Chapter 20

Ilioinguinal Lymphadenectomy
DOUGLAS F. MILAM

The extent of surgical dissection during ilioinguinal lymphad- UNILATERAL DISSECTION

enectomy remains controversial. Historically, in many centers
all patients with invasive penile cancer were treated with radi- Note distribution of lymph nodes and extent of exposure
cal ilioinguinal lymphadenectomy. Surgical treatment remains through an inguinal incision (Fig. 20-1). The black node is
today the most effective staging method, has therapeutic ben- the sentinel node. This node, usually the first to be involved
efit for those with minimal nodal disease, and provides effec- with penile carcinoma, lies no more than 1 cm away from
tive local control for high-volume nodal disease. Many investi- the superficial epigastric vein. In some cases, more than one
gators have questioned the need for radical ilioinguinal lymph node is found in this group. In this situation, all
lymphadenectomy in patients with clinically normal examina- nodes should be removed, but the sentinel node is always
tions. Less aggressive modified lymphadenectomy designed to the larger and more medially situated.
minimize postoperative morbidity in patients without evidence
of grossly positive nodes is now widely practiced (Catalona WJ. Sentinel Node Biopsy
Modified Inguinal Lymphadenectomy for Cancer of the Penis
with Preservation of Saphenous Veins: Technique and Prelimi- The usefulness of sentinel node biopsy is debated. Modi-
nary Results, J Urol 1988; 140: 306-310). Modified lymphade- fied superficial saphenous vein–sparing lymph node dis-
nectomy provides better staging information and better cancer section for patients with a clinically normal inguinal exam
control than sentinel node biopsy. can be strongly advocated. Sentinel node biopsy is dis-
Partial or total penectomy is performed at a separate set- cussed here for completeness. Proceeding directly to node
ting to determine the depth and extent of tumor invasion. dissection, even without evidence of nodal involvement,
Palpable inguinal lymph nodes may be due either to the is advocated with increasing frequency because 20% of
spread of tumor or inflammation due to chronic infection at patients with metastasis have no external evidence of
the primary tumor site. Treatment with oral antibiotics may nodal involvement.
minimize postoperative complications and are helpful in To biopsy the sentinel node, make a 5-cm incision
reducing the size of inflammatory nodes. For palpable 2 fingerbreadths lateral and 2 fingerbreadths inferior to
nodes, treat with antibiotic agents for 4 to 6 weeks before the pubic tubercle, positioning it over the junction of the
performing inguinal lymphadenectomy. Patients with palpa- saphenous vein with the femoral vein. Insert the index fin-
bly gross tumor should be treated with radical inguinal ger under the flap in the direction of the pubic tubercle to
lymphadenectomy. Other patients with a high-risk primary palpate the sentinel node group. Retraction of the small
tumor, but clinically negative nodes may be treated with flap allows dissection of the local nodal group while pre-
modified inguinal lymphadenectomy. serving all surrounding structures.
On the day of lymphadenectomy, give appropriate intra- It is usually better to perform biopsy and frozen section
venous antibiotics perioperatively and postoperatively. After examination as a step in the lymphadenectomy rather than
resecting gross inguinal metastasis using radical inguinal as a separate procedure. If the frozen section biopsy results
lymphadenectomy, consider a myocutaneous flap to repair are positive from the sentinel node, proceed with lymphad-
the defect. Select unilateral dissection if ipsilateral nodes enectomy. During modified lymphadenectomy, consider
are detected late after penectomy; perform bilateral dissec- performing a biopsy of the sentinel node first; if it is nega-
tion for most patients due to bilaterality of nodal metastasis. tive and no nodes are palpable, then a more superficial
Instruments. Include a marking pen, skin hooks, loop saphenous vein sparing procedure may be considered. The
retractors, vascular clips, closed suction, and a standard presence of positive nodes may necessitate radical lymph
surgical tray. node dissection.

123
124 SECTION IV ■ PENIS: MALIGNANCY

10cm

8cm
Linguinal fold
2cm

Superficial
circumflex iliac v.
6cm

Saphenous v.

