Search

Objective: Radiotherapy is a crucial treatment modality for pelvic cancers, but uncertainties persist in defining the clinical target volume (CTV) for the inguinal lymphatic drainage region. Suboptimal CTV delineation may compromise treatment efficacy and result in subpar disease control. This study aimed to investigate and map the distribution of lymph node metastases (LNM) in the groin area to facilitate an improved and detailed CTV definition using 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT)., Methods: Inguinal LNM in patients with biopsy-proven pelvic malignancies were identified using 18 F-FDG PET/CT scan. The longitudinally nearest axial plane was determined based on six typical bony landmarks, and the axial direction relative to the femoral artery of LNM was recorded. The distances from the LNM to the nearest edge of the femoral artery were measured on the axial plane. An optimal margin to cover 95% of LNM was estimated to develop contouring recommendations., Results: In this study, 500 positive LNM were identified by 18 F-FDG PET/CT among 185 patients with primary pelvic malignancies. Relative to the femoral artery, lymph nodes were distributed laterally (10:00-11:00, n = 35), anteriorly (12:00-1:00, n = 213), and medially (2:00-4: 00, n = 252). For CTV delineation, the recommended distances from the femoral artery on the SFH were lateral 19 mm, anterior 19 mm, and medial 25 mm; on the SGT were lateral 26 mm, anterior 20 mm, and medial 25 mm; on the SPS were lateral 28 mm, anterior 29 mm, and medial 26 mm; on the IPS were anterior 29 mm and medial 28 mm; on the IIT were anterior 27 mm and medial 27 mm; on the ILT were anterior 25 mm and medial 23 mm. Use interpolation to contour the area between six axial slices, including any radiographically suspicious LNM., Conclusions: Using 18 F-FDG PET/CT, we investigated the distribution pattern of inguinal LNM and propose a more comprehensive guideline for inguinal CTV delineation., (© 2024. The Author(s).)

Objective: To predict preoperative inguinal lymph node metastasis in vulvar cancer patients using a machine learning model based on imaging features and clinical data from pelvic magnetic resonance imaging (MRI)., Methods: 52 vulvar cancer patients were divided into a training set (n=37) and validation set (n=15). Clinical data and MRI images were collected, and regions of interest were delineated by experienced radiologists. A total of 1688 quantitative imaging features were extracted using the Radcloud platform. Dimensionality reduction and feature selection were applied, resulting in a radiomics signature. Clinical characteristics were screened, and a combined model integrating the radiomics signature and significant clinical features was constructed using logistic regression. Four machine learning classifiers (K nearest neighbor, random forest, adaptive boosting, and latent dirichlet allocation) were trained and validated. Model performance was evaluated using the receiver operating characteristic curve and the area under the curve (AUC), as well as decision curve analysis., Results: The radiomics score significantly differentiated between lymph node metastasis positive and negative patients in both the training and validation sets. The combined model demonstrated excellent discrimination, with AUC values of 0.941 and 0.933 in the training and validation sets, respectively. The calibration curve and decision curve analysis confirmed the model's high predictive accuracy and clinical utility. Among the machine learning classifiers, latent dirichlet allocation and random forest models achieved AUC values >0.7 in the validation set. Integrating all four classifiers resulted in a total model with an AUC of 0.717 in the validation set., Conclusion: Radiomics combined with artificial intelligence can provide a new method for prediction of inguinal lymph node metastasis of vulvar cancer before surgery., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To establish if it is appropriate to treat the inguinal lymph node (LN) of anal canal adenocarcinoma (ACA) as the intermediate LN according to the Japanese classification., Methods: The characteristics of 346 ACA patients were examined from the nationwide registry. The effect of LN dissection was evaluated using the therapeutic value index (TVI). Furthermore, the prognostic classification ability of N factors and stage was evaluated using Akaike's information criterion (AIC), the concordance index (C-index), and the 5-year overall survival (OS) rate., Results: The rate of metastasis of the inguinal LN was 7.5% and the TVI was 3.05. Evaluation using AIC and the C-index showed better results when the inguinal LN was treated as the intermediate LN. The 5-year OS rate for 66 patients with perirectal or intermediate LN metastasis, 7 with inguinal LN metastasis, and 13 with inguinal and perirectal or intermediate LN metastasis were 49.2%, 68.6%, and 47.6%, respectively. When inguinal LN metastases were treated as N3, the 5-year OS rates were 66.7% for those with T1N3 and T2N3 disease, and 49.2% for those with T3N3 disease., Conclusions: The inguinal LN of ACA was evaluated and staged as the intermediate LN to devise an appropriate treatment strategy., Competing Interests: Declarations. Conflict of interest: Kazutaka Yamada and the co-authors have no conflicts of interest to declare. Ethics statement: This study was approved by the Institutional Review Board of the JSCCR (88-5). This study was also approved by the Hospital Review Board of Takano Hospital (23-27). Informed consent was obtained using an “opt-out” method under the approved the ethics committee. The study was performed in accordance with the Declaration of Helsinki., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Competing Interests: The authors declare no conflict of interest.

Objective: To report outcomes of multicenter series of penile cancer patients undergoing robot-assisted video endoscopic inguinal lymph node dissection (RA-VEIL). Materials and Methods: In this retrospective analysis from 3 tertiary care centers in India, consecutive intermediate-/high-risk carcinoma penis (CaP) patients with nonpalpable inguinal lymphadenopathy and/or nonbulky (<3 cm) mobile inguinal lymphadenopathy undergoing RA-VEIL were included. Patients with matted/bulky (>3 cm) and fixed lymphadenopathy were excluded. Demographic, clinical, and intraoperative data were recorded. Perioperative complications were graded by the Clavien-Dindo classification (CDC). The International Society of Lymphology (ISL) {0-III} grading was used for the assessment of lymphedema. Incidence and pattern of recurrences were assessed on follow-up. Results: From January 1, 2011, to September 30, 2023, 115 patients (230 groins) underwent bilateral RA-VEIL for CaP. The median age of the cohort was 60 (50-69) years. Clinically palpable (either unilateral or bilateral) inguinal lymphadenopathy was seen in 54 patients (47%). The "per groin" median operative time was 120 (100-140) minutes with median lymph node yield of 12 (9-16). No complications were recorded in 87.8% groins operated, with major complications (CDC 3) seen in 2.6% groins. At a median follow-up of 13.5 months, 13 patients had documented recurrences and there were 10 cancer-related deaths. No port-site recurrences were observed. No/minimal lymphedema (ISL 0/I) was seen in 94% legs. Conclusion: RA-VEIL demonstrates safety and oncologic efficacy in penile cancer patients presenting with clinically nonpalpable and/or nonbulky inguinal lymphadenopathy, with favorable functional outcomes.

