Re: Video-assisted left inguinal lymphadenectomy for penile cancer

Abstract

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.

Efficacy and Safety of Lateral Approach-Video Endoscopic Inguinal Lymphadenectomy (L-VEIL) over Open Inguinal Block Dissection: a Retrospective Study

“…Because of this, L-VEIL procedure does not require a sartorius flap that is usually needed with the open procedure. Nonetheless, there are operative concerns with both VEIL and open surgery in order to minimize pre and postoperative complications and morbidity, and maximize the benefits of minimally invasive technique namely initial blunt dissection of the correct plane (under Scarpa's fascia) of dissection [33], by maintaining some fat under the skin [34]. Moreover, an experienced hand is a requirement that contributes to the increased success of VEIL over open surgery.…”

“…Moreover, an experienced hand is a requirement that contributes to the increased success of VEIL over open surgery. Emphasis is laid on three more steps in VEIL: distal lymphatic tissue ligation at the femoral triangle vertex, proximal control of visualized lymphatics, and ligation of the proximal portion of the lymphatic tissue at the deep portion of the femoral channel using clips or tissue sealers [34]. The authors believe that the bipolar tissue sealers used in VEIL contribute to the reduced drain and early removal of drains [35,36].…”

A single-center comparison of our initial experiences in treating penile and urethral cancer with video-endoscopic inguinal lymphadenectomy (VEIL) and later experiences in melanoma cases

“…Moreover, only 10 published series employing VEIL have been published to date, and these just included 7-32 patients each (21). VEIL procedures are currently routinely performed in only 15 referral hospitals worldwide, as summarized in Table 1 (7,8,10,13,16,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33).…”

“…Given the aforementioned problems, a new minimally invasive endoscopic technique commonly referred to as video-endoscopic inguinal lymphadenectomy (VEIL) has been developed and ushered in as a welcome addition to surgeons' arsenal of tools for performing inguinal lymphadenectomy. Initial data suggest that, although this endoscopic surgical technique is not completely complication-free ( 14 ), it produces less morbidity than open-surgery approaches ( 15 , 16 ), better cosmetic results ( 15 , 17 , 18 ), and is safe for use in different malignancies involving inguinal lymph-nodes ( 19 , 20 ). Given that penile cancer is rare, and VEIL has not yet demonstrated reproducible and safe long-term oncology results, VEIL has not yet replaced conventional radical inguinal lymphadenectomy as the standard-of-care treatment.…”

“…Given that penile cancer is rare, and VEIL has not yet demonstrated reproducible and safe long-term oncology results, VEIL has not yet replaced conventional radical inguinal lymphadenectomy as the standard-of-care treatment. Even though VEIL is becoming more common, in 2012 it was used in no more than 20 centers worldwide ( 16 ). Moreover, only 10 published series employing VEIL have been published to date, and these just included 7–32 patients each ( 21 ).…”