Early Wound Complications After Inguinal Lymphadenectomy in Penile Cancer: A Historical Cohort Study and Risk-factor Analysis

doi:10.1016/j.eururo.2013.02.037

European Urology

Volume 64, Issue 3, September 2013, Pages 486-492

https://doi.org/10.1016/j.eururo.2013.02.037 Get rights and content

Abstract

Background

Complication rates after inguinal lymph node dissection (ILND) are high. Risk factors for early wound complications after ILND in patients with penile carcinoma have not yet been studied.

Objectives

To assess the frequency of early wound complications in a contemporary series and to identify clinical risk factors for early wound complications after ILND for penile carcinoma.

Design, setting, and participants

We evaluated 237 ILNDs in 163 patients with penile cancer treated between 2003 and 2012 at the Netherlands Cancer Institute.

Outcome measurements and statistical analysis

We assessed the occurrence of wound infection, skin-flap problems, and seroma formation and graded complications using the modified Clavien system. Univariable and multivariable penalised mixed effects logistic regression was used to identify clinical risk factors for occurrence of any complication (grade ≥1) and of moderate to severe complications (grade ≥2).

Results and limitations

One complication or more occurred in 58% of the procedures, and 10% of those complications were severe. Wound infection occurred in 43%, seroma formation occurred in 24%, and skin-flap problems occurred in 16%.

Palpable disease was the only factor associated with grade ≥1 complications in the univariable analysis (odds ratio [OR]: 0.43; p = 0.02). In the multivariable model, after penalisation, no statistically significant risk factors remained.

Univariable associations for grade ≥2 complications were present for body mass index (BMI; OR of 1.66 for a 5.8-point change in BMI; p = 0.05) and sartorius muscle transposition (OR: 2.64; p = 0.04). In the reduced multivariable model, the OR for sartorius muscle transposition was 2.12 (p = 0.06) and for BMI was 1.76 (p = 0.03). In addition, bilateral dissection approached significance in the multivariable model (OR: 2.17; p = 0.06). This study is limited by its observational nature.

Conclusions

Wound complication rates after ILND are high in this cohort. BMI, sartorius muscle transposition, and bilateral dissection were the factors most strongly associated with the occurrence of grade ≥2 wound complications.

Introduction

Inguinal lymph node dissection (ILND) is performed in penile cancer patients at high risk for lymph node metastases or in patients with established regional lymph node metastases. ILND can also be performed after a tumour-positive sentinel node procedure or following tumour-positive fine needle aspiration cytology. ILND is carried out simultaneously with the removal of the primary tumour or as an elective procedure. In cases of pelvic lymph node involvement or in patients at high risk for pelvic involvement, simultaneous pelvic lymph node dissection (PLND) is performed.

ILND is associated with a high morbidity rate. Short-term surgical complications include wound infection, seroma formation, skin-flap problems, and wound breakdown. The reported incidence of early postoperative wound complications varies strongly in the current literature but can be as high as 77% [1], [2], [3], [4], [5], [6]. Over a longer period, lymphedema of the leg and/or the genital area may occur in varying degrees [2], [6], [7], [8], [9].

Previous studies in melanoma patients and vulvar cancer patients have tried to identify clinical risk factors for the occurrence of surgical complications after ILND [1], [4], [5], [7], [10]. To our knowledge, such attempts have not yet been made explicitly in patients with penile carcinoma, although complication rates have been compared for prophylactic dissection versus therapeutic and palliative dissection [11] and for radical ILND versus modified ILND [12].

Risk factors for any early surgical complication after ILND, as reported in the surgical literature, in patients with melanoma or vulvar cancer are age [1], [10], diabetes [10] and other comorbidity [1], body mass index (BMI) [1], [7], and drain production [10]. However, the presence of each risk factor is inconsistent and varies among studies [1], [7], [10].

Identification of risk factors for wound complications is clinically relevant. Therefore, we performed a historical cohort study, with two objectives: (1) to assess the frequency of early surgical wound complications after groin dissection for penile carcinoma and (2) to identify patient, tumour, and treatment characteristics as risk factors for the occurrence of early wound complications after ILND.

Section snippets

Data collection

We performed a chart review of all patients with penile cancer and ILND between 2003 and 2012 at the Netherlands Cancer Institute, a high-volume, specialised cancer hospital. Patients for whom the ILND was part of extensive resection that involved reconstructive surgery with myocutaneous flaps were excluded. We collected patient characteristics, tumour type and treatment characteristics, and data on early surgical wound complications, which were defined as complications occurring within 30 d

Complication rates

Between 2003 and 2012, 171 consecutively treated patients were identified who underwent an ILND. Eight patients were excluded due to additional reconstructive surgery. Another 73 patients had a bilateral dissection (45 of which were performed in a single procedure), and 1 patient had three procedures due to recurrence. The total number of ILNDs was 237 ILNDs in 163 patients. Table 1 summarises the patient characteristics.

One wound complication or more occurred in 58% of the procedures, with

Discussion

This study shows that even in a high-volume specialised centre, complication rates of ILND in penile carcinoma patients can be high. Our findings contrast with those of recently published studies in patients with penile cancer [2]. Complication rates in contemporary series (2002–2008) were between 49% and 57% when including lymphedema. Short-term morbidity in these studies was limited, with infection rates between 7.5% and 10% and wound-breakdown and necrosis rates between 2.5% and 11%. One

Conclusions

ILND is associated with a high wound-complication rate in patients with penile carcinoma, even in a high-volume, specialised cancer hospital. In this cohort, BMI, transposition of the sartorius muscle, and bilateral dissection were the factors most strongly associated with the occurrence of moderate to severe wound complications.

