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Robot-Assisted Inguinal Lymphadenectomy to Treat Penile and Vulvar Cancers: A Scoping Review - Beyond the Abstract

Penile (PC) and vulvar cancers (VC), though uncommon in Western countries, are both aggressive and disfiguring diseases, with the inguinal lymph nodes (ILN) being the most frequent site of metastasis.1,2 Approximately one-third of men with intermediate/high risk T1 PC harbor lymph node metastases, and the rate doubles among those with T2-3 disease.3 Surprisingly, only 15% of women with T1 VC are diagnosed with ILN metastases, while the rate rises to 30% in locally advanced cases.2

Despite the potentially different biological behaviors of penile and vulvar cancers, invasive local staging and surgical treatment of inguinal metastases are potentially life-saving treatments, supported by clear recommendations.2-4 Nevertheless, several studies have highlighted low adherence to guidelines, potentially stemming from anticipated morbidity, with complication rates as high as 50-90%. In fact, in the USA, only 27% of men and 20% of women requiring ILN dissection (ILND) for cancer of the external genitalia receive the appropriate treatment.5

In the 1950s, Daseler codified the principles of open radical ILND.6 With the aim of reducing the complication rate of this surgery (which was around 66%), Machado and Josepson proposed a laparoscopic (2003) and robotic (2009) approach, respectively.7-8

According to our scoping review,9 since then, only 18 papers have been published concerning robot-assisted ILND (RAIL), and 171 patients have been treated so far. Most of these were men (91%). Operation times spanned from 45 to 300 minutes per groin, and the estimated blood loss ranged from 10 to 300 ml. The number of retrieved ILNs varied from 3 to 26 per groin, with 17/18 studies reporting an adequate median yield of >7 nodes.10 Hospital stays ranged from 1 to 7 days (being <4 days in 8/13 studies), and the most commonly observed postoperative complications were lymphocele (22%), lymphedema (13%), and cellulitis (11%).

Despite the limited number of studies, these findings indicate that RAIL is a safe and effective procedure with a lower complication rate compared to open surgery. Therefore, minimally-invasive approaches to ILND could represent the gold standard for future treatments. Further research, including randomized controlled trials, is necessary to confirm these findings and establish these techniques as the standard of care.

Written by: Brassetti Aldo,¹ Chiacchio Giuseppe,² * Galosi B. Andrea², Simone Giuseppe,¹

  1. Department of Urology, IRCCS - “Regina Elena” National Cancer Institute, Rome, Italy
  2. Urology Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Università Politecnica delle Marche, Ancona, Italy
References:

  1. Pow-Sang MR, Ferreira U, Pow-Sang JM, Nardi AC, Destefano V. Epidemiology and natural history of penile cancer. Urology. 2010 Aug;76(2 Suppl 1):S2-6.
  2. Oonk MHM, Planchamp F, Baldwin P, Bidzinski M, Brännström M, Landoni F, et al. European Society of Gynaecological Oncology Guidelines for the Management of Patients With Vulvar Cancer. Int J Gynecol Cancer. 2017 May;27(4):832–7.
  3. Brouwer OR, Albersen M, Parnham A, Protzel C, Pettaway CA, Ayres B, et al. European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update. Eur Urol. 2023 Jun;83(6):548–60.
  4. Brouwer OR, Albersen M, Parnham A, Protzel C, Pettaway CA, Ayres B, et al. European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update. Eur Urol. 2023 Jun;83(6):548–60.
  5. Bada M, Berardinelli F, Nyiràdy P, Varga J, Ditonno P, Battaglia M, et al. Adherence to the EAU guidelines on Penile Cancer Treatment: European, multicentre, retrospective study. J Cancer Res Clin Oncol. 2019 Apr;145(4):921–6.
  6. Daseler EH, Anson BJ, Reimann AF. Radical excision of the inguinal and iliac lymph glands; a study based upon 450 anatomical dissections and upon supportive clinical observations. Surg Gynecol Obstet. 1948 Dec;87(6):679–94.
  7. Tobias-Machado M, Tavares A, Ornellas AA, Molina 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 Mar;177(3):953–7; discussion 958.
  8. Josephson DY, Jacobsohn KM, Link BA, Wilson TG. Robotic-assisted endoscopic inguinal lymphadenectomy. Urology. 2009 Jan;73(1):167–70; discussion 170-171.
  9. Brassetti A, Chiacchio G, Anceschi U, Bove A, Ferriero M, D'Annunzio S, Misuraca L, Guaglianone S, Tuderti G, Mastroianni R, Tedesco F, Cacciatore L, Proietti F, Flammia SR, De Nunzio C, Cozzi G, Leonardo C, Galosi AB, Simone G. Robot-assisted inguinal lymphadenectomy to treat penile and vulvar cancers: a scoping review. Minerva Urol Nephrol. 2024 Jun;76(3):278-285. doi: 10.23736/S2724-6051.24.05532-0. PMID: 38920009.
  10. Brassetti A, Anceschi U, Cozzi G, Chavarriaga J, Gavrilov P, Gaya Sopena JM, et al. Combined Reporting of Surgical Quality and Cancer Control after Surgical Treatment for Penile Tumors with Inguinal Lymph Node Dissection: The Tetrafecta Achievement. Curr Oncol. 2023 Feb 3;30(2):1882–92.
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