Robot-Assisted Inguinal Lymphadenectomy for Urethral Carcinoma

Abstract

Introduction: A 69-year-old female with a history of distal invasive urethral squamous cell carcinoma treated with distal urethrectomy was found to have an enlarged left inguinal node during surveillance 17 months after the operation. Positron emission tomography (PET)/computed tomography showed a 1.5 cm lymph node (LN), which displayed increased activity on PET. Biopsy of this lesion revealed a poorly differentiated squamous cell carcinoma. This video describes our technique for a robot-assisted inguinal lymphadenectomy. Methods: The patient was placed on the split leg table. A 2 cm incision was made down to fascia lata in the midthigh 18 cm inferior to the inguinal ligament. Blunt dissection was used to create this plane above fascia lata. A Hassan-type 10 mm trocar was placed through the 2 cm incision and insufflation to 15 mm Hg was initiated. Two robotic ports were placed under direct vision 8 cm on both sides of the camera port. A 10 mm assistant port was also placed between the camera and the lateral robotic ports. The DaVinci Si robot was docked, and fenestrated bipolar grasper and monopolar scissors were used throughout the case as dissecting instruments. The saphenous vein was identified and followed to its insertion into the femoral vein. The split and roll technique was used to remove lymphatic tissue around vessels. Weck and metallic clips were used for vascular and lymphatic control. Weck clips were used as there was adequate overlying adipose tissue and no concern for palpating these from the skin level. The boundary of the LN dissection was the inguinal ligament superiorly, adductor longus muscle medially, and sartorius muscle laterally. LNs from above and below fascia lata were sent separately as superficial and deep LN packets, respectively. Adequate hemostasis was ensured and a 15F Blake drain was placed through a robotic port site. Results: The robotic console time was 3.5 hours with minimal blood loss. There were no intraoperative complications. Postoperatively, she developed minimal lower extremity lymphedema managed with compression stockings. She was discharged home on postoperative day 2 (POD 2). The drain was removed in the clinic on POD 13. Final pathology revealed 1 out 10 LNs positive for metastatic squamous cell carcinoma. At 9 months of follow-up, she had no evidence of recurrent disease and had trace edema of the lower extremity. Conclusion: Robot-assisted inguinal lymphadenectomy can be performed safely for the treatment of distal urethral carcinoma, while utilizing the same technical principles as the standard open surgical approach. The minimally invasive approach may lead to fewer postoperative complications, particularly related to wound healing, while maintaining good oncologic outcomes. Thomas P. Frye and Alex Gorbonos have nothing to disclose. Runtime of video: 6 mins 31 secs