Background/aim: Texture analysis is a quantitative imaging technique that provides novel biomarkers beyond conventional image reading. This study aimed to investigate the correlation between texture parameters and histopathological features of lymph nodes in patients with vulvar cancer., Patients and Methods: Overall, nine female patients (mean age 70.1±13.4 years, range=39-87 years) were included in the analysis. All patients had squamous cell carcinomas and underwent upfront surgery with inguinal lymph node resection. Immunohistochemical assessment was performed using several markers of the epithelial-mesenchymal transition. The presurgical magnetic resonance imaging (MRI) was analyzed with the MaZda package., Results: In discrimination analysis, several parameters derived from T1-weighted images showed statistically significant differences between non-metastatic and metastatic lymph nodes. The highest statistical significance was reached by the texture feature "S(0,3)InvDfMom" (p=0.016). In correlation analysis, significant associations were found between MRI texture parameters derived from both T1-weighted and T2-weighted images and the investigated histopathological features. Notably, S(0,3)InvDfMom derived from T1-weighted images highly correlated with the Vimentin-score (r=0.908, p=0.001)., Conclusion: Several associations between MRI texture analysis and immunohistochemical parameters were identified in metastasized lymph nodes of cases with vulvar cancer., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The Evaluation of Groin Lymphadenectomy Extent for Melanoma (EAGLE FM) study sought to address the question of whether to perform inguinal (IL) or ilio-inguinal lymphadenectomy (I-IL) for patients with inguinal nodal metastatic melanoma who have no clinical or imaging evidence of pelvic disease. Primary outcome measure was disease-free survival at 5 years, and secondary endpoints included lymphoedema., Methods: EAGLE FM was designed to recruit 634 patients but closed with 88 patients randomised because of slow recruitment and changes in melanoma management. Lymphoedema assessments occurred preoperatively and at 6, 12, 18, and 24 months postoperatively. Lymphoedema was defined as Inter-Limb Volume Difference (ILVD) > 10%, Lymphoedema Index (L-Dex ® ) > 10 or change of L-Dex ®  > 10 from baseline., Results: Prevalence of leg lymphoedema between the two groups was similar but numerically higher for I-IL at all time points in the first 24 months of follow-up; highest at 6 months (45.9% IL [CI 29.9-62.0%], 54.1% I-IL [CI 38.0-70.1%]) and lowest at 18 months (18.8% IL [CI 5.2-32.3%], 41.4% I-IL [CI 23.5-59.3%]). Median ILVD at 24 months for those affected by lymphoedema was 14.5% (IQR 10.6-18.7%) and L-Dex ® was 12.6 (IQR 9.0-17.2). There was not enough statistical evidence to support associations between lymphoedema and extent of surgery, radiotherapy, or wound infection., Conclusions: Despite a trend for patients who had I-IL to have greater lymphoedema prevalence than IL in the first 24 months after surgery, our study's small sample did not have the statistical evidence to support an overall difference between the surgical groups., (© 2024. Crown.)

Methods: 30 male patients with primary inguinal hernias undergoing primary inguinal herniorrhaphy were prospectively recruited for ilioinguinal nerve resection and evaluation. Three samples of the resected ilioinguinal nerve (proximal, canal, and distal) were evaluated using Masson's trichrome stain to measure fascicle and total nerve cross-sectional area and detect changes in collagen., Results: The fascicle cross-sectional area in the canal segment was significantly decreased compared to the proximal control with a large effect size observed ( p = 0.016, η 2  = 0.16). There was no significant difference in the nerve cross-sectional area between locations, but there was a moderate to large effect size observed between locations ( p = 0.165, η 2  = 0.105). There was no significant difference in collagen content nor effect size observed between locations ( p = 0.99, η 2  = 1.503 × 10 -4 ). Interpretation . The decrease in the fascicle cross-sectional area within the inguinal canal further suggests that there is chronic pressure applied by hernia tissue consistent with axon degeneration. Collagen content is uniformly distributed along the length of the nerve. Further studies with larger samples are needed to confirm the observed effect of nerve location on the total nerve cross-sectional area and axon loss., Competing Interests: The authors declare that they have no conflicts of interest as outlined by the International Committee of Medical Journal Editors., (Copyright © 2024 Robert Wright et al.)

