Pelvic Lymphadenectomy

Pelvic lymphadenectomy can be undertaken simultaneously at the time of inguinal node dissection or as a separate procedure. In the first case, removal of the lymph nodes using one or two incisions has been described; most authors prefer two separate incisions (Fig. 9.11). A comparison of the various types of incisions has shown that the lowest complication rate occurs when two separate incisions are used.12,13 The pelvic node dissection is undertaken either through a lower abdominal midline incision or a unilateral muscle splitting incision. The boundaries of the pelvic node dissection are proximally, the common iliac vessels; distally, the passage of

Fig. 9.10 (a) Large primary tumor with outlined horizontal rectus abdominal flap. (b) After excision and closure of the wound. (c) Anterior view. (d) Ulcerating lymph node metastases, with outlines of two horizontal rectus abdominal flaps and a right tensor fascia lata flap. (e) View from the right side (f) Defect after resection. (g) Wound after closure

Fig. 9.10 (a) Large primary tumor with outlined horizontal rectus abdominal flap. (b) After excision and closure of the wound. (c) Anterior view. (d) Ulcerating lymph node metastases, with outlines of two horizontal rectus abdominal flaps and a right tensor fascia lata flap. (e) View from the right side (f) Defect after resection. (g) Wound after closure

Fig. 9.11 Appearance after bilateral lymphadenectomy and bilateral pelvic lymphadenectomy using separate incisions

Fig. 9.11 Appearance after bilateral lymphadenectomy and bilateral pelvic lymphadenectomy using separate incisions

Penile Cancer ImagesBilateral Pelvic Lymphadenectomy

Fig. 9.12 (a) Boundaries of a pelvic node dissection. Cranial: common iliac artery, caudal: inguinal canal, medial: bladder, prostate, and the medial branches of the internal iliac artery, lateral: ilioinguinal nerve, bottom: obturator fossa. (b) Medial retraction shows clearance of all tissue up the promontorium

Fig. 9.12 (a) Boundaries of a pelvic node dissection. Cranial: common iliac artery, caudal: inguinal canal, medial: bladder, prostate, and the medial branches of the internal iliac artery, lateral: ilioinguinal nerve, bottom: obturator fossa. (b) Medial retraction shows clearance of all tissue up the promontorium

lymphatic vessels to the groin; laterally, the ilio-inguinal nerve; medially, the bladder and prostate; and the base is the deepest part of the obturator fossa (Fig. 9.12). Care must be taken to completely remove the obturator fossa, especially the space behind the external iliac vessels, all the way to the sacrum. A large node can usually

Fig. 9.13 (a) Skin necrosis. (b) Wound infection and dehiscence

be found there and if left is prone to recurrence with intractable pain, because of neural ingrowth. After the dissection suction drains are left in place and removed if the spontaneous drainage is <50 mL. Laparoscopic pelvic node dissection has not had a major role in pelvic node dissection for penile cancer at our institute thus far although it is used in other centers. In view of the therapeutic potential of node dissection (with or without chemotherapy and/or radiotherapy), a complete dissection should be attempted.

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