemic and directly linked with socio-economic status (4).Despite these factors appropriate management and treatment outcomes in men with squamous cell carcinoma of the penis depends critically on the correct diagnosis, grading, and staging of the malignancy.
The presence and extent of regional lymph nodes are the most important determinants of survival in patients with penile squamous cell carcinoma (5).At initial presentation, clinically palpable inguinal lymph nodes are present in 28%-64% of patients with penile squamous cell carcinoma.In 47%-85% of these patients, lymphadenopathy is caused by metastatic invasion while inflammatory reactions account for the remainder (3).In this setting the management of inguinal lymph nodes is important.A prospective study published by Pompeo et al. showed that spread to the right side, left, and bilaterally occurred in 24%, 30%, and 46% of patients, respectively.Therefore, it was proposed that bilateral inguinal lymphadenectomy (ILND) should be the standard in the management for patients who require lymphadenectomy (6).
Although the survival benefits of lymphadenectomy in patients with penile cancer and impalpable lymph nodes have been well demonstrated, elevated morbidity remains an issue for the traditional surgical approach.The risks and complications associated with an open inguinal lymph node dissection include necrotic skin flaps and elevated risk of lymphoceles which has driven several investigators to develop techniques for performing a minimally invasive endoscopic inguinal lymph node dissection.The feasibility of endoscopic subcutaneous inguinal lymphadenectomy nowadays is well established and is an option in experienced laparoscopic hands (7).Since the introduction of VEIL by Tobias-Machado in 2006, there has been a surge of interest in this technique (8).Although VEIL surgery is technically demanding primarily because of the small working space, more than 20 centers, including the use of robotic platform, have reported their initial experience with similar technical success and improved morbidity rates (1).Sotelo et al. showed that VEIL carries a lower risk of skin complications compared with an open approach (9).A recent paper comparing open and laparoscopic lymphadenectomy suggested that VEIL may decrease postoperative morbidity without compromising oncological control (3).By performing a simultaneous bilateral procedure, it is thought that the morbidity would be further decreased while maintaining the oncological efficacy of conventional VEIL.
In our study, although there are a small number of patients, we describe the first experience in simultaneous bilateral VEIL.Despite the necessity of two laparoscopic sets, this new approach may decrease the operation room and anesthesiology time without compromising on- cological outcomes.Although this procedure was performed by two different surgeons, there was no clashing between the surgical groups demonstrating the feasibility and some advantages of this method.All VEIL procedures were completed without conversions (Table -1).Operative time ranged from 120-150 min.Patients were discharged at 1-2 days and the drain was removed after 5-10 days during the follow-up clinic visit.Mean number of nodes retrieved was 6 for each side and 2 patients presented with positive inguinal nodes.In a mean follow-up period of 12 months no systemic or local recurrence has been documented.No complications related to VEIL were reported.There was only 1 lymphocele from the bilateral lymphadenectomies that occurred in the open approach with the palpable node.This patient had prolonged drainage and the drain was withdrawn after 1 week.The patient later returned to the hospital 2 weeks postoperative with an inguinal fluid collection treated successfully by simple drainage.
To our knowledge, simultaneous bilateral inguinal lymph node dissection has only been performed in one other institution (10).A minimally invasive approach circumventing the need for thick skin flaps coupled with the simultaneous procedure's improvement in operative and anesthesia time could decrease the morbidity associated with inguinal lymphadenectomy while maintaining oncological principles.

Figure 2 -
Figure 2 -Final aspect of the trocar incisions and drainage.