The role of primary inguinal surgical debulking for locally advanced penile cancer followed by reconstruction with myocutaneous flap

Abstract

Purpose: To evaluate surgical complications and oncological outcomes of patients submitted to primary radical inguinal surgical debulking (PRISD) and myocutaneous pediculate flap reconstruction (MPFR) for locally advanced penile cancer (PC). Materials and Methods: Forty-two patients with ulcerated and/or fixed bulky inguinal masses underwent unilateral or bilateral PRISD with MPFR. Tensor fascia lata flap (TFL) was the standard of care for all patients. Additional use of the gracilis flap (GF) was carried out when necessary. Contra-lateral radical inguinal lymphadenectomy (RIL) was conduced when PRISD was performed unilaterally. Surgical complications were analyzed and stratified into minor and major according to the Bevan-Thomas classification. Adjunctive treatments were assessed and oncological outcomes analyzed. Results: Of the 42 patients evaluated, 10 (23.8%) underwent bilateral PRISD and 32 (76.2%) unilateral PRISD with contra-lateral RIL, totaling 84 lymphadenectomies. A total of 62 MPFRs were performed, 52 with TFL and 10 with GF. A total of 53 complications were identified, 49 related to PRISD with MPFR and 4 to RIL. Adjuvant chemotherapy was carried out in 16 patients. Median follow-up was 10.8 months with a median overall survival (OS) of 14.0 months against 6.0 months (p=0.006) for patients submitted to PRISD with adjuvant chemotherapy in relation to surgery alone. Conclusions: PRISD alone for advanced loco-regional PC is unlikely to promote long-term survival, although it can lead to temporary local control of the disease. Despite the feasibility of the procedure, it is related to high incidence of complications. Surgical treatment with adjuvant chemotherapy is associated with improved OS.

The role of surgery for loco-regional and advanced urological cancers

“…Reconstructive techniques allow more extensive inguinal resections to be performed whenever necessary to relieve tumour burden, and when successful, promotes patient autonomy as patients can be discharged with more manageable wounds: three recent series (Table 3) of advanced penile cancer patients who underwent reconstruction with vertical rectus abdominis myocutaneous (VRAM) [57,58] and tensor fascia lata (TFL) [59 ▪ ] flaps observed mostly minor complications such as lymphoceles and partial wound breakdown with rates of Clavien–Dindo grade at least three complications ranging from 5 to 30%.…”

Risk factors for inguinal lymph node metastasis in patients with penile cancer

“…In the current edition of the International Brazilian Journal of Urology, the authors analyze thorough a cross-sectional study, the risk factors for inguinal lymph node metastasis in patients with penile cancer (1). It is well established that the presence and extent of inguinal metastases are the most important prognostic factors related to survival of patients with penile carcinoma (2). Although this carcinoma is potentially curable by radical inguinal lymphadenectomy, the procedure is historically associated with a significant incidence of morbidity, leaving many patients at risk for inguinal metastases without the appropriate approach (3).…”

“…2022; 48: 314-5 imaging, which was found to be an independent risk factor (p= 0.045) for inguinal metastasis. Palpable lymph nodes are strongly indicative of metastasis and should be promptly treated with radical inguinal lymphadenectomy (2,4,5). Furthermore, it is reasonable to assume that lymph nodes with diameter >1.5 cm can be identified by simple physical examination, leaving imaging methods in such cases to staging or evaluation of obese patients in cases where physical examination is unreliable (5).…”

Predictive histopathological factors of nodal metastasis in penile cancer

“…It is important to determine advanced loco--regional disease to define its management. Primary radical inguinal surgical debulking alone for these cases is unlikely to promote long-term survival and is related to a high incidence of complications ( 34 )…”