Background: Radical inguinal lymph node dissection (rILND) is the most available treatment to cure penile cancer (PC) with limited inguinal-confined disease. However, guidelines regarding acceptable boundaries of rILND are controversial, and consensus is lacking. The authors aimed to standardize the surgical boundaries of rILND with definite pathological evidence and explore the distribution pattern of inguinal lymph nodes (ILNs) in PC., Methods: A total of 414 PC patients from two centers who underwent rILND were enrolled. The ILN distribution was divided into seven zones anatomically for pathological examination. Student's t test and Kaplan-Meier survival analysis were used., Results: ILNs displayed a funnel-shaped distribution with high density in superior regions. ILNs and metastatic nodes are present anywhere within the radical boundaries. Positive ILNs were mainly concentrated in zone I (51.7%) and zone II (41.3%), but there were 8.7% and 12.3% in inferior zones V and VI, respectively, and 7.1% in the deep ILNs. More importantly, a single positive ILN and first-station positive zone was detected in all seven regions. Single positive ILNs were located in zones I through VI in 40.4%, 23.6%, 6.7%, 18.0%, 4.5%, and 1.1%, respectively, and 5.6% presented deep ILN metastasis directly., Conclusions: The authors established a detailed ILN distribution map and displayed lymphatic drainage patterns with definite pathological evidence using a large cohort of PC patients. Single positive ILNs and first-station metastatic zones were observed in any region, even directly with deep ILN metastasis. Only rILND can ensure tumor-free resection without the omission of positive nodes., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To evaluate perioperative and oncologic outcomes of a cohort of clinically node negative high-risk penile cancer patients undergoing robotic assisted inguinal lymph node dissection (RAIL) compared to patients undergoing open superficial inguinal lymph node dissection (OSILND)., Patients and Methods: We retrospectively reviewed the clinical characteristics and outcomes of clinically node negative high-risk penile cancer patients undergoing RAIL at MDACC from 2013-2019. We sought to compare this to a contemporary open cohort of clinically node negative patients treated from 1999 to 2019 at MDACC and Moffit Cancer Center (MCC) with an OSILND. Descriptive statistics were used to characterize the study cohorts. Comparison analysis between operative variables was performed using Fisher's exact test and Wilcoxon's rank-sum test. The Kaplan-Meier method was used to estimate survival endpoints., Results: There were 24 patients in the RAIL cohort, and 35 in the OSILND cohort. Among the surgical variables, operative time (348.5 minutes vs. 239.0 minutes, P < 0.01) and the duration of operative drain (37 vs. 22 days P = 0.017) were both significantly longer in the RAIL cohort. Complication incidences were similar for both cohorts (34.3% for OSILND vs. 33.3% for RAIL), with wound complications making up 33% of all complications for RAIL and 31% of complications for OSILND. No inguinal recurrences were noted in either cohort. The median follow-up was 40 months for RAIL and 33 months for OSILND., Conclusions: We observed similar complication rates and surgical variable outcomes in our analysis apart from operative time and operative drain duration. Oncological outcomes were similar between the two cohorts. RAIL was a reliable staging and potentially therapeutic procedure among clinically node negative patients with penile squamous cell carcinoma with comparable outcomes to an OSILND cohort., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Inguinal endometriosis is one of the most common forms of endometriosis. The present study introduces 8 cases of inguinal endometriosis and discusses probable theories of inguinal endometriosis by reviewing the literature., Case Presentation: 8 Iranian cases of inguinal endometriosis with a mean age of 36 years were presented. Catamenial groin pain and swelling were the most common complications. Also, patients usually had accompanying symptoms such as pelvic pain and dysmenorrhea. One-half of patients had a history of previous abdominal surgery. Ultrasound was diagnostic in 4 patients (50%), and magnetic resonance imaging was used in two patients (25%). Among 6 patients who underwent hormonal therapy, 4 experienced an endometriosis size increase. Inguinal endometriosis was right-sided in 87.5% of patients, and among 4 patients who underwent surgery, 75% had proximal site involvement of the round ligament., Conclusion: According to the rarity of inguinal endometriosis, it is more likely to be a misdiagnosis with other inguinal disorders such as inguinal hernia. Inguinal endometriosis should be considered in patients who undergo inguinal herniorrhaphy, with suspected findings such as thickening of the hernia sac wall, bloody fluid inside the sac, or thickening of the extraperitoneal round ligament during the surgery., (© 2024. The Author(s).)

Purpose: Penile cancer is a rare malignancy, where extranodal extension in inguinal or pelvic lymph nodes is associated with decreased 5-year cancer-survival rate in this study, we try to assess survival and quality of life in a penile cancer patient with bulky lymph node., Methods: We retrospectively reviewed data from penile cancer patients with bulky lymph nodes who underwent treatment between July 2016 and July 2021 at tertiary referral hospital care. The inclusion criteria (age >18 yr, histologically proven penile cancer, and completion of last treatment 6 months prior to this study) yielded a cohort of 20 eligible penile cancer patients with bulky lymph nodes (> 4 cm/bilateral mobile/unilateral fixed). Only patients who had completed therapy at least 6 months prior to the study were included. After obtaining consent, they were asked to complete the EORTC QLQ-C30 questionnaire to evaluate the patient's quality of life., Results: Out of 20 patients, 5 patients underwent direct ILND and 15 patients underwent chemotherapy. Median follow-up after primary diagnosis was 114+32 months in patients with early ILND and 52+11 months in patients who underwent delayed lymph node dissection. Out of 5 patients who underwent early ILND, all of them survived during follow-up, and achieved cancer-free status without residual tumor and with excellent functional outcomes (Karnofsky 90). There was no significant difference in social function (p-value = 0.551), physical function (p-value = 0.272), role function (p-value = 0.546), emotional function (p-value = 0.551), cognitive function (p-value = 0.453), and global health status (p-value = 0.893) between patient which treated with early ILND and Neoadjuvant Chemotherapy. However, patients who underwent early ILND showed a relatively better clinical outcome., Conclusion: Early ILND followed by adjuvant chemotherapy for penile cancer with palpable lymph nodes is more favourable than neoadjuvant TIP chemotherapy.

Adenocarcinoma of the rectum and anal canal with inguinal lymph node metastasis(ILNM)is rare and the prognosis is generally poor. The aim of this study was to clarify the clinical significance of selective inguinal lymph node dissection and total mesorectal excision after preoperative therapy for adenocarcinoma of the rectum and anorectal canal with clinically suspected ILNM. Of the 15 patients, 11 received preoperative chemoradiotherapy, 3 received chemotherapy, and 1 received chemotherapy after chemoradiotherapy. 14 patients received preoperative therapy followed by FDG-PET scans were performed in 14 patients after preoperative treatment. 5 patients had negative FDG accumulation in inguinal lymph nodes on FDG-PET scans, and postoperative pathological diagnosis was also negative for metastasis in the inguinal lymph nodes. Of the 9 patients with positive FDG accumulation, 4 had pathologically positive inguinal lymph nodes, 7 had postoperative inguinal seroma, the 5-year survival rate was 77.5%, and the 5-year recurrence-free survival rate was 64.2%. No patient had a recurrence in the inguinal region. Patients with adenocarcinoma of the rectum and anal canal with clinical ILNM had good long-term survival after radical resection with preoperative therapy.

Competing Interests: Competing interests: None declared.

Purpose: Inguinal lymph nodes are a rare but recognised site of metastasis in rectal adenocarcinoma. No guideline or consensus exists for the management of such cases. This review aims to provide a contemporary and comprehensive analysis of the published literature to aid clinical decision-making., Methods: Systematic searches were performed using the PubMed, Embase, MEDLINE and Scopus and Cochrane CENTRAL Library databases from inception till December 2022. All studies reporting on the presentation, prognosis or management of patients with inguinal lymph node metastases (ILNM) were included. Pooled proportion meta-analyses were completed when possible and descriptive synthesis was utilised for the remaining outcomes. The Joanna Briggs Institute tool for case series was used to assess the risk of bias., Results: Nineteen studies were eligible for inclusion, encompassing 18 case series and one population-based study using national registry data. A total of 487 patients were included in the primary studies. The prevalence of ILNM in rectal cancer is 0.36%. ILNM are associated with very low rectal tumours with a mean distance from the anal verge of 1.1 cm (95% CI 0.92-1.27). Invasion of the dentate line was found in 76% of cases (95% CI 59-93). In patients with isolated inguinal lymph node metastases, modern chemoradiotherapy regimens in combination with surgical excision of inguinal nodes are associated with 5-year overall survival rates of 53-78%., Conclusion: In specific subsets of patients with ILNM, curative-intent treatment regimens are feasible, with oncological outcomes akin to those demonstrated in locally advanced rectal cancers., (© 2023. The Author(s).)

