Open Access

Video endoscopic-assisted inguino-femoral lymphadenectomy (VEIL) in squamous cell invasive vulvar carcinoma: our initial experience

Gynecological SurgeryEndoscopic Imaging and Allied Techniques20119:704

https://doi.org/10.1007/s10397-011-0704-6

Received: 7 July 2011

Accepted: 16 September 2011

Published: 14 October 2011

Abstract

Inguinal lymphadenectomy is a part of the surgical treatment of invasive perineal cancers and lower extremities and inferior trunk melanomas. Inguinal node metastasis represents a major prognostic factor; therefore, inguinal lymphadenectomy has a central role in oncological patient management. Nevertheless, inguinal node dissection is associated with significant morbidity such as lymphedema, wound dehiscence, flap necrosis, infection, seroma, femoral hernia, and deep venous thromboembolism. Recently, several publications have reported experiences with video endoscopic-assisted techniques attempting to reduce the high morbidity related to open inguinal lymphadenectomy. The primary results are promising in terms of feasibility, oncological survey and goals, postoperative complications, and esthetic results. We discuss here our initial experience with video endoscopic inguino-femoral lymphadenectomy (VEIL) in a patient with invasive vulvar carcinoma. To our knowledge, this is the first report of a bilateral VEIL in vulvar carcinoma.

Keywords

Invasive vulvar carcinomaInguinal lymph node dissectionInguinal lymphadenectomyVideo-assisted surgeryVideo-assisted inguino-femoral lymphadenectomy (VEIL)Minimal invasive surgery

Background

Vulvar carcinomas represent the fourth most common gynecological malignancy, accounting for 4% of all female genital tract cancers [1]. Inguinal nodal metastasis is the essential independent prognostic factor. Predictors of metastasis in inguinal lymph nodes are: histological grade, extent of tumor stromal invasion, capillary-like space involvement with the tumor, clinically suspect regional nodes, and clitoral or perineal location. In pT1 vulvar tumors, the survival rate is reduced from 90% to 55% in cases of nodal metastasis [1]; therefore, the lymphadenectomy has a major role in surgical management with prognostic and potentially therapeutic implications [2, 3]. Traditional single extended incision for bilateral inguinal node dissection and radical vulvectomy has a reported morbidity of up to 76% [4, 5] including infections, flap necrosis, wound dehiscence, chronic lymphedema, lymphocyst formation, femoral hernia, and deep venous thromboembolism [49]. The mortality related to classical lymphadenectomy is as much as 3%.

In response to this morbidity, several less invasive surgical techniques were developed: separate incisions for inguinal lymphadenectomy, unilateral inguinal node dissection for lateralized lesions, saphenous vein preservation [9], and sartorius muscle transposition. Superficial lymphadenectomy was also proposed as a less invasive alternative to complete inguinal node dissection in order to diminish local complications. This procedure excludes the inguinal deep nodes located beneath the cribriform fascia and medial to femoral vein (including the Cloquet node). However, excessive nodal recurrences were reported in the literature [10, 11] with this technique.

One of the most interesting approaches to reduce the morbidity of extensive inguinal lymphadenectomy in vulvar cancer is the sentinel lymph node biopsy. This minimally invasive procedure allows selective ablation of the first draining tumor node, thereby permitting a less aggressive inguinal surgery. Published results are promising [1215]. In 2008, the GROINSS-V study concluded that the sentinel lymph node procedure in early stage unifocal vulvar cancer reduces morbidity without increasing groin recurrence or compromising overall survival.

The newest minimal invasive procedure—video endoscopic inguino-femoral lymphadenectomy (VEIL)—was developed by Bishoff [16], an oncological urologist who demonstrated its feasibility by dissecting two cadaveric models in 2003. In 2006, Tobias-Machado et al. [17] published an initial case report of video endoscopic inguinal lymphadenectomy compared with a controlateral open radical procedure. VEIL continues to evolve: single site and robotic variants were recently presented [1820].

Material and method

A 55-year-old postmenopausal female presented with an exophytic and ulcerated mass in both the minor labia and clitoris. A preoperative biopsy suspected a VIN III lesion. The superficial anterior vulvectomy established the diagnosis of invasive vulvar carcinoma, pathological stage pT1b with no carcinomatous lymphangitis. A CT scan infirmed pelvic and inguinal nodes involvement. Video-assisted inguino-femoral lymphadenectomy was scheduled 5 weeks after the vulvectomy.

