VEIL is a safe complementary procedure for treatment of PC, even in patients with PILN. Oncological results in patients with PILN seem to be appropriate but are still very premature. Prospective multicenter studies with larger samples and long-term follow-up should be conducted to determine the oncological equivalence of VEIL compared with open surgery in patients with PILN.
The concept of endoscopic inguinal dissection for penile cancer was proposed by Bishoff et al. from San Antonio, Texas, USA in 2003 with the dissection of 2 cadaveric models. After some modifications, the first case in clinical scenario was successfully operated at ABC Medical School, São Paulo, Brazil in 2003 by Tobias-Machado et al which nominate their procedure as VEIL (video endoscopic inguinal lymphadenectomy) (1).In order to achieve the maximum benefits of the minimally invasive approach, regarding morbidity reduction, the ABC Medical School technique was based in 10 major steps and we would like to emphasize 3 of them: distal lymphatic tissue ligation at the femoral triangle vertex, proximal control of visualized lymphatics with clips and ligation of the proximal portion of the lymphatic tissue at the deep portion of the femoral channel (2). We are concerned about these issues because in the presented video no lymphatic clipage was documented, the tissue was sectioned using only monopolar electrocautery. This can increase the post-operative complications related to the lymphatic tissue, thereby reducing the benefits of minimally invasive procedure. It is fundamental to stress that no energy source (electric, ultrasonic, ligasure) can adequately seal lymphatic vessels. One other interesting observation is that monopolar energy can be used but control is needed when it is utilized near the skin to prevent an isquemic event. The present video demonstrates the dissection in the correct plane (under Scarpa´s fascia) to maintain some fat under the skin.A randomized comparison with open surgery in nonpalpable inguinal nodes patients showed a reduced overall complication rate of endoscopic technique (20 X 70%) specially related to skin events (0 x 40%) (3). The same number of nodes could be obtained comparing the approaches. Five year follow-up series showed cancer specific survival of 100% for negative inguinal nodes and 80% for positive nodes suggesting that VEIL is oncological effective (4).Veil is having a growing international acceptance but experience is yet small. Actually about 20 centers around the world performed the endoscopic procedure with success and very similar results. Some centers are applying endoscopic surgery for other tumors as melanoma, vulvar and anal cancers. Actual results lead us to think that this technique has the potential to reduce post-operative morbidity (2-6).Nevertheless we would like to congratulate Britto et al who demonstrated the reproducibility of the method at the Federal University of Rio Grande do Norte, it could be consider especially important because VEIL can be of great value in a region which has a high incidence of penile cancer.
LESS sacrocolpopexy performed with conventional instruments is feasible and a safe procedure reproducing surgical steps of conventional laparoscopic or robotic surgery.
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