Objective: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL)., Materials and Methods: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range., Results: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively., Conclusion: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Purpose: Modified and superficial inguinal lymph node dissection (MILD and SILD) are the 2 widely used templates for surgical staging of clinically node negative (cN0) penile cancer (PeCa); however, no previous reports have compared their outcomes. We compared these 2 surgical templates for oncological outcomes and complications., Materials and Methods: We retrospectively reviewed records of cN0 PeCa patients who underwent MILD/SILD at our cancer care center from January 2013 to December 2019. Patients who developed a penile recurrence during follow up were excluded from analysis of oncological outcomes. The 2 groups (MILD and SILD) were compared for baseline clinico-pathological characteristics. The primary outcome was the groin recurrence free survival (gRFS). Secondary outcomes included the false negative rate (FNR) and disease free survival (DFS) for both templates and also the post-operative wound related complication., Results: Of the 146 patients with intermediate and high risk N0 PeCa, 74 (50.7%) and 72 (49.3%) underwent MILD and SILD respectively. The 2 groups were comparable with regards to the distribution of T stage, tumor grade and the proportion of intermediate and high-risk patients. At a median follow up of 34 months (47 for SILD and 23 for MILD), a total of 5 groin recurrences were encountered; all of them occurred in the MILD group. The gRFS and DFS for the MILD group was 93.2% and 91.8% respectively; while that for the SILD group was 100% and 94.4% respectively. Too few events had occurred to determine any statistically significant difference. The FNR for MILD and SILD was 26.3% and 0% respectively. The overall complication rate was significantly higher in the SILD group (46% vs 20.3%, p=0.001), especially for Clavien Dindo 3A complications., Conclusion: MILD can fail to pick up micro-metastatic disease in a small proportion of cN0 PeCa patients, while SILD provides better oncological clearance with no groin recurrences. This oncological superiority comes at the cost of a higher incidence of wound-related complications., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare that are relevant to the content of this article., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To describe our surgical technique and report the oncological outcomes and complication rates using a fascial-sparing radical inguinal lymphadenectomy (RILND) technique for penile cancer patients with cN+ disease in the inguinal lymph nodes., Methods: Over a 10-year period, 660 fascial-sparing RILND procedures were performed in 421 patients across two specialist penile cancer centres. The technique used a subinguinal incision with an ellipse of skin excised over any palpable nodes. Identification and preservation of the Scarpa's and Camper's fascia was the first step. All superficial inguinal nodes were removed en bloc under this fascial layer with preservation of the subcutaneous veins and fascia lata. The saphenous vein was spared where possible. Patient characteristics, oncologic outcomes and perioperative morbidity were retrospectively collected and analysed. Kaplan-Meier curves estimated the cancer-specific survival (CSS) functions after the procedure., Results: Median (interquartile range, IQR) follow-up was 28 (14-90) months. A median (IQR) number of 8.0 (6.5-10.5) nodes were removed per groin. A total of 153 postoperative complications (36.1%) occurred, including 50 conservatively managed wound infections (11.9%), 21 cases of deep wound dehiscence (5.0%), 104 cases of lymphoedema (24.7%), 3 cases of deep vein thrombosis (0.7%), 1 case of pulmonary embolism (0.2%), and 1 case of postoperative sepsis (0.2%). The 3-year CSS was 86% (95%Confidence Interval [95% CI] 77-96), 83% (95% CI 72-92), 58% (95% CI 51-66), respectively, for the pN1, pN2 and pN3 patients (p < 0.001), compared to a 3-year CSS of 87% (95% CI 84-95) for the pN0 patients., Conclusion: Fascial-sparing RILND offers excellent oncological outcomes whilst decreasing the morbidity rates. Patients with more advanced nodal involvement had poorer survival rates, emphasizing the need for adjuvant chemo-radiotherapy., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: In 95% of cases, penile cancer is a squamous cell carcinoma whose specificity is lymphatic spread with the inguinal lymph nodes as the first relay route. Inguinal lymph node dissection is a primordial part of the treatment. The objective was to assess the oncological results of inguinal lymph node dissection in penile cancer at our centre., Methods: We retrospectively included all patients having undergone inguinal lymph node dissection at our centre between 1 January 2004 and 1 January 2020 for the treatment of penile cancer. Patients for whom lymphadenopathy was palliative were excluded. Depending on indications, the procedures consisted in either dynamic sentinel node biopsy, modified lymphadenectomy or radical lymphadenectomy. All cancers were reclassified using the 2016 TNM classification system. Survival was analysed according to the Kaplan-Meier method., Results: 242 inguinal lymph node dissections were performed in 122 patients. There were 71 pN0 (58%), 9 pN1 (7%), 4 pN2 (3%) and 38 pN3 (31%). Mean follow-up was 51 ± 45 months. The 3-year recurrence-free survival rate was 76% in pN0 patients and 17% in pN3 patients. The 5-year specific and overall survival rates were, respectively, 82% and 73% for pN0 stages, and 14% and 17% for pN3 stages. Extracapsular extension on an inguinal lymphadenopathy appeared as a highly negative prognostic factor., Conclusion: Inguinal lymph node dissection is essential in the treatment of penile cancer. Recurrence-free, specific and overall survival are closely linked to the lymph node stage. Extracapsular extension and pelvic lymph node invasion are highly negative prognostic factors., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

We have carefully read the comment by May et al. [...].

