Inguinal lymph node dissection in the era of minimally invasive surgical technology

Abstract

Background

Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications.

Methods

The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000–2020.

Findings

There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Introduction

Inguinal lymph node dissection (ILND) is an important component of staging and treatment in different malignancies that can metastasize to this area of the body including penile and vulvar cancers according to National Comprehensive Cancer Network guidelines [1], [2], [3]. Additionally, for malignant melanoma lesions draining to the inguinal lymph node basin, ILND has been advocated for cancers with a positive sentinel lymph node biopsy [4]. Historically, ILND was performed via an open incision which was associated with a high incidence of morbidity including skin edge necrosis, wound dehiscence, infection, lymphocele, lymphorrhea, femoral vessel and femoral nerve injury, deep vein thrombosis, and chronic extremity lymphedema. Reported complication rates range from 50% to 90% with a significant impact on quality of life, potentially limiting utilization of recommended ILND for oncologic indications, including in the modern era [5], [6], [7].

Many different approaches, and sometimes their combination, are utilized in order to diminish the morbidity of ILND. Dynamic Sentinel Node Biopsy (DSNB) is considered to be the least morbid method for excisional biopsy of clinically non-palpable groin lymph nodes. A positive DSNB mandates proceeding with formal ILND while negative DSNB avoids the morbidity of a full ILND. Another approach is to modify the dissection template lowering morbidity by reducing the field of dissection. However, that theoretically increases the risk of under sampling, and advantage is lost when histopathological examination reveals a positive node as radical dissection often times becomes mandatory at that point. Another approach to decrease the morbidity of ILND is to use novel technologies to perform the surgery in a minimally invasive fashion. In this review, we discuss different templates as well as minimally invasive techniques and their outcomes and complications.