Great Saphenous Vein Sparing Robot-Assisted Video Endoscopic Inguinal Lymphadenectomy for Carcinoma of Penis: Video Demonstration

Introduction: Inguinal lymph node dissection in carcinoma of the penis is associated with significant wound complications such as flap necrosis, infection, and lower limb edema. Video endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive technique with a similar template of dissection as open surgery, but with reduced wound-related morbidity and equal oncologic outcomes. Robotic approach for VEIL (RVEIL) has additional advantages of ergonomics, three-dimensional enhanced vision, and flexible instrumentation. We report our experience and technique of great saphenous vein sparing (SVS)-RVEIL, highlighting its advantages. Materials and Methods: From June 2012 to January 2019, 34 patients who underwent RVEIL at our institute were analyzed. Seven patients (five bilateral and two unilateral) underwent a SVS procedure, accounting for 12 groins (group 2). In the other 27 patients (53 groins), saphenous vein was sacrificed (group 1). All patients underwent either partial or total penectomy for the primary disease. SVS was done in clinically nonpalpable groins (cN0). We analyzed patients and tumor-related characteristics, compared limb edema, and compared oncologic outcomes between the two groups. Surgical Steps: These include creating working space above fascia lata by finger dissection, placing the ports distal to apex of the femoral triangle, opening fascia lata, and dissection of tissue around the femoral artery and vein. This is followed by identification and dissection around the saphenofemoral junction. Ligating three named tributaries and dissection of the entire length of great saphenous vein (GSV) were done. Finally, all the lymphofatty tissue is dissected off from the skin flap. Results: The median follow-up of the entire group was 34.5 months (interquartile range, 20.7–55.5), and the mean age of the patients was 57.3 years (range, 43–73 years). There was no difference in mean operative time between two groups [110 minutes (range, 70–180) for group 1 and 100 minutes (range, 70–170) for group 2 (p = 0.0245)]. The mean number of lymph nodes dissected in each groin was 10.52 ± 1.45 in group 1 and 11.11 ± 1.96 in group 2 (p = 0.0245). Blood loss was 50 mL in both groups (range 30–100 mL). None of the patients had flap necrosis. Six patients (19.4%) in group 1 developed mild-to-moderate edema of the leg in the postoperative period, and none in group 2. Final histopathology report showed 12 groins (22.64%) had pN+ disease in group 1, and 3 groins (25%) in group 2 (p = 0.890). During follow-up, one patient developed nodal recurrence that had pN+ disease in group 1, and none in group 2. The median overall survival was 62 months in group 1 and 56 months in group 2 (p = 0.356). Conclusions: SVS-RVEIL is a safe and technically feasible option in managing cN0 inguinal lymph nodes in carcinoma penis, with a lesser incidence of postoperative limb edema while maintaining oncologic principles. Moreover, it facilitates good lower limb drainage and does not increase the chances of local recurrences. However, we need further studies with more number of patients to identify the role of sparing GSV and its benefits. Patient Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. No competing financial interests exists. Runtime of video: 8 mins 16 secs