Background: There is promising data on minimally invasive inguinal lymphadenectomy indicating decreased wound complications compared with the standard open approach. We examined our institutional experience with starting a minimally invasive inguinal lymphadenectomy program., Methods: This is a retrospective case series of consecutive patients undergoing videoscopic minimally invasive inguinal lymphadenectomy from August 2017 to March 2022 by a single surgeon. Patients meeting criteria for inguinal lymphadenectomy were considered for minimally invasive inguinal lymphadenectomy unless there was skin involvement by tumor or bulky disease. Data collected included patient characteristics, primary cancer, surgery, and postoperative complications., Results: There were 26 patients included. The mean age was 60.6 ± 16.2 years. Most patients were female (n = 17, 65.4%), and the primary diagnosis was melanoma (n = 21, 19.2%). In 6 cases (23.1%), minimally invasive inguinal lymphadenectomy was combined with deep pelvic node dissection, but most patients did not have a concurrent procedure (n = 15, 57.7%). The median operative time was 119.0 minutes (range, 89.0-160.0), or 130.5 minutes (range, 89.0-345.0) when including concurrent procedures. The mean number of nodes retrieved was 9.8 ± 3.7, with a positive node identified in 19 patients (73.1%) during minimally invasive inguinal lymphadenectomy. There were 12 (46.2%) patients experiencing at least one postoperative complication within 30 days of surgery, the most common being infection (n = 4, 15.4%). One patient required reoperation for infected hematoma washout. Postoperative intervention for seroma was undertaken in 3 patients (11.5%)., Conclusion: Minimally invasive inguinal lymphadenectomy is a safe approach to inguinal lymph node dissection, in terms of node retrieval and postoperative complications, and can feasibly be adopted into practice with minimal learning curve., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Inguinal lymph node dissection (ILND) is used for diagnosis and treatment in penile cancer (PC), vulvar cancer (VC), and melanomas draining to the inguinal lymph nodes. However, ILND is often characterized by its morbidity and high wound complication rate. Consequently, we aimed to characterize wound complication rates after ILND., Study Design: The NSQIP database was queried for ILND performed from 2005 to 2018 for melanoma, PC, or VC. Thirty-day wound complications included wound disruption and superficial, deep, and organ-space surgical site infection. Multivariable logistic regression was performed with covariates, including cancer type, age, American Society of Anesthesiologists score ≥3, BMI ≥30, smoking history, diabetes, operative time, and concomitant pelvic lymph node dissection., Results: A total of 1,099 patients had an ILND with 92, 115, and 892 ILNDs performed for PC, VC, and melanoma, respectively. Wound complications occurred in 161 (14.6%) patients, including 12 (13.0%), 17(14.8%), and 132 (14.8%) patients with PC, VC, and melanoma, respectively. Median length of stay was 1 day (interquartile range 0 to 3 days), and median operative time was 152 minutes (interquartile 83 to 192 minutes). Readmission rate was 12.7%. Wound complications were associated with longer operative time per 10 minutes (odds ratio 1.038, 95% CI 1.019 to 1.056, p < 0.001), BMI ≥30 (odds ratio 1.976, 95% CI 1.386 to 2.818, p < 0.001), and concomitant pelvic lymph node dissection (odds ratio 1.561, 95% CI 1.056 to 2.306, p = 0.025)., Conclusions: Predictors of wound complications after ILND include BMI ≥30, longer operative time, and concomitant pelvic lymph node dissection. There have been efforts to decrease ILND complication rates, including minimally invasive techniques and modified templates, which are not captured by NSQIP, and such approaches may be considered especially for those with increased complication risks., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications., Methods: The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020., Findings: There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To assess the morbidity of inguinal lymph node dissection (ILND) in penile cancer, then to compare this morbidity with that of ILND performed in the context of skin cancer treatment., Methods: We retrospectively included all patients having undergone ILND between 1 January 2004 and 31 December 2019 in our centre's urology department in the context of treatment of penile cancer or skin cancer. Postoperative complications were reported in accordance with the Clavien-Dindo classification system., Results: Two hundred forty-two ILNDs were performed in 122 patients with penile cancer and 56 ILNDs were performed in 56 patients with skin cancer. The most common early complication was postoperative fluid collection (lymphocele or haematoma), which complicated 44% of ILNDs overall and 60% of radical lymphadenectomies. The most common late complication was leg lymphoedema, found in up to 36% of radical lymphadenectomies. Major complications (grade ≥ III) were very rare (4% of radical lymphadenectomies). Radical lymphadenectomies resulted in significantly more cases of postoperative fluid collection, skin necrosis and dehiscence, as well as leg lymphoedema, than modified lymphadenectomy techniques. Two factors significantly increasing postoperative morbidity were demonstrated: ASA score = 3 (OR = 3.09) and operating time (OR = 1.01)., Conclusion: ILNDs are morbid surgical procedures for which the indications must be well defined. However, the complications are almost exclusively minor, for a major oncological benefit., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Abstract: A 71-year-old man with prostate adenocarcinoma underwent 68 Ga-prostate-specific membrane antigen (PSMA) PET/CT for staging. 68 Ga-PSMA PET/CT showed the primary lesion along with bladder, rectum, bilateral seminal vesicle invasion, and metastatic pelvic lymph nodes with intense 68 Ga-PSMA uptake. Also, PET/CT showed rarely seen bilateral vas deferens invasion and metastasis to the inguinal canal. These rare metastases may be indicative of poor biological behavior and prognosis., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: The surgical treatment of inguinal lymph node (ILN) metastases secondary to anorectal adenocarcinoma remains controversial. This study aimed to clarify the surgical treatment and management of ILN metastasis according to its classification., Methods: This retrospective, multi-centre, observational study included patients with synchronous or metachronous ILN metastases who were diagnosed with rectal or anal canal adenocarcinoma between January 1997 and December 2011. Treatment outcomes were analysed according to recurrence and prognosis., Results: Among 1181 consecutively enrolled patients who received treatment for rectal or anal canal adenocarcinoma at 20 referral hospitals, 76 (6.4%) and 65 (5.5%) had synchronous and metachronous ILN metastases, respectively. Among 141 patients with ILN metastasis, differentiated carcinoma, solitary ILN metastasis and ILN dissection were identified as independent predictive factors associated with a favourable prognosis. No significant difference was found in the frequency of recurrence after ILN dissection between patients with synchronous (80.6%) or metachronous (81.0%) ILN metastases. Patients who underwent R0 resection of the primary tumour and ILN dissection had a 5-year survival rate of 41.3% after ILN dissection (34.1% and 53.1% for patients with synchronous and metachronous ILN metastases, respectively, P = 0.55)., Conclusion: The ILN can be appropriately classified as a regional lymph node in rectal and anal canal adenocarcinoma. Moreover, aggressive ILN dissection might be effective in improving the prognosis of low rectal and anal canal adenocarcinoma with ILN metastases; thus, prophylactic ILN dissection is unnecessary., (© 2022 Association of Coloproctology of Great Britain and Ireland.)