Preoperative vascular Doppler ultrasound mapping was performed to identify the internal saphenous vein, its accessory vein, and the femoral vessels projection on the femoral triangle. The landmarks of the femoral triangle, the course of femoral vessels, and the saphenous veins were traced with indelible ink before prepping and draping (Fig. 1). This allows the correct placement of trocars outside the perimeter of the femoral triangle and permits the constant survey of the extent of subcutaneous dissection by transillumination during the endoscopic procedure.
Fig. 1

The landmarks of the femoral triangle, the course of the femoral vessels and saphenous veins traced with indelible ink before prepping and draping

The patient was placed in a supine position on a regular table with split movable footrests, which allowed abduction and external rotation of the thighs. The surgeon was positioned between the legs of the patient and the assistant was positioned lateral to the operated groin. The monitor was opposite the patient's shoulder. A Foley catheter was placed in the bladder.

A 15-mm incision was made 2 cm below the vertex of the femoral triangle. After the incision of Camper's fascia, scissors and digital blunt dissection were used to develop a space beneath it. The second and the third 10-mm incisions were placed at 6 cm external and 6 cm internal to the vertex of the femoral triangle. Three 10-mm Hasson trocars were placed in these incisions and fixed to the skin with nonresorbable sutures. A zero-degree laparoscope was inserted through the first trocar. CO2 insufflation pressure was started at 15 mmHg for 15 min to help the dissection and was subsequently reduced to 5 mmHg during the rest of the procedure.

The retrograde dissection beneath the Camper fascia was continued until clear identification of the inguinal ligament (Fig. 2). Selective electrocoagulations or clip ligations were necessary before division of several saphenous veins and femoral artery branches. Early identification of the internal saphenous vein is needed for a precise and bloodless technique.
Fig. 2

Retrograde dissection with development of anterior space beneath the Camper fascia. A and B saphenous veins and their respective accessories; C sartorius muscle; D adductor longus muscle; E inguinal ligament

The distal lymphatic tissue and saphenous veins were divided at the vertex of the femoral triangle with the Endo GIA Roticulator™ 45-2.5-mm endovascular stapler and a harmonic scalpel. The lymphatic tissue was lifted from the fascia lata by a combination of blunt and sharp dissection up to the fossa ovalis. The femoral sheet was carefully dissected and opened at the inferior limit of the fossa ovalis. The femoral vessels and the saphenofemoral junction were identified and skeletonized up to the femoral channel. The same Endo GIA endovascular stapler was used to transect the saphenous arch. Inguinal lymphadenectomy was continued medially to the femoral vein to harvest the deep inguinal nodes up to the Cloquet node. At the level of the inguinal ligament, the lymphatic tissue was divided with the harmonic scalpel and completely liberated. The nodal tissue was removed through the lateral 10-mm incision using an endobag. A suction drainage was placed and exteriorized at the lateral port incision.

Findings

The total operative time for the bilateral inguinal lymphadenectomy was 260 min. The estimated blood loss was less than 50 ml on each side. No subcutaneous CO2 emphysema was observed beyond the upper thighs. Prophylactic 1.5 g intravenous cefuroxime was administered at the anesthetic induction and a second equivalent dose after 180 min. An adapted compression stocking was applied immediately post-intervention. Postoperative pain control was achieved with oral nonsteroidal anti-inflammatory drugs. Early ambulation was encouraged. The inguinal drainage was maintained until the 24-h output was less than 50 ml (seventh postoperative day for both sides). On the right side, acute lymphangitis occurred on the fifth postoperative day and successfully managed by oral antibiotics for 1 week (Fig. 3). The definitive pathological stage was pT1bN0M0 (eight negative nodes on each side).
Fig. 3

Postoperative aspect on the fifth day after surgery

An external vulvar radiation therapy and a close clinical follow-up were recommended to the patient. The patient was satisfied with both the functional and esthetic results 4 months after the procedure.

Conclusion

The video-assisted approach follows the same main steps as those for the open technique but in a reverse manner as lymphadenectomy is started caudally and continued up to the saphenous arch and the inguinal ligament. Inguinal lymphadenectomy is a challenging surgical procedure with a high complication rate even for skilled surgeons and in the most recent series [9, 21, 22]. This can be related to the devascularization of skin flaps, the disruption of lymphatic afferents, concomitant medical conditions that predispose to poor wound healing, and simultaneous septic operative steps as ablation of a potential necrotic and infected primary tumor. Since the first description of an endoscopic approach by Bishoff in 2003 [16], Tobias-Machado et al. have published a consistent comparison with the open procedure on the same patient [17, 2326] demonstrating a significant reduced morbidity for the video-assisted approach (70% versus 20%) [2325]. Other published series have consistently reported fewer skin postoperative events and lymphatic morbidity [2729].

