V8-09: Robotic-Assisted Inguinal Lymphadenectomy: Early outcomes and technical modifications

Video

Introductions and Objectives
Penile cancer with nodal metastases is associated with poor cancer-specific survival. Both resection of metastatic nodes and prophylactic removal of benign nodes provide durable survival advantages. Open inguinal lymph node dissection (ILND) is associated with a high rate of cutaneous and lymphatic complications, particularly skin flap necrosis. Endoscopic ILND prevents iatrogenic disruption of the inguinal skin’s vascular supply, thus reducing the incidence of major complications. Our objective is to use video to describe our robotic-assisted inguinal lymphadenectomy (RAIL) technique and report early outcomes in both clinically node-negative and positive patients.

Methods
We conducted 10 RAIL procedures in 6 patients with invasive penile squamous cell carcinoma from 2013-2014. Four patients received bilateral RAIL in the same setting and two had unilateral RAIL after contralateral open ILND. We stationed the robotic base directly over the midline at the patient’s head and put the patient in moderate Trendelenburg to eliminate the need for intraoperative repositioning. The median post-operative follow-up period was 87 days (17-511). We classified complications as early (≤30 days) or late (31-90 days) and graded them by the Clavien Dindo classification system.

Results
In our cohort, median age was 74.7 years (IQR 73-79), Charlson comorbidity index was 6 (5-12), and BMI was 36.1 kg/m2 (29-42). Per limb, median operative time was 157.5 minutes (137-182), blood loss was 25 mL (8-25), superficial nodal yield was 8 nodes (6-11), and time to drain removal was 24.5 days (20-27). There were no intraoperative complications. Median length of stay was 2 days (2-4). Two patients with clinically node-positive cancer had bilateral metastatic nodes (1.5 per limb (1-3)). All other patients had pN0 cancer. Clavien I-II complications occurred in 4 patients in 6 limbs (seroma, wound infection). One patient had a seroma requiring operative drainage (Clavien III). Early complications occurred in 6 limbs, and there was a late complication (seroma) in 1 limb. In follow-up, 2 patients had locoregional recurrence (1 died), and 1 had lung metastases.

Conclusions
RAIL is a safe procedure with similar nodal yield to open ILND, no intraoperative complications, and technical advantages for the surgeon. Postoperative complications are mostly minor and no skin flap necrosis was seen, yet surgical site complications remain problematic. Reducing the morbidity of RAIL and proving oncological efficacy will require continued investigation.

Funding: none