Introduction: The videoendoscopic approach to inguinal lymph node dissection (VEIL) has been suggested as an excellent alternative carrying lower morbidity but equivalent oncological control. One of its most difficult steps is the development of an appropriate plane of dissection. A suprafascial approach would allow for better exposure. The objective of this study is to determine the feasibility, in terms of safety and oncological control, of a technical modification to the classical VEIL technique using a suprafascial plane of dissection in an initial series of patients., Patients and Methods: A single institution retrospective review of patients undergoing VEIL technique using our modified suprafascial approach was conducted. A step-by-step surgical description is provided. Data collected included demographics; comorbid conditions; disease characteristics; intraoperative factors; and postoperative factors., Results: A total of 7 patients (12 procedures) were included. Average age was 64.42 years old, and 71.42% of the patients were male. The procedure was performed bilaterally in 71.4% of the cases. Median estimated blood loss was 10 mL (range 10-25). Mean operative time was 185 min (range 120-170). Median number of nodes removed was 10.25 nodes (range 7-11). Only one of the patients (8.3%) experienced a Clavien-Dindo grade IIIa complication requiring delayed percutaneous drainage replacement. Median time until drainage removal was 13 days (range 10-16). Median length of stay was 48 hours but ranged from 24-96 hours within the series., Conclusions: The modified VEIL technique using a suprafascial plane of the dissection, allows a bilateral ILND in highly competitive operative times and with limited morbidity, without compromising its oncological efficacy., (Copyright © 2022 AEU. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To describe our modified technique of performing video endoscopic inguinal lymphadenectomy (VEIL) with the proposed benefits of a shallow learning curve and better ergonomics., Methods: We describe our modified VEIL technique: the deep first approach, in a squamous cell carcinoma penis patient with a pathological T3 disease and bilateral palpable, mobile inguinal lymph nodes post penectomy., Results: The surface markings and the port incision sites for the procedure were conventional. However, in contrast to the standard superficial dissection plane development below the Scarpa's fascia at the initial camera port site, our technique commenced with a deep dissection plane just above the fascia lata. The dissection limits were directly identified: the sartorius muscle laterally, the inguinal ligament superiorly, and the adductor longus muscle medially. The saphenous vein was identified early and close to the saphenofemoral junction, allowing undemanding dissection. The superficial flap dissection was done entirely under direct vision, with better ergonomics owing to a continuous counter-traction by the pressure of insufflated gas. Deep inguinal nodal dissection then concluded the procedure., Conclusion: The described technique is surmised to be easier to perform, given the lack of ambiguity in the correct initial dissection plane, direct visualization of surgical landmarks early in the procedure, and early identification of the saphenous vein close to the SFJ. It may improve the learning curve allowing for a wider acceptance of VEIL., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The cyst of the canal of Nuck is an extremely rare female hydrocele, usually occurring in children, but also in adult women. It is caused by pathology of the canal of Nuck, which is the female equivalent to the male processus vaginalis. Due to its rarity and the lack of awareness among physicians, the cyst of the canal of Nuck is a seldom-encountered entity in clinical practice and is commonly misdiagnosed. We report on a case of cyst of the canal of Nuck in a 42-year-old woman, who presented with a painful swelling at her right groin. In addition, we conducted a review of the current available literature. This review gives an overview of the anatomy, pathology, diagnostics, and treatment of the cyst of the canal of Nuck. The aim of this review is not only to give a survey, but also to raise awareness of the cyst of the canal of Nuck and serve as a reference for medical professionals.

Objectives: To investigate the contemporary rates of 30-day complications after surgery for penile cancer and to discuss the currently used preventative and therapeutic practices aimed at mitigation of these postoperative adverse events., Data Sources: A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed, and studies reporting on the contemporary rates, nature, or management of acute complications following primary penile surgery or inguinal lymph node dissection for penile cancer were abstracted. Medline (PubMed) and EMBASE libraries were used to retrieve the articles published between January 1984 and December 2021 (n = 170 articles). Ultimately, 38 articles were included. The primary outcome of interest was 30-day (acute) postoperative complications, stratified by those associated with treatment of the primary penile lesion and those with inguinal lymph node dissection. Risk of bias assessment was undertaken. Special attention was paid to studies reporting management strategies for these complications., Conclusion: This comprehensive review revealed that the quality of existing studies reporting on complications is poor and the risk of bias is high. Within these studies, the rates of acute complications following primary penile surgery and inguinal lymph node dissection ranged between 0% and 29.4% and 6% and 90%, respectively. More than 50% of these complications were wound related. Over the past two decades, several studies have reported on improved surgical techniques and protocolized postsurgical care pathways. Although the newer techniques have been associated with improved outcomes, the absolute rates of complications have remained high even in the most contemporary series. Therefore, there is an urgent need for health care providers and stakeholders to reach consensus regarding preoperative workup and medical optimization goals, stage appropriate therapies, and postoperative care pathways, as has been done for other malignancies associated with high morbidity., Implications for Nursing Practice: Penile cancer is a disease of the elderly, and surgical management of the primary lesion or the groins is associated with a high rate of complications. Most complications are wound related. Meticulous surgical technique and careful postoperative monitoring with early intervention are keys to mitigating surgery-related morbidity. However, equally important is dissemination and adoption of these principles by all health care workers universally., (Copyright © 2022 Elsevier Inc. All rights reserved.)

As the canal of Nuck normally obliterates before birth, a patent canal is a rare anatomic variant in adult women analogue to the patent processus vaginalis in men. In a patent canal of Nuck, pathologies such as hernias and cyst can build within time. Such cysts themselves are so uncommon that they are mostly described in case reports. Normally, cysts of the canal of Nuck present as a consistent, inguinal swelling with or without pain. Interestingly, in our case, the painful swelling was cyclic changing from the size of a plum to being clinically undetectable within the course of a day. To the best of our knowledge, this is the first description of such an unusual course. The cyst was removed operatively via an open approach. The spasms declined shortly after the operation. At 1 year postoperatively, the patient was still asymptomatic., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

A groin lump is not an uncommon condition in girls and female infants, and US plays a fundamental role in its exploration. The main pathologic conditions are related to the failure of obliteration of the canal of Nuck. Radiologists should gain a full understanding of the embryology and US anatomy of the inguinal canal before assessing this entity for the first time. An optimal age-adjusted US technique-including examinations at rest and during straining-is essential to help assess the canal of Nuck, diagnose a hernia, and analyze its content. The radiologist must be aware of the various types of hernial content depending on the patient's age, including intestinal, omental, ovarian, or tubouterine hernia, and the US features of each. Incarcerated hernias are common in girls and mostly contain an ovary. In such cases, it is crucial to screen for US signs suggestive of ovarian ischemic damage, thereby calling for urgent surgery. US can also depict a cyst or hydrocele of the canal of Nuck and its complications. Moreover, other rare pathologic conditions involving the inguinal area may be depicted at US, which helps guide appropriate treatment. US is the ideal modality for evaluating an inguinal lump in girls and female infants. Online supplemental material is available for this article. © RSNA, 2022.