VEIL appears attractive in current oncological practice. The number of lymph nodes harvested is comparable with open inguinal lymphadenectomy [18, 23, 26, 29, 30] and with the advantage of less subcutaneous flap injuries and attendant complications, shorter hospitalization, and early patient ambulation and recovery [17, 2326, 2931]. Our operating time was significantly longer compared to classical surgery, but we believe that standardized surgical procedures, improvements of endoscopic instrumentation, and a dedicated trained surgical team could considerably improve this aspect. Reports indicate that operating time significantly decrease with the learning curve [32]. Our feeling is that the learning curve is not steep for a trained oncologist surgeon with experience in laparoscopic techniques as the main principles of endoscopic surgery apply. In addition there are the advantages of enhanced visualization of anatomical structures and optical magnification.

In 2009, Master et al. developed a modified endoscopic approach permitting completion of a lymphadenectomy even for large or adherent inguinal adenopathy, in cases of previous groin surgery and for obese patients expanding the indications for this minimally invasive technique. Thus, VEIL has the potential to replace open inguinal surgery for a large panel of patients. The middle-term outcome of the initial series seems to fulfill the oncological objectives [25], but extended follow-up is needed for more definitive conclusions and a better patient selection. To our knowledge, this is the first report of a video endoscopic bilateral inguinal lymphadenectomy in a patient with low genital tract malignancy.

Declarations

Acknowledgments

Many thanks go to M.E. Visher for her essential and gracious support in revising the manuscript's English.

