MDACC 2018: Robotic Assisted Inguinal Lymph Node Dissection: Ready for Prime Time?
Initial attempts at a minimally invasive approach were reported by Bishoff et al2 with the video endoscopic inguinal lymph node dissection (VEIL)—this purely laparoscopic procedure was notable for difficult ergonomics, as well as a steep learning curve. In 2009, Josephson et al reported the robotic-assisted inguinal lymph node dissection (RAIL),3 noting the improved ergonomics and visualization conferred by the robot. Dr. Adibi postulated that RAIL offers better preservation of skin lymphatics and vasculature due to small port incisions in the thigh instead of the groin, atraumatic retraction by gas instead of by mechanical retractors, and an overall decrease in skin-related complications. Disadvantages of the robotic approach include longer operative times, a higher learning curve, inapplicability of the modality currently to cN3 or bulky lymphadenopathy, the potential risk of lower LN yield, and added costs.
Currently, RAIL is indicated for clinically non-palpable LNs (cN0) or small clinically palpable nodes. Dr. Adibi showed data from the Phase 1 MD Anderson experience,4 involving 10 patients with cT1b, T2-3, clinical N0 penile SCC. The mean number of nodes removed was equivalent when compared toa historical open cohort. Singh et al reported on a larger retrospective series of 100 open ILND cases vs 51 RAIL cases; they noted similar LN yields, with the robotic approach favoring a shorter hospitalization, fewer days with a surgical drain, and longer operative times. Major complications were also lower in the RAIL cohort.5 Analysis and data from a Phase 2 study at MD Anderson are pending.
Take home messages: The robotic inguinal lymph node dissection is a feasible surgical approach in select cases, albeit with a greater learning curve and increased OR times. Lymph node yields are comparable to the open approach and the procedure may offer decreased morbidity, though data is still emerging in this area.
Presented by: Mehrad Adibi, MD, Assistant Professor, Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
References:
1. Spiess PE, Hernandez MS, Pettaway CA. Contemporary inguinal lymph node dissection: minimizing complications. World J Urol [Internet]. 2009 Apr;27(2):205–12.
2. Bishoff J, Basler J, Teichman J, Thompson I. Endoscopic subcutaneous modified inguinal lymph node dissection (ESMIL) for squamous cell carcinoma of the penis. J Urol. 2003;169(4):78.
3. Josephson DY, Jacobsohn KM, Link BA, Wilson TG. Robotic-assisted endoscopic inguinal lymphadenectomy. Urology [Internet]. 2009 Jan;73(1):167-70; discussion 170-1.
4. Matin SF, Cormier JN, Ward JF, Pisters LL, Wood CG, Dinney CPN, et al. Phase 1 prospective evaluation of the oncological adequacy of robotic-assisted video-endoscopic inguinal lymphadenectomy in patients with penile carcinoma. BJU Int [Internet]. 2013 Jun;111(7):1068–74.
5. Singh A, Jaipuria J, Goel A, Shah S, Bhardwaj R, Baidya S, et al. Comparing Outcomes of Robotic and Open Inguinal Lymph Node Dissection in Patients with Carcinoma of the Penis. J Urol [Internet]. 2018 Jun;199(6):1518–25.
Written by Dr. Vikram M. Narayan (@VikramNarayan), Urologic Oncology Fellow with Ashish M. Kamat, MD (@UroDocAsh), (@UroAshDoc), Professor, Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX at the 13th Update on the Management of Genitourinary Malignancies, The University of Texas (MDACC - MD Anderson Cancer Center) November 9-10, 2018, Dan L. Duncan Building, Houston, TX