Objective: To perform a systematic review and meta-analysis evaluating the peri-operative outcomes, complications, and oncological outcomes of Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL)/Video-Endoscopic Inguinal Lymphadenectomy (VEIL) with Open Inguinal Lymph-Node Dissection (OILND) for management of inguinal lymph-nodes in carcinoma of the penis., Methods: A comprehensive literature search was performed in January 2021 using the PubMed, Embase, and Cochrane databases. Data from human studies comparing RAVEIL/VEIL vs. OILND in carcinoma of penis published in English was extracted and analyzed by two independent authors., Results: Two Randomised Controlled Trials and 6 cohort studies were included in the meta-analysis. RAVEIL/VEIL group exhibited increased operative time (Mean Difference [MD] = 15.28 [14.19; 16.38], P < 0.001), shorter hospital stay (MD = -1.06 [-1.14; -0.98], P < 0.001), and decreased duration of drainage (MD = -2.82 [-3.21; -2.43], P < 0.001), wound infection (Odds Ratio [OR] = 0.15 [0.08; 0.27], P < 0.001), skin necrosis (OR = 0.12 [0.05; 0.28], P < 0.001), lymphedema (OR = 0.41 [0.24; 0.72], P = 0.002), and major complications (OR = 0.11 [0.05; 0.24], P < 0.001) as compared to OILND group. Recurrence rate and number of deaths were comparable in both the groups. RAVEIL/VEIL groups showed slightly larger lymph-node yield (MD = 0.44 [0.18; 0.70], P < 0.001) as compared to OILND group., Conclusion: RAVEIL/VEIL has lesser skin complications, lymphedema, and better lymph-node yield as compared to OILND. It is comparable in terms of lymphocele and recurrence. It has lesser hospital stay and duration of drainage but owing to heterogeneity, the results should be interpreted with caution. Further studies are required to determine long-term oncological outcomes like overall survival and disease-specific survival., Competing Interests: Conflict of interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To assess the feasibility, safety, and efficiency of bilateral inguinal lymphadenectomy using simultaneous double laparoscopies for penile cancer., Materials and Methods: We reviewed retrospectively the records of 65 patients who underwent inguinal lymph nodes dissection (ILND) for penile cancer from January 2012 to May 2019. Treatments included open ILND (OILND, 19 patients), video-endoscopic inguinal lymphadenectomy (VEIL) using single laparoscopy (S-VEIL, 24 patients), and VEIL using double laparoscopies (D-VEIL, 22 patients). We evaluated the peri-operative and short-term oncological outcomes of the three groups., Results: The mean operative time of D-VEIL (105.91 ± 10.87 minutes) was significantly shorter than the other two groups, OILND shorter than S-VEIL (160.47 ± 13.74 minutes, 191.67 ± 17.80 minutes, respectively) (P < 0.001). Intraoperative blood loss in the S-VEIL and D-VEIL groups were 53.54 ± 8.78 and 48.41 ± 13.22 ml, respectively; they were significantly lower than that of the OILND group (99.74 ± 9.64 ml; P < 0.001). The numbers of unilateral and total lymph nodes harvested were similar in all groups. The complication rates in the S-VEIL group (4.2%) and the D-VEIL group (4.5%) were significantly lower than that in the OILND group (63.2%; P < 0.001). Compared with open surgery (13.53 ± 1.74 days for hospitalization; 11.37 ± 1.92 days for the left side of drain, 11.95 ± 1.84 days for the right side), the two VEIL groups had significantly shorter drainage tube residence time (7.42 ± 2.02 and 7.32 ± 1.52 days, respectively for the left side; 7.63 ± 1.81 and 7.27 ± 1.58 days, respectively for the right side), shorter postoperative hospitalization (9.46 ± 1.64 and 9.00 ± 1.83 days, respectively) (P < 0.001). There were no statistically significant differences in rates of regional recurrence and short-term survival among the three groups., Conclusion: Bilateral inguinal lymphadenectomy using double laparoscopies simultaneously can provide adequate oncological outcomes safely and efficiently, and carry significantly lower morbidity than OILND, at a median follow-up of 33.5 months. It is a more time-saving surgical approach for penile cancer patients who need bilateral ILND., Competing Interests: Conflict of interest All the authors declare that they have no conflict of interest., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Aims: We report the first UK case series of minimally invasive inguinal lymphadenectomy (MILND) for patients with metastatic cutaneous pathology., Methods: This was a retrospective, single-centre, single-surgeon cohort study. Twenty-one patients who underwent MILND from May 2015 to February 2019 were included. Demographic data, disease burden, and surgical quality assurance parameters were analysed., Results: Median age was 69 (IQR: 58-76) with 14 women (66%) and 7 men (33%). Eighteen (85%) patients had melanoma with the rest having other skin malignancies. The median number of nodes resected was eight (IQR:6-11) and the median N-ratio was 0.18 [0.05-1.00]. The median surgical time for the procedure was 180 minutes (IQR: 147-225) Seven (33%) patients had complications--three trivial and four (19%) grade IIIB. Only one case (the first) was converted to an open procedure., Conclusions: We report the first UK series of MILND in a cutaneous oncology service. Our results show that MILND is a safe technique that can be introduced into a busy NHS practice with a structured training program, with surgical quality assurance outcomes identical to open inguinal lymphadenectomy. Our learning curve was similar to previously published data., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest and nothing to disclose., (Copyright © 2021. Published by Elsevier Ltd.)

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies., Competing Interests: Declaration of competing interest None., (Copyright © 2021. Published by Elsevier B.V.)

