Combined Partial Penectomy With Bilateral Robotic Inguinal Lymphadenectomy Using Near-infrared Fluorescence Guidance

doi:10.1016/j.urology.2017.11.021

Urology

Volume 113, March 2018, Page 251

https://doi.org/10.1016/j.urology.2017.11.021 Get rights and content

Objective

To describe our novel technique for performing a combined partial penectomy and bilateral robotic inguinal lymphadenectomy using intraoperative near-infrared (NIR) fluorescence guidance with indocyanine green (ICG) and the DaVinci Firefly camera system.

Methods

A 58-year-old man presented status post recent excisional biopsy of a 2-cm lesion on the left coronal aspect of the glans penis. Pathology revealed “invasive squamous cell carcinoma of the penis with multifocal positive margins.” His examination was suspicious for cT2 primary and his inguinal nodes were cN0. He was counseled to undergo partial penectomy with possible combined vs staged bilateral robotic inguinal lymphadenectomy. Preoperative computed tomography scan was negative for pathologic lymphadenopathy. Before incision, 5 mL of ICG was injected subcutaneously beneath the tumor. Bilateral thigh pockets were then developed simultaneously and a right, then left robotic modified inguinal lymphadenectomy was performed using NIR fluorescence guidance via the DaVinci Firefly camera. A partial penectomy was then performed in the standard fashion.

Results

The combined procedure was performed successfully without complication. Total operative time was 379 minutes and total robotic console time was 95 minutes for the right and 58 minutes to the left. Estimated blood loss on the right and left were 15 and 25 mL, respectively. A total of 24 lymph nodes were retrieved.

Conclusion

This video demonstrates a safe and feasible approach for combined partial penectomy and bilateral inguinal lymphadenectomy with NIR guidance using ICG and the DaVinci Firefly camera system. The combined robotic approach has minimal morbidity and avoids the need for a staged procedure. Furthermore, use of NIR guidance with ICG during robotic inguinal lymphadenectomy is feasible and may help identify sentinel lymph nodes and improve the quality of dissection. Further studies are needed to confirm the utility of NIR guidance for robotic sentinel lymph node dissection.

References (0)

Cited by (13)

Inguinal lymph node dissection in the era of minimally invasive surgical technology
2023, Urologic Oncology: Seminars and Original Investigations
Citation Excerpt :
The boundaries of the dissection and surgical steps are similar to VEIL procedure described above. Several studies describe the use of near-infrared fluorescence technology available in the da Vinci (Intuitive Surgical, Sunnyvale, CA) Xi platform (FireFly) to assist in node identification [18–20]. When using this technology, Indocyanine green (ICG) dye (0.5–5 ml) is injected subcutaneously or intradermally near the previous tumor site or the base of the penis (if penectomy has occurred) prior to start of the surgery.
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.
The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000–2020.
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.
Future Platforms of Robotic Surgery
2022, Urologic Clinics of North America
Citation Excerpt :
The widespread use of this technology has enabled more meticulous partial nephrectomy and pelvic lymph node dissection for prostate cancer.99 Several other innovative uses are microdissection of testicular and vessels for chronic orchialgia100; inguinal lymphadenectomy with a partial penectomy101; prevention of digestive fistulas and ureteral strictures in ileal neobladders102; and exceptional detection of lymph nodes in combination with a gamma probe for prostate cancer.103 Tissue-specific fluorescent-tagged antibodies (fluorophobes) can target specific tumor cells and help surgeons visualize cancer in real time.
Robot-assisted endoscopic inguinal lymphadenectomy: A review of current outcomes
2021, Asian Journal of Urology
Citation Excerpt :
Since the first RAIL described in 2009 and the relative rarity of this disease, small reports have been published suggesting feasibility, acceptable OT, low estimated blood loss (EBL), short LOS, proper amount of lymph nodes retrieved and promising postoperative outcomes, especially regarding few rates of complications [21,22,24–28]. Of note, two from this previously reports described also initial experience with the use of near-infrared fluorescence imaging (NIRF) using indocyanine green (ICG) to facilitate lymph node identification during robotic groin dissection for PSCC [26,28]. Hereafter, results from the three largest series are presented and their weighted means are evaluated.
To review the role of robot-assisted endoscopic inguinal lymphadenectomy (RAIL) in the management of penile cancer.
A PubMed search for all relevant publications regarding RAIL series up until August 2019 was performed using the keyword “robotic”, “inguinal lymph node dissection”, and “penile cancer”. Weighted mean was calculated in the largest series for all outcomes using the number of patients included in each study as the weighting factor.
We identified 23 articles, of note the three largest series that included 102, 27, and 20 RAIL in 51, 14, and 10 patients, respectively. Saphenous vein was spared in 88.93% of RAIL cases in these series and node yield was 11.42 per groin; 35.28% of patients had positive pathological nodes. The weighted mean of operative time was 87.98 min per RAIL and the estimated blood loss was 37.08 mL per patient. The mean length of hospital stay was 1.29 days and the drain was kept in place for 17.02 days; the major complication rate was only 5.31% in these series. The mean follow-up was 33.46 months with a recurrence-free survival of 96.33%.
The literature regarding RAIL describes promising results, although it has shorter follow-up and higher costs when compared to historically series from the open approach. Initials series reported lower cutaneous complications compared to conventional approach, without compromising oncological outcomes. However, long-term results and larger trials are crucial to validate those findings.
Indocyanine Green (ICG) in Urologic Surgery
2019, Urology
Citation Excerpt :
In 2018, Sávio et al also published a demonstrational video in Urology, but showed a combined partial penectomy with robotic inguinal lymphadenectomy using ICG NIRF. This surgery similarly had minimal morbidity and avoided the need for a two-stage procedure.48 Of course, further prospective, randomized controlled studies are needed to show the efficacy of this procedure (Fig. 1; Table 1).
Comprehensive Assessment of Indocyanine Green Usage: One Tracer, Multiple Urological Applications
2018, European Urology Focus
Citation Excerpt :
To specifically visualize the SNs and to prevent contamination of the surgical field during resection, ICG can be bound to a carrier before injection, for example, 99mTechnetium (Tc)-nanocolloid, yielding ICG-99mTc-nanocolloid [5]. Fluorescence guidance has been studied as a tool during the nodal dissection in prostate [5] and penile cancer [6]. In prostate cancer, three different nodal templates of drainage can be distinguished with dominant nodal drainage via the umbilical ligament and internal iliac regions [7].
The intraoperative use of fluorescent tracers and matching cameras can empower urologists’ ability to recognize critical anatomical and functional features. Indocyanine green is the most extensively used near-infrared fluorescent tracer. It has been widely applied due to its ability to illuminate vascular and lymphatic anatomies. A plurality of fluorescence cameras are available allowing the connection of this technology with many surgical approaches, including robotic surgery. Although large comparative validation studies are lacking, numerous studies support the role of fluorescence guidance in urology.
Exploring the Applications of Indocyanine Green in Robot-Assisted Urological Surgery: A Comprehensive Review of Fluorescence-Guided Techniques
2023, Sensors

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: Financial Disclosures: The authors declare that they have no relevant financial interests.

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“Show Me How” VideoCombined Partial Penectomy With Bilateral Robotic Inguinal Lymphadenectomy Using Near-infrared Fluorescence Guidance

Objective

Methods

Results

Conclusion

“Show Me How” Video
Combined Partial Penectomy With Bilateral Robotic Inguinal Lymphadenectomy Using Near-infrared Fluorescence Guidance