| Objective To evaluate the effects,complications,and long-term oncological outcomes of different surgical modalities and technical strategies,such as open Inguinal lymph node dissection,video endoscopic inguinal lymphadenectomy,and noninflating video endoscopic inguinal lymphadenectomy in patients with penile cancer;to analyze the risk factors and associated prognostic factors for inguinal lymph node metastasis in penile cancer,and to identify clinical and pathological variables that may be predictors of inguinal lymph node involvement in penile cancer,to provide a basis for clinical treatment decisions in patients with penile cancer.Methods The clinical data of patients who were diagnosed with penile squamous cell carcinoma and underwent inguinal lymph node dissection in the Department of Urology of the First Affiliated Hospital of Anhui Medical University from January 2014 to July 2020 were collected.The basic clinical data,surgical conditions,postoperative complications,and postoperative pathological indicators of the patients were recorded.All patients were followed up by outpatient service or telephone,and the follow-up time was from 24 months to 103 months to understand the survival of the patients.To analyze the differences in surgery situation and postoperative complications of conventional video endoscopic inguinal lymph node dissection,noninflating video endoscopic inguinal lymph node dissection and open inguinal lymph node dissection;To analyze the differences in surgical effects and complications between preservation of the great saphenous vein and resection of the great saphenous vein;To analyze the influencing factors of postoperative wound-related complications,the related pathological variables to predict inguinal lymph node involvement;To analyze the survival differences and prognostic factors between different surgical methods and different surgical timings.Results Eighty-nine patients with penile squamous cell carcinoma who underwent inguinal lymph node dissection were finally included.The baseline conditions of the endoscopic group and the open group were basically the same and comparable,and the follow-up time was similar.A total of 36 patients in the open group underwent 69 inguinal lymph nodes dissection,and 53 patients in the laparoscopy group underwent 98 inguinal lymph nodes dissection.There was no significant difference in the number of dissected lymph nodes,the number of positive lymph nodes and the pathological lymph node staging between the two groups(p>0.05).The average operation time of the endoscopic group was longer than that of the open group,and the difference was statistically significant(118.2±12.32 vs 89.44±22.75,p=0.012).There was no significant difference in the amount of surgical blood loss and drainage tube indwelling time between the two groups(p>0.05).The hospital stay in the open group was longer than that in the endoscopic group,and the difference was statistically significant(14.22±4.14 vs 9.35±3.27,p=0.021).The open group [21 cases(58.3%)] had a higher complication rate than the endoscopic group [13 cases(24.5%)],and the difference was statistically significant(p = 0.001).There was no significant difference in lymph noderelated complications between the two groups(p>0.05).Wound infection was more common in the open group than in the endoscopic group,and the difference was statistically significant(7vs2,p=0.021).There was no subcutaneous emphysema in the open group,and 7 patients(13.2%)in the endoscopic group developed subcutaneous emphysema.Two cases of skin necrosis required rehospitalization within 30 days of skin grafting after open surgery.There was no significant difference between the saphenous vein preservation group and the resection group in terms of surgical blood loss and drainage tube indwelling time(p>0.05).The saphenous vein preservation group had a longer average operation time than the resection group,and the difference was statistically significant(115.44±32.05 vs 100.44±25.90,p = 0.003).There was no significant difference in the number of dissected inguinal lymph nodes and lymph noderelated complications between the two groups(p>0.05).The incidence of postoperative lower extremity edema in the saphenous vein preservation group was significantly lower than that in the resection group,and the difference was statistically significant(p=0.001).Subgroup analysis found that in the open group,the saphenous vein preservation group had more delays in drain removal than the resection group(p=0.045),but there was no significant difference in the endoscopic group(p=0.552).No matter in the open group or the endoscopic group,the saphenous vein preservation group had less complications of lower extremity edema than the resection group(p<0.05).There were no significant differences in complications such as wound infection,delayed wound healing,wound dehiscence,and lymphocyst between the two groups(p>0.05).Subgroup analysis was performed for the operation conditions and postoperative complications of the conventional endoscopic and air-free endoscopic groups,the operation time,intraoperative blood loss,number of dissected lymph nodes,postoperative wound pain score and postoperative arterial blood CO2 partial pressure in the two groups.There was no significant statistical difference(p>0.05).Subcutaneous emphysema occurred in 7 patients(8.5%)in the conventional endoscopy group,while no subcutaneous emphysema occurred in the non-inflation group.In univariate logistic regression analysis,wound complications and type of surgery(open vs laparoscopic)[p=0.001,HR 0.202(95% CI 0.076–0.528)],preservation of the great saphenous vein [p=0.024,HR 0.171(95% CI 0.136–0.829)] was associated with lymph node pathological stage [p=0.002,HR 4.516(95% CI 1.778–11.613).In multivariate logistic regression analysis,surgical type(open vs laparoscopic)and lymph node pathological stage were statistically significant with p values 0.021 [HR 0.187(95% CI0.045–0.654)] and 0.003 [HR 7.424(95% CI 1.969–28.481),respectively.The predictors of lymph node involvement in univariate analysis were: tumor size(P<0.05),histological grade(P<0.05),vascular invasion(P<0.05),neural invasion(P<0.05),cavernosal invasion(P<0.05),urethral infiltration(P<0.05)and primary tumor pathological stage(P<0.05).Multivariate analysis showed that the pathological stage,vascular invasion,neural invasion and histological grade of the primary tumor were predictors of lymph node metastasis(p<0.05).Vascular/nerve invasion and cavernosal/urethral invasion are predictors of lymph node metastasis in cN0 patients.Kaplan-Meier analysis and Log-rank test showed that there was no significant difference in OS and PFS between the open group and the endoscopy group,the immediate dissection group and the delayed dissection group,the conventional endoscopy group and the airless endoscopy group(p>0.05).In a univariate analysis of Cox regression,inguinal lymph node dissection surgical method,smoking history,age,BMI,and tumor T stage did not show any statistically significant differences in survival.There were significant differences in survival by cN stage(p=0.037),pN stage(p=0.005),pathological grade(p=0.002),and surgical method of penile tumor resection(partial penile resection vs.total penile resection)(p=0.042).Multivariate Cox regression analysis of all known prognostic factors showed significant differences in survival by pathological grade and p N stage with p values of 0.045 [HR 2.590(95%CI1.051–6.624)] and 0.023 [HR 3.221(95%CI),respectively 0.927–7.778)].Conclusion Compared with open inguinal lymphadenectomy,laparoscopic inguinal lymphadenectomy is a safe and effective surgical modality.Laparoscopic surgery shows the advantages of rapid recovery of minimally invasive surgery,and achieves similar long-term efficacy as open surgery,and more prospective controlled studies with large samples are expected to be further confirmed.Air-free laparoscopic inguinal lymph node dissection can obtain sufficient operating space,successfully complete the operation,and has an exact therapeutic effect.It can effectively avoid the impact of carbon dioxide inflation on the body in traditional endoscopic surgery,and its clinical application is safe and feasible.More clinical case-control studies and further technical improvements are needed.Preservation of the saphenous vein during inguinal lymph node dissection can reduce the incidence of lower extremity edema.Immediate ILND do not show a prognostic advantage compared to delayed ILND.The pathological stage,grade,vascular invasion and neural invasion of penile squamous cell carcinoma are important risk factors for lymph node metastasis.Early ILND is recommended for cN0 patients with vascular invasion and/or neural invasion. |
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