Short-Term Surgical Outcomes of Standard and Lateral Video Endoscopic Inguinal Lymphadenectomy: A Multinational Retrospective Study

Abstract

Background:

Video endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive technique that gives superior surgical outcomes than open inguinal lymphadenectomy (IL) for treating lymph node metastasis in penile, vulvar, and skin cancers. This study compared surgical outcomes obtained with two different approaches of VEIL, standard VEIL and lateral VEIL (L-VEIL), in cancer patients.

Methods:

Sixty-two patients who underwent standard VEIL (n = 15) or L-VEIL (n = 47) for treatment of lymph node metastasis were evaluated retrospectively from three centers in Brazil, Egypt, and India. Primary endpoint analyzed was conversion rate to open IL in the two groups, and the secondary endpoints included operative time, estimated blood loss, nodal yield, nodal positivity, postoperative drain duration, and postoperative complications.

Results:

The conversion rate to open IL was higher in L-VEIL compared with VEIL group (2% vs. 0%). Significantly lesser blood loss was reported with L-VEIL compared with VEIL (mean difference: 3.63 mL; P = .01). Postoperative drain duration was significantly lower with L-VEIL (−4.34 days; P < .05) than VEIL. The L-VEIL group had a higher number of lymph nodes without infiltration (mean difference: −0.48; P = .02). Operative time, nodal yield, nodal positivity, and hospitalization duration were similar in both groups. Postoperative complications were higher in the L-VEIL versus VEIL group (35 vs. 11 cases). Lymphedema events were significantly higher with L-VEIL in comparison with VEIL (38.8% vs. 16.7%; P = .03). Among patients with penile cancer, no significant difference was observed in outcomes obtained with VEIL and L-VEIL.

Conclusion:

As L-VEIL and VEIL approaches lead to comparable surgical outcomes, surgeons may choose either of these as per their convenience.

Introduction

Penile cancer is a rare disease with incidence less than 1/100,000 men worldwide.¹ More than 95% of the penile cancers result from epithelial squamous cell carcinoma (SCC) and generally occurs in 50–70-year aged men.^1–3 Vulvar carcinoma is also an uncommon cancer and occurs in both young and older women.^4,5 In case of melanoma, the mortality and prevalence present a paradox. While there is a decrease in disease mortality, the prevalence and incidence of melanoma are on the rise compared with other types of cancer.⁶ Lymph node metastasis is a major concern in penile,⁷ vulvar,⁸ and skin cancers⁹ as it affects the treatment response, as well as survival in these patients.¹⁰ Hence, it is imperative to detect and treat lymph node metastasis at early stages electively or therapeutically.^11,12

Inguinal lymphadenectomy (IL) has been the standard of care for patients with tumors originating from the trunk, pelvis, and lower limb, and is used for staging and treatment of inguinal lymph node metastasis, including melanoma and genitourinary neoplasms (vulvar and penile cancers).^13–16 Previous studies reported significantly improved survival of patients following IL surgery.¹⁷ However, conventional open IL is associated with significant morbidity and postoperative complications such as wound infections and breakdowns, seroma formations, and skin flap problems,^18–20 and thus, adversely affects patients' quality of life.²¹ Hence, several minimally invasive modifications of the IL have been attempted by researchers to improve surgical outcomes of IL.^20,22,23

Video endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive, three-port approach that has evolved as the preferred method for the treatment of inguinal lymph node metastasis.¹³ Tobias-Machado et al. were the first to report the technique of VEIL for penile cancer, which enabled complete resection of inguinal lymph nodes without causing skin complications.²⁴ Furthermore, Xu et al. used VEIL for vulvar cancer, in which it reduced wound-related complications and prevented recurrence after 13 months of follow-up.²⁵ In comparison with open IL, VEIL requires smaller incisions, has a higher stage-I healing rate, and provides better cosmetic effect.²⁶ Generally, the endoscope and surgical equipment are placed into the inguinal region through the umbilicus and the lower abdomen, downward, or through the midthigh, upward, following which, the fat tissues containing lymph nodes are removed.²⁴ Wu et al. explored a 3-incision lateral approach VEIL for vulvar cancer, and reported satisfactory oncologic and cosmetic outcome.²⁷ Recently, Nayak et al. reported that lateral VEIL (L-VEIL) can provide better surgical outcomes, including nodal yield, compared with open IL.²⁸

However, till date, there is no study comparing surgical outcomes of standard or classical VEIL approach with those obtained with L-VEIL. Hence, this study aimed to compare short-term outcomes of VEIL and L-VEIL.

