Clinically Negative Inguinal Lymph Nodes cN0 Disease

This has been the main area of controversy in the management of penile cancer. It is clear that early inguinal lymph node dissection (ILND) is superior to delayed ILND.8 Although the evidence for this is retrospective, a prospective randomized trial is currently neither feasible nor ethical given that surgical cure of patients with metastatic disease is limited to those patients with low volume metastases.3,9 However, traditional ILND is associated with significant morbidity, from both the incision and the disruption of lymphatic channels.10 This has fueled very different strategies. The first is improving patient selection for ILND by performing dynamic sentinel node biopsy (DSNB). This approach is associated with a significantly reduced morbidity. After a decade of evolution in penile cancer, the false negative rate is down to about 7% in a report on 323 patients from the two pioneering centers.11 Of note the authors of the study did not see significant evidence for a learning curve at the second center where recurrence rates were similarly low. This suggested that the modified procedure developed by the Netherland's group was transferable to another center. 1 1 Despite this low rate, the consequences of a false negative study are of a concern as development of nodal disease proved fatal in 4 of the 6 patients who had an initial negative DSNB. i 2 The technique of DSNB is likely to be refined further with the development of alternative dyes or markers, which will hopefully reduce the false negative rate further. A superficial inguinal lymph node dissection with frozen section analysis of the lymph nodes remains an excellent option for the initial management of high-risk patients presenting with clinically negative groins.13

The other strategy of reducing the morbidity of ILND has been addressed by two pioneering groups. These have been termed video endoscopic inguinal lymph-adenectomy (VEIL)14 or the endoscopic lymphadenectomy for penile cancer

(ELPC).15 Both use laparoscopic access approaches and principles to perform an ILND. This reduces the skin incision related morbidity substantially. The lymphatic complications such as prolonged lymph drainage or lymphocoele are similar to open ILND. Further innovations in this field may involve use of fibrin glue or other tissue sealants. There have been no reports on this technique since first described in 1990.16 These biological products are frequently used in other minimal access procedures such as laparoscopic partial nephrectomy as hemostatic agents but their efficacy is unproven for sealing lymph vessels. This is an area for a future penile cancer study whereby novel sealants for lymphatic channels may be investigated. One could certainly also envisage a future randomized trial between DSNB and VEIL/ELPC in determining efficacy as a staging procedure, complications, and quality of life among clinically node negative high-risk patients.

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