Preoperative preparation and evaluation

A complete metastatic evaluation should be performed prior to biopsy of the presenting penile lesion or partial penectomy when indicated. The presence of carcinoma of the penis is established with biopsy to determine the diagnosis, extent of invasion, presence of vascular invasion, and grade of the lesion prior to lymphadenectomy. Distant metastatic disease without lymph node involvement is rarely seen. However, distant metastatic spread to bone, brain, liver, and lung should be considered as part of the overall work‐up for penile cancer. Computerized tomography of the pelvis and inguinal region can be helpful in determining the presence of large pelvic and inguinal nodes, especially in the obese patient.

Waist‐high elastic stockings should be fitted and obtained prior to surgery. Preoperative intravenous antibiotics for skin flora coverage are given 60 minutes prior to the skin incision. A sterile prep of the area is performed in the usual fashion.

Operating room configuration and patient position

The operating room (OR) is configured so that all of the staff can view the procedure. The surgeon’s monitor is placed on the contralateral side of the dissection, near the shoulder and arm of the patient. A second monitor is placed on the opposite side in the case of bilateral dissection or as needed for viewing by the entire team (Figure 90.1).

The patient is placed in a supine position, with the ipsilateral knee flexed and hip abducted. The foot on the side of dissection is secured to the contralateral leg in a unilateral dissection or both feet secured together in the case of a bilateral procedure. A pad placed under the bent knee will help maintain the correct position (Figure 90.2).

Trocar placement

Before placing the first trocar, the limits of the dissection are marked on the skin to preserve the orientation once the skin is distorted from the insufflation used to create the working space. A line is drawn from the pubic tubercle to the anterior superior iliac crest. The width of the area of dissection is approximately 11–12 cm and the length 15 cm down the medial thigh and 20 cm down the lateral thigh (Figure 90.3).

Trocar placement is the same for the left and right sides. The trocars are placed just outside the delineated area of dissection. Initially, a 2.5 cm incision is made over the saphenous vein 15 cm below the pubic tubercle. It is important to avoid making the incision any larger than 2.5 cm to prevent CO₂ escape during the procedure once the trocar is inserted and the subcutaneous cavity insufflated. Sharp, fine scissors are used to develop the plane of dissection elevating the skin from the deep membranous fascia and Scarpa’s fascia toward the area of dissection drawn on the skin for as far as the surgeon can see inside the lighted cavity. The laparoscope provides an excellent light source for the initial dissection. A blunt‐tipped trocar is placed in the incision to create an airtight seal. The blunt‐tipped trocar (USSC, Norwalk, CT, USA) is ideal for this procedure since its unique internal balloon and foam collar create an excellent seal and leaves a very small profile inside the area of dissection. This trocar will become the medial working trocar, and since it is 10 mm it can accommodate a retrieval sac to remove lymph node packets during the procedure. If a large nodal packet is placed in the sac and cannot be extracted through the trocar, the balloon on the trocar can be deflated and the packet (secured inside the retrieval bag) can be extracted directly through the incision. In order to prevent seeding the trocar site, fatty and lymphatic tissue specimens should not be extracted directly through the skin incision without being placed inside an extraction sac.

A second 2.5 cm incision is placed outside the area of dissection approximately 16 cm inferior to the middle of the inguinal ligament. Scissors are used to establish the correct plane of dissection toward the first trocar until the two planes of dissection are joined and a second blunt‐tipped trocar is placed. The laparoscope is usually placed through the second trocar during the procedure. The working space is insufflated to a pressure of 5 mmHg.

A pair of endoscopic scissors or ultrasonic or bipolar cautery shears are used to dissect the inferior skin margin toward the edge of the surgical field so that the third trocar can be placed. A 5 mm threaded trocar is placed outside the area of dissection approximately 15 cm below the iliac crest (Figure 90.4).

Procedure

Inguinal lymph nodes are divided into superficial and deep nodes. The superficial nodes are those located anterior to the fascia lata and the deep nodes posterior to the fascia lata. Inguinal lymph nodes dissection is carried out 2 cm above the inguinal ligament superiorly, lateral to the sartorius muscle and medial to the adductor longus. The superficial nodes are located in four quadrants centered around the saphenofemoral junction: (i) nodes in the area of the superficial circumflex iliac vein; (ii) nodes in the area of the superficial epigastric vein and the superficial external pudendal vein; (iii) nodes located in the inferomedial quadrant around the saphenous vein; and (iv) nodes around the insertion of the superficial circumflex iliac vein and the lateral accessory saphenous vein (Figure 90.5).

The deep inguinal lymph nodes include the most cephalad node, known as the node of Cloquet, which is located in the area of the femoral vein and the lacunar ligament (Figure 90.6).

The dissection begins above Scarpa’s fascia anteriorly, removing the tissue located between the skin and the fascia lata. Early in the dissection, the saphenous vein should be identified and preserved. If possible, it is helpful to identify the borders of dissection medially at the adductor longus and laterally at the sartorius muscle edges. In some patients it can be difficult to identify these landmarks without opening the fascia lata, but the margins marked on the skin will help in the dissection of the superficial nodal tissue. Subcutaneous vessels and saphenous branches can be divided using ultrasonic energy or electrocautery. Lymph node‐bearing tissue is dissected from the fascia lata to the fossa ovalis.

As the dissection progresses toward the inguinal ligament, the external ring is identified and the fat and lymphatics in the area of the cord to the base of the penis medially are removed. The lymph node dissection is continued for 3–4 cm superior to the inguinal ligament. Once the nodal tissue and fat are removed from the external oblique and the inguinal ligament, the femoral vessels can be identified inside the femoral sheath.

To gain access to the deep nodes, the fascia lata is opened to the edge of the adductor longus medially and the sartoris muscle laterally. The triangular‐shaped lymph packet within the femoral triangle is carefully removed. Opening the femoral sheath down toward the apex of the triangle will reveal the deep lymph nodes. Medial dissection will free the node of Cloquet. Any residual tissue between the femoral artery and vein is removed. Care is taken to prevent injury to the femoral nerve by limiting the lateral dissection to the femoral artery.

If the skin overlying the exposed vessels seems compromised in any way, the sartorius can be mobilized from the anterior superior iliac crest using ultrasonic or bipolar cautery and transferred over the exposed vessels. Three or four size 2‐0 polydioxanone sutures are used to attach the sartorius muscle to the inguinal ligament.

At the end of the procedure a 7 mm Jackson–Pratt drain is placed inside the cavity to ensure drainage at the most dependent site of dissection. This can be placed through the 5 mm trocar sit or a new site chosen as needed. The two 10 mm trocar sites are closed with skin adhesive or subcuticular sutures. Once the skin adhesive is dry, a circular bandage is placed around the surgical area and held in place with an elastic bandage for 24 hours.