Methods

Patients and settings

This retrospective cohort study evaluated surgical data collected from 62 cancer patients who were operated with VEIL or L-VEIL at three centers in Brazil, Egypt, and India (one center from each country) from 2013 to 2017. Patients were divided into two groups: the VEIL group comprised patients with penile SCC who underwent standard bilateral VEIL (n = 15, 30 limbs), and the L-VEIL group comprised penile SCC, melanoma, vulvar SCC, or cutaneous SCC patients, who underwent modified L-VEIL (n = 47, 60 limbs). Patients were followed-up for 26.73 months.

The study was exempted from informed patient consent as identifiable patient information was not used for the study and patients were not contacted for the purpose of the study. The study was approved by institutional review boards of the participating centers, and was conducted in accordance with the national guidelines and the Declaration of Helsinki.

Study outcomes and endpoints

Surgical efficacy outcome was analyzed with multiple endpoints with conversion rate of the minimally invasive procedure to open surgery as the primary endpoint. Other efficacy endpoints such as nodal yield, number of positive nodes, hospitalization period, and postoperative drain duration were the secondary efficacy endpoints. Safety outcomes with mean blood loss and complications (lymphocele, wound infection, flap necrosis, lymphedema, inguinal recurrence, distant metastasis) based on Clavien–Dindo classification grade 1 to 5 were the other secondary endpoints.

Statistical analyses

All the statistical analyses were performed using SPSS software (version 22). Descriptive statistics summarized continuous variables. Categorical variables were compared using chi-squared and Fisher-exact test, whereas continuous variables were compared by t-test and Mann–Whitney tests. For postoperative complications, risk ratios (RR) were calculated. P < .05 was considered statistically significant. Subgroup analysis compared the outcomes of the two techniques in patients with penile cancer.

Results

Baseline characteristics of the patients

A total of 62 patients were included in the study, of which 15 patients with penile cancer underwent VEIL (mean age ± standard deviation [SD]: 51.86 ± 5.54), while 47 patients with penile, vulvar cancer, and melanoma underwent L-VEIL (mean age ± SD: 54.48 ± 12.55). A total of 22 male patients and 25 females underwent L-VEIL (Table 1). Patients who underwent L-VEIL had significantly higher body mass index (BMI) than the other group (mean difference: 5.95 and P = .003).

Table 1.

Baseline Data and Demographics

Variables	VEIL approach	L-VEIL approach
Number of patients, n	15	47
Total number of ILs	30	60
Male, n (%)	15 (100)	22 (47)
Female, n (%)	0	25 (53)
Age (years), mean ± SD	51.86 ± 5.54	54.48 ± 12.55
BMI (kg/m²), mean ± SD	25.43 ± 3.92	30.5 ± 8.73
Type of cancer, number of ILs (%)
Penile cancer (SCC)	30 limbs (100)	15 limbs (25)
Vulvar cancer (SCC)	—	18 limbs (30)
Melanoma	—	16 limbs (27)
Cutaneous SCC	—	5 limbs (8)
Others	—	6 limbs (10)

BMI, body mass index; L-VEIL, lateral VEIL; SCC, squamous cell carcinoma; SD, standard deviation; VEIL, video endoscopic inguinal lymphadenectomy.

Surgical efficacy endpoints

The conversion rate (to open IL) was nonsignificantly lower in VEIL group than that in L-VEIL group (0% vs. 2%; P = .54) (Table 2). Mean blood loss was significantly higher in VEIL group compared with L-VEIL group (mean difference: 3.63 mL; P = .01) (Table 2). A significantly higher number of lymph nodes without infiltration were observed in L-VEIL group compared with VEIL group (mean difference: −0.48; P = .02) (Table 2). Operative time was higher in VEIL group in comparison with L-VEIL group, however, the difference was not significant (mean difference: 6.83 minutes; P = .32) (Table 2). Furthermore, postoperative drain duration was significantly lower in VEIL compared with L-VEIL (P = .05) (Table 2).

Table 2.

Surgical Outcomes Based on the Technique Used

Parameters	VEIL	L-VEIL	Mean difference	P
Operative time (minutes), mean ± SD	128 ± 28.48	121.16 ± 31.28	6.83	.32
EBL (mL), mean (range)	20 (15–35)	20 (15–30)	3.63	.01
Nodal yield, n ± SD	10.73 ± 3.60	10.56 ± 3.99	0.17	.85
No lymph node infiltrated, mean (range)	0 (0–2)	0 (0–12)	−0.48	.02
Nodal positivity, n (%)	6 (20)	16 (26.7)	0.07	.49
Hospitalization duration (days), mean (range)	3 (3–14)	3 (2–7)	0.58	.09
Postoperative drain duration (days), mean (range)	3 (3–21)	7 (3–21)	−4.34	.05

EBL, estimated blood loss; L-VEIL, lateral VEIL; SD, standard deviation; VEIL, video endoscopic inguinal lymphadenectomy.