Lateral accessory
saphenous v.

Sentinal node of Cloquet

Femoral a.

FIGURE 20-1.

If a percutaneous biopsy has been previously performed, vein to minimize lower extremity lymphedema, uses a
incise the tissue widely around the site and include the skin shorter 10-cm incision, avoids dissection lateral to the femo-
in the specimen. ral artery, and eliminates the need for sartorius muscle
transposition.
Modified Inguinal Lymphadenectomy for Position. Abduct and externally rotate the thigh, and
Squamous Cell Carcinoma of the Penis place a small pillow under the knee. Anchor the foot to the
opposite leg (Fig. 20-2). Put the elastic stocking on to the
The modified lymphadenectomy described here has a level of the knee; after the operation, extend it to the thigh.
lower complication rate than the traditional radical opera- Venous compression stockings are helpful to minimize the
tion. Modified lymphadenectomy preserves the saphenous chance of deep venous thrombosis. Drape to expose the
 CHAPTER 20 ■ ILIOINGUINAL LYMPHADENECTOMY 125

FIGURE 20-2.

umbilicus, pubic tubercle, anterior superior iliac spine, and and if the nodes are not palpable, excise one of them for
anterior thigh. It may be advisable to insert an 18-French biopsy and obtain a frozen-section diagnosis. If the biopsy
urethral catheter through the penile stump. Exposure may results are positive, proceed to the next step.
be improved by suturing the scrotum to the opposite thigh. Important. To prevent lymphoceles, control all subcuta-
Mark a 10-cm skin incision 2 cm below the inguinal fold. neous lymphatics at the periphery of the dissection and
The extent of the tissue to be excised can also be marked leave at least two Jackson-Pratt suction drains under the tis-
with a pen on the skin. Flaps are developed about 8 cm su- sue flaps.
periorly and 6 cm inferiorly. Fashion skin flaps above and below by sharp dissection,
Incision. Incise the skin obliquely from the anterosupe- extending to the marked margins and to the depth of the
rior iliac spine to the pubic tubercle, running it about 2 cm fascia lata (Fig. 20-3). The skin should be supported ade-
below and parallel to the groin crease. If a biopsy specimen quately by developing the plane immediately superficial to
was obtained, excise a strip of skin to include that site; if not Scarpa’s fascia with its attached subcutaneous fat. Use skin

FIGURE 20-3.
126 SECTION IV ■ PENIS: MALIGNANCY

hooks, stay sutures, and retractors. Handle the flap edges Free the deep lateral and medial margins by dissection
gently, and keep them covered with saline-moistened and ligation. When the greater saphenous vein is reached
sponges. Avoid grasping flap edges with forceps, which inferomedially, dissect around it but preserve it to reduce
would crush the tissue. Mobilize to the premarked margins edema of the leg postoperatively (Fig. 20-6). With bulky
but not beyond. If skin is involved with tumor, excise it; disease, the vein may require sacrifice. Avoid dissection in-
consider muscle flap coverage with subsequent skin graft ferolaterally to the fossa ovalis.
placement or the use of a myocutaneous flap. Mobilize the mass by blunt and sharp dissection from
Begin at the upper margin of the incision to expose the the lateral to medial side, over the branches of the femoral
external oblique fascia, and clear the superficial fascia and nerve and then over the femoral sheath (Fig. 20-7). Preserve
areolar tissue downward over the inguinal ligament to the the motor nerves but sacrifice the cutaneous nerves, and
fascia lata of the thigh (Fig. 20-4). divide those branches of the femoral vascular system supply-
Start incising the fascia lata just below the inguinal ing the overlying subcutaneous tissue.
ligament along its lateral margin over the sartorius mus- Mobilize the deep fascia medially from the adductors to
cle, dividing the tissue between clamps and ligating it the femoral sheath and excise the fascia (Fig. 20-8).
with fine synthetic absorbable sutures (Fig. 20-5). Avoid Skeletonize the femoral vasculature medially and anteri-
lymphatic leakage by clipping or tying all identifiable orly in the femoral triangle (Fig. 20-9). Avoid dissection
vessels. lateral to the femoral artery below the fossa ovalis, but ligate

FIGURE 20-4.
FIGURE 20-6.