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Nodal metastasis is a major survival and prognostic factor in penile cancer (PeCa). Thus, accurate staging, prognosis, and treatment selection require adequate inguinal lymphadenectomy (ILND). ILND surgery should balance oncologic rigor with morbidity and postoperative complications. Our aim was to compare the feasibility and safety of open ILND (OILND) and videoendoscopic ILND (VEILND) in patients with PeCa.
We conducted a single-center randomized trial with a within-patient design between October 2019 and April 2023. Patients who were undergoing either staging or radical ILND for PeCa were included and randomized to receive either OILND or VEILND on one side, with the other technique then used on the contralateral side. The trial was approved by the local ethics committee and was registered on ClinicalTrials.gov (NCT05887921). The primary outcome was the safety of VEILND. Secondary outcomes included intraoperative and postoperative morbidity rates and surgical outcomes for the two procedures, as well as oncological outcomes according to survival estimates.
We included 14 patients in the study. Median follow-up was 12 mo (interquartile range [IQR] 12–17). There were no significant differences in operative time and the number of lymph nodes removed between OILND and VEILND. However, the median time to drain removal was significantly shorter in the VEILND group (15 d, IQR 13–17, 95% confidence interval [CI] 12–17) than in the OILND group (27 d, IQR 20–41, 95% CI 24–31; p = 0.025). No intraoperative complications were observed, but postoperative complications occurred in three cases (21.4%, 95% CI 8.4–37.8%) in the VEILND group and eight (57.1%, 95% CI 18.6–54.3%) in the OILND group (p = 0.032).
VEILND represents a safe technique to consider for either staging or curative intent in PeCa and seems to have an advantage over OILND in terms of morbidity. Further high-powered studies are warranted to confirm these preliminary results.
We compared the outcomes of two different surgical techniques to remove lymph nodes in patients with penile cancer. We found that a video-assisted keyhole surgery approach seems to result in a lower rate of complications than after open surgery.
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Lymph node dissection has been a long-standing diagnostic and therapeutic strategy for metastatic cancers. However, questions over myriad related complications and survival outcomes are continuously debated. Immunotherapy, particularly neoadjuvant immunotherapy, has revolutionized the conventional paradigm of cancer treatment, yet has benefited only a fraction of patients. Emerging evidence has unveiled the role of lymph nodes as pivotal responders to immunotherapy, whose absence may contribute to drastic impairment in treatment efficacy, again posing challenges over excessive lymph node dissection. Hence, centering around this theme, we concentrate on the mechanisms of immune activation in lymph nodes and provide an overview of minimally invasive lymph node metastasis diagnosis, current best practices for activating lymph nodes, and the prognostic outcomes of omitting lymph node dissection. In particular, we discuss the potential for future comprehensive cancer treatment with effective activation of immunotherapy driven by lymph node preservation and highlight the challenges ahead to achieve this goal.
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To assess the clinical effectiveness of treatment options available for the management of inguinal and pelvic lymphadenopathy in men with penile cancer.
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We identified 107 studies, involving 9582 patients from two RCTs, 28 NRCSs, and 77 CSs. The quality of evidence is considered poor. Surgery is the mainstay of LN disease management, with early inguinal LN dissection (ILND) associated with better outcomes. Videoendoscopic ILND may offer comparable survival outcomes to open ILND with lower wound-related morbidity. Ipsilateral pelvic LN dissection (PLND) in N2–3 cases improves overall survival in comparison to no pelvic surgery. Neoadjuvant chemotherapy in N2–3 disease showed a pathological complete response rate of 13% and an objective response rate of 51%. Adjuvant radiotherapy may benefit pN2–3 but not pN1 disease. Adjuvant chemoradiotherapy may provide a small survival benefit in N3 disease. Adjuvant radiotherapy and chemotherapy improve outcomes after PLND for pelvic LN metastases.
Early LND improves survival in nodal disease in penile cancer. Multimodal treatments may provide additional benefit in pN2–3 cases; however, data are limited. Therefore, individualised management of patients with nodal disease should be discussed in a multidisciplinary team setting.
Spread of penile cancer to the lymph nodes is best managed with surgery, which improves survival and has curative potential. Supplementary treatment, including the use of chemotherapy and/or radiotherapy, may further improve survival in advanced disease. Patients with penile cancer with lymph node involvement should be treated by a multidisciplinary team.
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Penile CancerEarly Wound Complications After Inguinal Lymphadenectomy in Penile Cancer: A Historical Cohort Study and Risk-factor Analysis

Abstract

Background

Objectives

Design, setting, and participants

Outcome measurements and statistical analysis

Results and limitations

Conclusions

Introduction

Section snippets

Data collection

Complication rates

Discussion

Conclusions

Eur J Surg Oncol

Gynecol Oncol

Urol Oncol

Surg Oncol

J Am Coll Surg

J Urol

Eur Urol

Urol Clin North Am

J Clin Epidemiol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Urology

Contemporary inguinal lymph node dissection: minimizing complications

World J Urol

Penile Cancer
Early Wound Complications After Inguinal Lymphadenectomy in Penile Cancer: A Historical Cohort Study and Risk-factor Analysis