Postoperative complications

Postoperative complications were higher in L-VEIL group than in the VEIL group (35 vs. 11 cases) (Table 3). Significantly higher events of lymphedema were observed in the L-VEIL group (38.3% vs. 16.7%; RR: 0.43; P = .03). No CLAVIEN 3B, 4, or 5 grade complications were observed in both the groups. Recurrence occurred more frequently in the L-VEIL group (16.7%) compared to standard VEIL (10%).

Table 3.

Postoperative Complications

Variables	VEIL, n (%)	L-VEIL, n (%)	Risk ratio	P
Lymphocele	3 (10)	9 (15)	0.67	.74
Wound infection	2 (6.7)	1(1.7)	4	.26
Flap necrosis	1 (3.3)	2 (3.3)	1	1
Lymphedema	5 (16.7)	23 (38.3)	0.43	.03
Inguinal recurrence	1 (3.3)	3 (5)	0.67	1
Distant metastasis	2 (6.7)	7 (11.7)	0.57	.71
CLAVIEN 1	2 (6.7)	1 (1.7)	4	.32
CLAVIEN 2	1 (3.3)	2 (3.3)	1	.74
CLAVIEN 3a	3 (10)	9(15)	0.67	.26

There were no CLAVIEN 3b, 4, or 5 grade complications.

L-VEIL, lateral VEIL; VEIL, video endoscopic inguinal lymphadenectomy.

Subgroup analysis

For the subgroup of patients with penile cancer, the surgical outcomes were similar between VEIL and L-VEIL groups (Table 4). Mean operative time was higher in the VEIL group than that in the L-VEIL group, while patients who underwent VEIL also had a higher risk for postoperative complications than L-VEIL, although the differences were not statistically significant (Table 5).

Table 4.

Surgical Outcomes in the Subgroup of Penile Cancer Patients

Variables	Mean difference (VEIL vs. L-VEIL)	P
Blood loss (mL)	1.12	.38
Operative time (minutes)	3.33	.74
Hospital stay (days)	0.47	.23
Drain duration (days)	−0.13	.91
Nodal yield	−0.60	.60

L-VEIL, lateral VEIL; VEIL, video endoscopic inguinal lymphadenectomy.

Table 5.

Postoperative Complications in Penile Cancer Subgroup

Variables	VEIL, n (%)	L-VEIL, n (%)	Risk ratio	P
Lymphocele	3 (10)	1 (6.6)	1.42	.45
Wound infection	2 (6.7)	0 (0)	15	.06
Flap necrosis	1 (3.3)	1 (6.6)	0.43	.2
Lymphedema	5 (16.7)	4 (26)	0.65	.1
Inguinal recurrence	1 (3.3)	0 (0)	7	.19
Distant metastasis	2 (6.7)	0 (0)	5	.29
Positive nodes	6 (20)	3 (20)	1	1
CLAVIEN 1	2 (6.7)	0 (0)	5	.29
CLAVIEN 2	1 (3.3)	1 (6.6)	0.43	.2
CLAVIEN 3a	3 (10)	1 (6.6)	1.42	.44

L-VEIL, lateral VEIL; VEIL, video endoscopic inguinal lymphadenectomy.

Discussion

To the best of our knowledge, this is the first study that compared surgical outcomes of standard or classical VEIL with L-VEIL considering both surgical efficacy and safety outcomes in genital cancer patients. The results showed that L-VEIL produces similar short-term outcomes as standard VEIL. In addition, patients who underwent L-VEIL reported increased risk for postoperative complications than those who underwent VEIL. Due to the rare nature of genital cancers in the general population, the number of patients in the study groups was small, which could be attributed as the reason for the lack of statistical significance in some of the analyzed endpoints.

