LETTERS TO EDITOR
|Year : 2022 | Volume
| Issue : 3 | Page : 240-241
Re: Kandasamy SG, Chandran KR, Pooleri GK. Minimal invasive approaches in lymph node management of carcinoma of penis: A review. Indian J Urol 2022;38:15-21
Anand Raja1, Arun Ramdas Menon1, Kanuj Malik2
1 Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
2 Department of Surgical Oncology, Metro Cancer Institute, Delhi-NCR, Faridabad, Haryana, India
|Date of Submission||16-Mar-2022|
|Date of Acceptance||04-May-2022|
|Date of Web Publication||1-Jul-2022|
Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raja A, Menon AR, Malik K. Re: Kandasamy SG, Chandran KR, Pooleri GK. Minimal invasive approaches in lymph node management of carcinoma of penis: A review. Indian J Urol 2022;38:15-21. Indian J Urol 2022;38:240-1
|How to cite this URL:|
Raja A, Menon AR, Malik K. Re: Kandasamy SG, Chandran KR, Pooleri GK. Minimal invasive approaches in lymph node management of carcinoma of penis: A review. Indian J Urol 2022;38:15-21. Indian J Urol [serial online] 2022 [cited 2022 Aug 9];38:240-1. Available from: https://www.indianjurol.com/text.asp?2022/38/3/240/349701
We read with great interest the article by Kandasamy et al., published in this journal where they bring out various aspects of video endoscopic inguinal lymphadenectomy (VEIL) and compare it to open inguinal lymphadenectomy. We commend the authors for the article.
Penile cancer lymphatics follow the pathway of stepwise nodal metastasis from the superficial to the deep inguinal and finally to the pelvic nodes. This forms the basis of staging the groin by way of sentinel node biopsy or superficial inguinal lymphadenectomy. Therapeutic inguinal lymphadenectomy (superficial plus deep) is only offered to patients with positive superficial nodes.
Two problems inherent in the practice of VEIL are overtreatment and residual disease. VEIL entails the removal of both superficial and deep inguinal lymph nodes. Patients with pathological N0 groin will never have deep inguinal nodal metastasis, and removal of these is overtreatment for >70% of patients who are offered this procedure. VEIL may have better perioperative outcomes, but the potential for long-term lymphedema of the limb is increased manifold by futile removal of deep lymphatics which forms a very important channel for lymphatics along the femoral vessels. Long-term studies addressing this are lacking.
Superficial inguinal nodes lying between the Camper's fascia and the fascia lata of the thigh represent the first echelon nodes for metastasis from penile cancer. Extracapsular extension from nodal metastasis frequently involves the Camper's fascia and then the skin. The plane of dissection for VEIL lies immediately deep to the Camper's fascia. Dissection in this plane in patients with extranodal extension raises the possibility of leaving behind microscopic residual disease over the flap, which can give rise to recurrences. In the authors' experience, a large proportion of pathologic node-positive groins need resection of the skin overlying the node. The problem is more acute in thin and emaciated patients who have less fat and thus involvement of the Camper's fascia is a very early event. Case selection, thus, plays a very important role in selecting patients for VEIL with a pathologic N0 groin.
In conclusion, VEIL and its robotic version are exciting new technologies and have captured the attention of the surgical community for their ease, versatility, and excellent perioperative outcomes. We, however, advise a word of caution in the use of this technique. The potential for overtreatment in pathologic node negative is high and the consequences of lymphedema can be devastating. The risk of residual disease in pathologic node-positive patients is real and recurrence can compromise survival.
Financial support and sponsorship: Nil.
Conflicts of interest: There are no conflicts of interest.
| References|| |
Kandasamy SG, Chandran KR, Pooleri GK. Minimal invasive approaches in lymph node management of carcinoma of penis: A review. Indian J Urol 2022;38:15-21. [Full text]
Leijte JA, Kirrander P, Antonini N, Windahl T, Horenblas S. Recurrence patterns of squamous cell carcinoma of the penis: Recommendations for follow-up based on a two-centre analysis of 700 patients. Eur Urol 2008;54:161-8.
Kathiresan N, Raja A, Ramachandran KK, Sundersingh S. Role of dynamic sentinel node biopsy in carcinoma penis with or without palpable nodes. Indian J Urol 2016;32:57-60.
] [Full text]
Teh J, Duncan C, Qu L, Guerra G, Narasimhan V, Pham T, et al.
Inguinal lymph node dissection for penile cancer: A contemporary review. Transl Androl Urol 2020;9:3210-8.