Conflicts of interests

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Authors’ Affiliations

(1)
Obstetrics and Gynecology, CHCV Sion Hospital

References

  1. Jemal A et al (2010) Cancer statistics. CA Cancer J Clin 60(5):277–300PubMedView ArticleGoogle Scholar
  2. Courtney-Brooks M et al (2010) Does the number of nodes removed impact survival in vulvar cancer patients with node-negative disease? Gynecol Oncol 117(2):308–311PubMedView ArticleGoogle Scholar
  3. Butler JS et al (2010) Isolated groin recurrence in vulval squamous cell cancer (VSCC). The importance of node count. Eur J Gynaecol Oncol 31(5):510–513PubMedGoogle Scholar
  4. Nelson BA et al (2004) Complications of inguinal and pelvic lymphadenectomy for squamous cell carcinoma of the penis: a contemporary series. J Urol 172(2):494–497PubMedView ArticleGoogle Scholar
  5. Gaarenstroom KN et al (2003) Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 13(4):522–527PubMedView ArticleGoogle Scholar
  6. Han LY et al (2004) A gelatin matrix-thrombin tissue sealant (FloSeal) application in the management of groin breakdown after inguinal lymphadenectomy for vulvar cancer. Int J Gynecol Cancer 14(4):621–624PubMedView ArticleGoogle Scholar
  7. Magrina JF et al (1997) Femoral hernia: a complication of laparoscopic pelvic lymphadenectomy after groin node dissection. J Laparoendosc Adv Surg Tech A 7(3):191–193PubMedView ArticleGoogle Scholar
  8. Senn B et al (2010) Period prevalence and risk factors for postoperative short-term wound complications in vulvar cancer: a cross-sectional study. Int J Gynecol Cancer 20(4):646–654PubMedView ArticleGoogle Scholar
  9. Zhang SH et al (2000) Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer 89(7):1520–1525PubMedView ArticleGoogle Scholar
  10. Iyibozkurt AC et al (2010) Groin recurrence following stage IA squamous cell carcinoma of the vulva with negative nodes on superficial inguinal lymphadenectomy. Eur J Gynaecol Oncol 31(3):354–356PubMedGoogle Scholar
  11. Gordinier ME et al (2003) Groin recurrence in patients with vulvar cancer with negative nodes on superficial inguinal lymphadenectomy. Gynecol Oncol 90(3):625–628PubMedView ArticleGoogle Scholar
  12. Radziszewski J et al (2010) The accuracy of the sentinel lymph node concept in early stage squamous cell vulvar carcinoma. Gynecol Oncol 116(3):473–477PubMedView ArticleGoogle Scholar
  13. Cabanas RM (2000) The concept of the sentinel lymph node. Recent Results Cancer Res 157:109–120PubMedView ArticleGoogle Scholar
  14. Levenback CF et al (2009) Sentinel lymph node biopsy in patients with gynecologic cancers Expert panel statement from the International Sentinel Node Society Meeting, February 21, 2008. Gynecol Oncol 114(2):151–156PubMedView ArticleGoogle Scholar
  15. Van der Zee AG et al (2008) Sentinel node dissection is safe in the treatment of early stage vulvar cancer. J Clin Oncol 26(6):884–889PubMedView ArticleGoogle Scholar
  16. Bishoff JA, Lackland A, Basler JW et al (2003) Endoscopic subcutaneous modified inguinal lymph node dissection (ESMIL) for squamous cell carcinoma of the penis. J Urol 169(4):78Google Scholar
  17. Tobias-Machado M et al (2006) Video endoscopic inguinal lymphadenectomy (VEIL): initial case report and comparison with open radical procedure. Arch Esp Urol 59(8):849–852PubMedView ArticleGoogle Scholar
  18. Tobias-Machado M et al (2011) Single-site video endoscopic inguinal lymphadenectomy: initial report. J Endourol 25(4):607–610PubMedView ArticleGoogle Scholar
  19. Josephson DY et al (2009) Robotic-assisted endoscopic inguinal lymphadenectomy. Urology 73(1):167–170, discussion 170–171PubMedView ArticleGoogle Scholar
  20. Tobias-Machado M, Neto AS (2009) Re: Josephson et al.: robotic-assisted endoscopic inguinal lymphadenectomy (Urology 2009;73:167–170). Urology 73(6):1424–1425PubMedView ArticleGoogle Scholar
  21. Manci N et al (2009) Inguinofemoral lymphadenectomy: randomized trial comparing inguinal skin access above or below the inguinal ligament. Ann Surg Oncol 16(3):721–728PubMedView ArticleGoogle Scholar
  22. Micheletti L, Bogliatto F, Massobrio M (2005) Groin lymphadenectomy with preservation of femoral fascia: total inguinofemoral node dissection for treatment of vulvar carcinoma. World J Surg 29(10):1268–1276PubMedView ArticleGoogle Scholar
  23. Tobias-Machado M et al (2008) Can video endoscopic inguinal lymphadenectomy achieve a lower morbidity than open lymph node dissection in penile cancer patients? J Endourol 22(8):1687–1691PubMedView ArticleGoogle Scholar
  24. Tobias-Machado M et al (2007) Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure for radical management of inguinal nodes in patients with penile squamous cell carcinoma. J Urol 177(3):953–957, discussion 958PubMedView ArticleGoogle Scholar
  25. Walter F, Correa MT-M (2010) Video-endoscopic inguinal lymphadenectomy. Eur Oncol 6(2):80–84Google Scholar
  26. Tobias-Machado M et al (2006) Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes. Int Braz J Urol 32(3):316–321PubMedView ArticleGoogle Scholar
  27. Machado MT, Molina W Jr, Tavares A et al (2005) Comparative study between video-endoscopic inguinal lymphadenectomy (VEIL) and standard open procedure for penile cancer: preliminary surgical and oncological results. J Urol 173:226View ArticleGoogle Scholar
  28. Thyavihally Y, Tongaonkar H (2009) Video-Endoscopic inguinal lymphadenectomy (VEIL): our initial experience. J Urol 72:181(4):427Google Scholar
  29. Master V et al (2009) Leg endoscopic groin lymphadenectomy (LEG procedure): step-by-step approach to a straightforward technique. Eur Urol 56(5):821–828PubMedView ArticleGoogle Scholar
  30. Sotelo R, Sanchez-Salas R, Clavijo R (2009) Endoscopic inguinal lymph node dissection for penile carcinoma: the developing of a novel technique. World J Urol 27(2):213–219PubMedView ArticleGoogle Scholar
  31. Sotelo R et al (2007) Endoscopic lymphadenectomy for penile carcinoma. J Endourol 21(4):364–367, discussion 367PubMedView ArticleGoogle Scholar
  32. Tobias-Machado M, Starling ES, Oliveira ABP, Pompeo AC, Wroclawski ER (2009) 5-years experience with video endoscopic inguinal lymphadenectomy (VEIL): learning curve and technical variations of a new procedure. J Androlog Sci 16:25–32Google Scholar

Copyright

© Springer-Verlag 2011

Advertisement