The objective was to describe our technique of robotic-assisted inguinal lymph node dissection (RAILND) in two patients presented with palpable inguinal lymph nodes, which is the first Indian experience of robotic inguinal lymph nodal dissection.
Two patients aged 38 and 46 years respectively presented to our institution with a penile mass and persistent palpable bilateral inguinal adenopathy (1--2 cm), T1G1 squamous cell carcinoma.
The patients were placed in the supine position with the ipsilateral leg (left) abducted and padded. The contralateral leg was kept straight. A 2 cm transverse incision was made approximately 25 cm inferior to the midpoint of inguinal ligament. Two vertical lines were drawn 15 cm and 20 cm from pubic tubercle and anterior superior iliac spine respectively to mark out the area of dissection. The subfascial space (deep to Camper's fascia) was developed using a peritoneal balloon dissector. A blunt tip balloon trocar was used for the midline robotic camera port (0°) and then two working robotic ports (8 mm) were placed approximately 8 cm away from the camera port. A 12 mm assistant port was placed in between the camera port and the lateral robotic port. The da Vinci S robotic system was docked at 30° to the contralateral thigh from the head end. The boundaries of the dissection extended from the inguinal ligament superiorly, the Sartorius muscle laterally, and the adductor longus muscle medially. The dissected superficial nodal package was entrapped separately in a bag and placed laterally for removal at the end of the procedure. The femoral artery and vein were skeletonized while preserving the saphenous vein. The dissected deep lymph node packets were removed separately. The specimen was removed at the completion of the procedure from the camera port incision. A closed suction drain was placed and crepe bandage was applied. Contralateral side (right) dissection was performed after 2 days. The instrument setup and robot docking were replicated on the other side.
The operative time was 90--110 minutes. The estimated blood loss was 50--100 ml. The patients were discharged on postoperative day 2 with advice regarding drain care and 1-week course of oral antibiotics. Pathologic examination revealed four lymph nodes with metastases on the right side in case 1 and two lymph nodes on the left side in case 2. There was no metastatic involvement in superficial/deep inguinal lymph nodes on the left in case 1 and on the right in case 2. The indwelling drain was removed 10 days after surgery when the output was 50 ml/day. There were no wound-related complications or lower extremity oedema in follow-up.
We believe that RAILND is an efficacious and safe procedure with minimal morbidity and has a place in managing carcinoma penis patients in India. It also opens a new chapter in the extended use of robotics in urology thus reducing the cost and increasing its multidimensional applicability.
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