Introduction: Penile cancer (PC) is an aggressive malignancy in which the most important prognostic factor for cancer specific survival (CSS) is the involvement of regional lymph nodes (LNs). Lymph node density (LND) could become a superior prognostic tool for CSS, by accounting for both extent of dissection and nodal disease burden. We aim to validate LND as a prognostic factor for CSS in a contemporary series of patients with PC treated and followed at a single high-volume center, treating more than 25 PC patients per year, over a 13-year period., Methods: Clinical charts of all patients with PC who underwent surgical treatment between 2007 and 2020 were reviewed. Clinicopathological data was collected and analyzed retrospectively. We only included patients with ≥ 8 LNs removed in a unilateral ILND or ≥16 LNs when a bilateral approach was used. We attempted to find an optimal threshold for LND, capable of maximizing effect difference in terms of CSS and RFS between dichotomized groups. To determine this threshold, we used the chi-squared and the Mann-Whitney tests, and it was required to fulfill the proportional hazards assumption. We assessed different thresholds previously reported in the literature. In our study the optimal threshold for LND was determined to be ≤ 20% Descriptive statistics were used to summarize patient characteristics, CSS and RFS were graphically represented by Kaplan-Meier estimates. Harrell's C index for CSS and RFS were calculated for LND and pN stage, to determine which variable has a superior predictive capacity RESULTS: We identified 110 patients with PC who underwent ILND at our institution, of these, 87 were node-positive and were included in the final analysis. Overall estimates of CSS showed a 3-year CSS of 43% (95% CI: 32-54), the estimated 3-year CSS for the patients with a LND ≤ 20% was 69% (95% CI: 50-82) and 26% (95% CI: 14-39) in the group with a LND >20% (Log-rank P = 0.001). The estimated 3-year RFS for the patients with LND ≤ 20% was 61% (95% CI: 42-76) and 30% (95% CI: 16-44) in the group with a LND >20% (Log-rank P = 0.009). The results of univariate analysis indicate that in patients with a LND >20% the risk for cancer specific mortality was increased (HR 2.68; 95% CI: 1.45-4.98, P =  0.002) compared with LND ≤ 20%. In the and Cox multivariate analysis after Adjusting for age and pN stage the association increased (HR 2.73; 95%, CI 1.38-5.40, P = 0.004). Harrell´s C index for CSS was 0.63 for LND vs. 0.54 for pN stage, suggesting a 9% higher concordance for LND and CSS., Conclusions: Lymph node density stands as a promising tool for risk-stratifying patients with node-positive PC after ILND. In this retrospective study, LND was a significant predictor of CSS and RFS when using a LND >20% threshold, and also showed a superior predictive ability than pN stage. These results support the use of the LND parameter in clinical practice with a final goal to improve risk stratification, and individualized adjuvant treatment decision-making to patients with high-risk of cancer specific mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To identify incidence and risk factors for upstaging from cN1 to pN2/N3 at inguinal lymphadenectomy (ILND) for penile cancer (pSCC). Our secondary objective is to assess survival outcomes and associations for cN1 patients undergoing ILND., Subjects/patients and Methods: Patients with pT≥1cN1cM0 pSCC who underwent bilateral ILND and had complete data were identified in a multi-institutional international cohort from 8 referral centers in 7 countries diagnosed from 1980 to 2017. Upstaging was defined as pN2/N3 at ILND. Multivariable logistic regression analysis was used to determine associations with upstaging, and Cox multivariable logistic regression analysis to determine associations with overall survival (OS)., Results: Of 144 patients were included in the final study population. 84 patients (58%) were upstaged from cN1 to pN2/N3, and 25 (17%) were down staged to pN0. Upstaging was associated with pT3/T4 (OR 4.1, 95%CI 1.5-11.7, P < 0.01) and pTX (OR 7.1, 95CI 1.6-51.1, P = 0.02). Age, smoking status, HPV status, and LVI were not associated with upstaging. Age (HR 1.03/y, 95%CI 1.01-1.06, P < 0.01) and upstaging (HR 2.8, 95%CI 1.3-5.9, P < 0.01) were associated with worse OS. Upstaged patients had a 5-year OS of 49%, compared with 86% for patients who were not upstaged., Conclusion: The majority of cN1 pSCC patients harbor a higher-risk disease state than their clinical staging suggests, especially those with higher pT stages. More intensive pre-operative workup may be warranted for these patients to identify upstaging prior to ILND and potentially qualify them for neoadjuvant chemotherapy or clinical trials., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Despite numerous experimental studies presenting laparoscopic treatment of inguinal hernia in a pig model so far no described technique has been used in clinical patients of this species. Minimal invasiveness and the simplicity of closure of the inguinal canal using the Percutaneous Internal Ring Suturing (PIRS) technique makes it the world's first technique for laparoscopic treatment of inguinal hernia in pigs as clinical patients., Aim: This study aims to assess the applicability and effectiveness of the laparoscopic PIRS technique in the treatment of inguinal hernia in pigs as clinical patients and to compare the PIRS technique with the open surgery technique, which is currently being used., Methods: The study was conducted on 22 non-castrated male pigs with inguinal hernia (clinical patients), divided into two equal groups: PIRS and open surgery (OS). In the PIRS group, the inner inguinal ring was closed with an optical trocar inserted at the umbilicus level and an injection needle with a suture material inserted percutaneously over the inguinal canal. The suture material was threaded through the inner inguinal ring and then tied, leaving the knot under the skin. As a result to this the inguinal canal was closed. In the OS group the procedure was performed with open access above the inguinal canal where, after dissection of the vaginal processus and reducing the contents of the hernia to the abdominal cavity, it was ligated as close to the inguinal canal as possible, and the wound was then closed in layers., Results: All operated pigs returned to full fitness immediately after recovery from anesthesia. There was one case of hernia recurrence in the PIRS group. In the OS group all the operated pigs had a temporary swelling of the postoperative wound and the scrotum on the side of the operated inguinal hernia, which was not found in the PIRS group., Conclusions: The effectiveness of the PIRS technique is comparable to that of open surgery. Considering the simplicity of the PIRS procedure and its minimal invasiveness, this technique may be used as an alternative to the open technique in the treatment of inguinal hernias in pigs not subjected to surgical castration., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Inguinal lymph node dissection (ILND) is essential to the accurate staging of advanced penile cancer and in determining prognosis. Open ILND is associated with significant morbidity. The robotic-assisted approach has been described with comparable nodal yield with the advantage of decreased postoperative complications when studied with the multiport robotic platform. This video shows our approach for an ILND with the Intuitive single port (SP) robotic platform., Method: A 54-year-old man underwent a partial penectomy for a penile mass that revealed squamous cell carcinoma invading the corpus spongiosum (pT2). Patient had non-palpable lymph nodes on physical examination. We proceeded with the bilateral inguinal lymph node dissection using the Intuitive da Vinci Single-Port Robot., Results: A standard template dissection was performed on both sides. Due to nodal enlargement noted on the pre-operative CT scan on the right side, superficial and deep ILND were performed on that side. Intra-operative frozen section pathologies of superficial lymph nodes were negative on the left side. Bilateral saphenous veins were preserved. Total procedure time was 4 hours and 51 minutes in duration with minimal blood loss noted (<30 mL). Pathology revealed one 4.5cm superficial positive node on the right with no extra-nodal extension and no other positive nodes. No complications were noted. He was discharged on post-operative day 1 with minimal pain or leg swelling., Conclusions: We describe the technique and feasibility of ILND using the SP robotic platform. This approach has the potential to reduce morbidity with comparable nodal dissection as the open approach., (Copyright © 2021. Published by Elsevier Ltd.)