Inguinal Lymphadenectomy

Author

Patients

Skin necrosis (%)

Skin infections (%)

Seroma (%)

Lymphocele (%)

Lymphedema (%)

Ravi (1962–1990)

112

–

Ornellas et al.

(1972–1987)

200

–

Ayyappan et al.

–

Lopes et al.

(1953–1985)

145

–

Bevan-Thomas et al. (2003)

–

Bouchot et al.

(1989–2000)

–

Koon et al.

(1994–2003)

129

Pandey et al.

(1987–1998)

128

–

Pompeo

(1984–1997)

–

Spiess et al.

(2008)

–

Ravi et al. in 231 inguinal and 174 ilio-inguinal lymphadenectomies on 234 patients with penile carcinoma described 18% of wound infections, 61% of wound necrosis, seroma in 5%, and lymphedema in 27%. Preoperative radiation to the groin significantly increased the healing complications [2].

Ornellas et al. made an analysis of 200 lymphadenectomies performed in 112 patients from 1972 to 1987 and illustrate 5% flap necrosis, 15% wound infection, 16% lymphedema, and 9% lymphocele [1].

Ten years after, Ayyappan et al. described 78 patients submitted to inguinal lymphadenectomy with 36% skin necrosis, 70% wound infections, 87% of lymphocele, and 57% lymphedema [3].

Bevan-Thomas et al. reported 106 lymphadenectomy procedures in 53 patients with complications (major or minor) in 58% of all cases [4].

Two years after, Nelson et al. reported a retrospective analysis of 40 inguinal lymphadenectomies and demonstrate lymphedema in 4 of 40 cases (10%), minor wound infection in 3(7.5%), and minor wound separation in 3(7.5%); 5 of 40 patients (12.5%) had lymphocele, which spontaneously resolved. Late complications were lymphedema in 2 of 40 patients (5%), flap necrosis in 1(2.5%), and lymphocele in 1(2.5%), requiring percutaneous drainage [5].

Bouchot et al. reported data from 176 lymphadenectomies from 88 patients between 1989 and 2000 with 74 complications including 12% skin necrosis, 7% wound infections, 19% seroma, and 22% lymphedema. He conclude that the procedure morbidity still significant especially in patients with multiple or bilateral inguinal lymph nodes [6].

Pandey et al. analyzed 128 patients underwent groin dissection for penis carcinoma and reported a 5-year survival of 51.5% after the procedure. Although they presented 20% skin necrosis, 17% wound infections, 16% seroma, and 19% lymphedema [7].

Pompeo et al. reported 50 patients that underwent inguinal lymphadenectomy from 1984 to 1997. The complication rates were 6% of skin necrosis, 12% of wound infections, 6% of seroma, and 18% of lymphedema [8].

Koifman et al. performed bilateral inguinal lymphadenectomy in 170 patients with penile cancer (340 procedures). They described 35 complications (10.3%). They noted lymphedema in 14 patients (4.1%), seroma in 4(1.2%), scrotal edema in 3(0.9%), skin edge necrosis in 3(0.9%), lymphocele in 3(0.9%), wound infection in 2(0.6%), flap necrosis in 2(0.6%), wound abscess in 2(0.6%), and deep venous thrombosis in 2(0.6%) [9].

Other authors reported complications as seroma or lymphocele in 0–26%, lymphorrhea in 9–10%, and wound infections or skin necrosis in 0–15% [10–13].

Morbidity Associated to Laparoscopic and Robotic ILND

The idea for development of video endoscopic inguinal lymphadenectomy (VEIL) was to allow a radical removal of inguinal lymph nodes in the same limits of conventional surgery with lower surgical morbidity reduction and similar oncological outcomes.

Tobias-Machado et al. in 2009 reported 20 patients underwent 30 inguinal lymphadenectomies (VEIL) and established 5% of cutaneous event, 10% of lymphatic event, and 15% of morbidity [14]. Three years after, Sudhir et al. illustrate 22 patients with 39 VEIL surgeries from 2007 to 2011 with 1 subcutaneous emphysema, 1 skin flap necrosis, and 4 lymphocele cases. None of the patients developed local recurrence on the period [14].

Sotelo et al. described 8 patients clinical stage T [2] N(0–3)M(0) penile carcinoma who underwent inguinal lymphadenectomy with an median operative time of 91 min(range 50–150). Lymphocele developed in three patients (23%) with no wound related complications [15].

In their initial report of 16 patients, Master et al. reported 25 procedures in 12 months with 147 min average operating time. They notice one patient with seroma and two with wound infection [16].

From 2006 to 2010, Romanelli et al. operated 33 VEIL in 20 patients with penis carcinoma. The average operative time was 119 min and the mean resected lymph node was 8 per lymphadenectomy with an overall complication rate of 33.2%. No skin necrosis was reported. Lymphatic complication rate was 27.2% and 80% survival rate in 20 months follow-up [17].

In 1992, Clavien et al. proposed a surgery complication classification in a review published series of cholecystectomies from 1960 to 1990. That classification should be applicable to most surgical procedures that do not correspond with the ideal course. After its routine use for 12 years, that classification system has been modified. In 2004, with a cohort of 6336 patients undergoing elective surgery between 1988 and 1977 prospectively collected, Clavien et al. proposed a morbidity scale based on the therapeutic consequences of complications [18].

With more accumulated experience Maters et al. publish the first report of endoscopic ILND with immediate and long-term complication using the Clavien scale . Video endoscopic ILND was associated to a total of 11(27%) minor and 6(14.6%) major complications [19].

Carlos et al. [20] and Romanelli et al. [10] reported two cases that have not been described in the literature on VEIL : one case of myocutaneous necrosis [21] and one case of local recurrence with multiple implants [10]. Myocutaneous necrosis and multiple implants occurred isolated, only 1 case in more than 350 procedures performed around the world, this means less than 0.3% of the procedures reported in the literature.

Unfortunately, there is no prospective large study comparing complications of open X endoscopic ILND.

If we consider VEIL results compared to the contemporary open series, we observe at least a half of reduction in overall surgical morbidity (23 × 53%).

The compilation of VEIL series reported a total of 355 limbs with 14.4% of lymphatic complications and 6.9% of cutaneous events (Table 32.2). The open series with more than 100 cases reported a total of 1033 inguinal lymphadenectomies with 30% of cutaneous events and 23% lymphatic complications (Table 32.1).

Table 32.2

Complications associated to VEIL