Editorial: Is minimally invasive inguinal node dissection the way forward?

In this issue of BJUI, Kumar and Sethia report their experience of laparoscopic inguinal node dissection for patients with penile cancer [1]. The authors should be congratulated for what is a technically and feasibly difficult study to complete.

The step-wise spread of penile carcinoma first to the inguinal lymph nodes is well known. It is also recognized that accurate staging and treatment of inguinal metastases play a crucial part in a patient’s management pathway. Furthermore, evidence points to a survival advantage for those who undergo prophylactic inguinal lymph node dissection (ILND) and have positive nodes, compared with those treated with surveillance and delayed dissection when nodes become palpable or radiologically positive.

The overall postoperative complication rate after ILND has been reported to be nearly 50% or even up to 75%. Patients with comorbidities or locally advanced disease are at particular risk of postoperative morbidity [2]. High rates of wound dehiscence and skin necrosis after ILND have also been reported [3]. More recently, complication rates among men with no palpable adenopathy have been reported to be decreasing in comparison with historical experience, but overall complication rates still range from 10 to 40%.

Adoption of dynamic sentinel node biopsy has reduced the absolute number of prophylactic ILNDs, but in any high-volume unit (as is the case in the UK supra-network centres), a large number of inguinal node dissections will still be undertaken [4].

For these reasons it is desirable to minimize or modify the inguinal wound to reduce the complication rate, and the use of minimally invasive techniques has gradually progressed over the last 10 years.

The first case series reporting the use of laparoscopic node dissection (videoendoscopic inguinal node dissection [VEILND]) described 10 patients who underwent bilateral ILND using standard lymphadenectomy on one side and the VEILND technique on the contralateral side [5]. A more recent development has been the incorporation of robotic assistance as an enabling tool for performing ILND [6].

In these small series the technique appeared to be safe and oncologically comparable to open surgery, but the numbers were too small to give a meaningful assessment of complications. It is therefore welcome to read a paper on a high-volume unit’s experience of VEILND.

The authors describe their experience of VEILND on a sequential prospective group of patients and compared them with a historical control cohort who underwent open inguinal node dissection. The data appear to show a significant difference in length of stay and wound-related comorbidity in favour of the minimally invasive approach without compromising oncological outcome. Interestingly, the rate of lower limb lymphedema was also significantly reduced in the VEILND group.

The headline data are impressive but the comparison does have a number of potential weaknesses. Firstly, the rate of wound-related complications is quite high in the open group, with 23% of patients needing re-exploration or debridement and 37% some form of drainage of collection. The choice of incision position, length and preparation of skin flaps can influence the rate of wound breakdown and length of stay.

Secondly, the headline 6% complication rate for VEILND does not include the 27% lymphocoele rate which is still a troublesome complication in both the open and endoscopic groups.

Finally, there is no mention of the limitations of the technique with size and extent of the malignant node burden. The paper states that all patients were included, and yet in any high-volume centre there must be patients with grossly enlarged and sometimes fungating or fixed nodes and I would have thought that VEILND would not be appropriate in these instances.

In conclusion, there is much to commend this paper and the direction of travel may well be towards minimally invasive techniques; however, as with all comparisons between open and keyhole surgery, the focus should be on improving the open technique to its limit. Only then will the results be meaningful and adopted with confidence.

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