The two approaches, that is, VEIL and L-VEIL, are similar in technical aspects. In the standard VEIL, the patient is kept in supine position with thigh abduction, and the camera port is placed alongside the long axis of thigh,^24,28 and hence, the camera movement is limited.²⁸ As surgeons are positioned ergonomically lateral to the leg of patient,²⁴ they need to extend the hand above the thigh to use the contralaterally placed instrument.²⁸ Wu et al. reported first use of L-VEIL for vulvar cancer.²⁷ The operator can perform surgery easily by positioning at the lateral side of the region of surgery, as all ports are positioned lateral to the thigh.²⁷ The increased convenience could have been the reason for shorter operative time required with L-VEIL in the current study, although the difference between the groups was not significant. The operative time recorded in this study for VEIL as well as L-VEIL was lower than that reported by Dhangar et al. (200–240 minutes), who used standard VEIL for penile cancer.²⁹

The procedure for none of the patients in the VEIL group was changed to open IL, whereas it was changed to open IL for 1 patient in the L-VEIL group due to bleeding that occurred after accidental injury to an accessory saphenous vein. The bleeding was difficult to control endoscopically. However, in the study by Sudhir et al., none of the patients receiving VEIL needed conversion to open surgery.²⁶ The conversion to open procedure due to accidental injury to the adjoining structures depends on the skill level of the treating surgeon. However, the apparent comfort in performing L-VEIL from the surgeon's perspective might reduce such complications. Furthermore, in the present study, patients in L-VEIL group had significantly higher BMI in comparison with those in VEIL group. It is reported that BMI >30 kg/m² increases the risk for conversion to open surgery in patients undergoing laparoscopic colectomy.³⁰ Bhama et al. suggested that patients with BMI >30 kg/m² should be counseled regarding the possible increased odds of requiring an open surgery.³⁰ Longer hospital stays, lower nodal yield, more positive surgical margins, and higher readmission rates are other factors associated with conversion to open surgery in patients undergoing laparoscopic surgery.³¹

Previous studies have shown that nodal yield with standard VEIL approach is similar to that of open IL.^32–34 Nayak et al. reported significantly better nodal yield (P = .001) and nodal positivity (P < .001) with L-VEIL in comparison with open IL.²⁸ In the current study, the nodal yield in both groups was comparable, indicating that L-VEIL is as technically efficient as VEIL for lymph node resection.

Furthermore, postoperative drain duration was significantly higher in the L-VEIL group (mean difference from VEIL group: 4.34; P = .05). We also noted that there was a significantly higher incidence of lymphedema, and greater incidence of lymphocele in the L-VEIL group compared with the VEIL group. They may arise due to insufficient closure of afferent lymphatic vessels.³⁵ It is a common complication of lymphadenectomy with a reported incidence of 2%–9% after pelvic lymphodenectomy.³⁶ The treatment options for lymphocele include puncture and/or drainage, sclerotherapy, or surgical interventions.³⁵ More studies are needed to understand if the difference is significant.

Previously, Sudhir et al. have also reported occurrence of lymphocele following VEIL,²⁶ whereas Wang et al. had observed 15.8%, 0%, 5.3%, and 5.3% incidence of lymphedema, lymphocele, wound infection, and skin necrosis, respectively.³⁷ In the current study, incidence of complications was similar in both the approaches in penile cancer (Tables 4 and 5). Hence, we believe that a higher incidence of complications in the L-VEIL group was related to the melanoma patients in this group. For melanoma, a greater extent of lymph node dissection is required due to a wider affected area in comparison with that in penile cancer cases. This might be the reason why higher events of complications such as lymphedema and lymphocele were observed with L-VEIL in comparison with VEIL, which could not be attributed to L-VEIL technique. However the incidence was lower than that reported with open IL.²⁸

The lateral approach is considered to have better ergonomics; however, more studies comparing L-VEIL with VEIL are warranted to ascertain this. Overall, the findings of this study suggest that both the approaches produce similar short-term outcomes. Hence, the choice of technique may be decided based on the expertise and comfort of the operating surgeon. Although VEIL and L-VEIL can lead to better outcomes than open IL, they are technically demanding and require a considerable level of training and expertise to be carried out.²⁸

This study had few limitations. First, as this was a retrospective study, there could be a bias in patient selection. Second, the follow-up duration was short. A longer follow-up study could provide a clearer picture of the efficacy of the two studied versions of VEIL. Third, the number of patients included in the study was limited. Fourth, all the patients in VEIL group had penile cancer, whereas those in L-VEIL group had different forms of cancer, including penile cancer, vulvar cancer, and melanoma. This might have affected the surgical outcomes observed in the two comparison groups as evident from the results of subgroup analysis.

Conclusions

The surgical outcomes of VEIL and L-VEIL were similar in the cohort included in this study. Although L-VEIL provides better ergonomics, further studies are required to evaluate its relative efficacy and safety. Based on the current evidence, either of these approaches can be used for minimally invasive lymphadenectomy depending on the convenience of the operating surgeon.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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