FIGURE 20-5. FIGURE 20-7.

 CHAPTER 20 ■ ILIOINGUINAL LYMPHADENECTOMY 127
lymph node dissection usually have little or a tolerable
amount of dependent lymphedema. Adding pelvic lymph
node dissection markedly increases the number of patients
who develop severe lymphedema. If needed, pelvic lymph-
adenectomy is usually performed at a separate setting after
the inguinal node dissection has adequately healed. If done
in that way, the pelvic lymphadenectomy can be approached
through a lower midline incision similar to that routinely
performed before radical retropubic prostatectomy. En
bloc pelvic node dissection done in continuity with inguinal
node dissection is described here.

Closure of Radical Inguinal Lymphadenectomy

or When Skin Flap Viability Is Questionable

Aggressive lymphadenectomy for large-volume inguinal

FIGURE 20-8. tumor will necessitate skeletonizing the femoral vessels.
Additionally, tissue coverage of the vessels may be compro-
mised by involvement of tumor into the superficial tissues,
necessitating substantial thinning of skin flaps. In these
cases, reliable coverage of the femoral vessels may be per-
formed by rotation of a muscle flap.

Coverage with Sartorius

Divide the sartorius muscle where it joins the anterior iliac

spine. Place it over the femoral nerve and vessels. Suture it to
the reflection of the inguinal ligament, tacking it laterally as
well (Fig. 20-11). Check the skin margins, especially the lower
margin, and excise any nonviable edges. If necessary, do not
bring the flap edges together and apply a split-thickness skin
graft. This strategy is preferable to having substantial flap
tissue loss later.

Coverage with Rectus Abdominis

Myocutaneous Flap
FIGURE 20-9.
An inferior rectus abdominis myocutaneous flap may be applied
in patients who have extensive unilateral inguinal node
metastasis with disruption of the overlying skin or who
required extensive dissection for inguinal metastasis with
all the branches, thus freeing the deep inguinal nodal mass. consequent postoperative skin breakdown and wound in-
The presence of grossly positive disease may necessitate fection. Raise a flap from the contralateral rectus muscle
resection of nodal tissue lateral to the femoral artery and (see Fig. 20-12). Include an ellipse of skin unless the flap
nerve as part of a radical inguinal lymphadenectomy. is to be covered with a split-thickness graft. Move the flap
Preserve the greater saphenous vein. Dissect it free, leav- anterior to the ipsilateral rectus muscle, and pass it through
ing an empty fossa with the nodal mass attached only at the a subcutaneous tunnel into the groin defect (Fig. 20-12).
femoral canal (Fig. 20-10). Send suspicious nodes for frozen- Place a suction drain in the abdominal defect before
section diagnosis. Grossly positive disease may necessitate closure, and place one in the groin area.
saphenous vein resection. Insert suction drains through nondissected areas, placing
the tubes on both sides of the sartorius muscle (Fig. 20-13).
Pelvic Lymphadenectomy for Squamous Cell Close the skin with absorbable subcuticular sutures. Do not
Carcinoma of the Penis apply a compression dressing. Raise the elastic stocking to the
thigh level. Continue antibiotics for 1 week or longer if drains
The value of pelvic lymphadenectomy in patients with squa- remain present. Position the patient in bed with the foot
mous cell carcinoma of the penis is widely debated. The of the bed slightly elevated for a long enough postoperative
lack of effective chemotherapy causes some urologists to period to ensure flap viability. Remove the drains when out-
advocate resection of gross disease seen on computed put remains low after ambulation. Warn the patient about
tomography imaging. While the value of pelvic lymphade- sitting with the thighs flexed and about the need for wearing
nectomy is debated, the influence on postoperative morbid- the stockings. With this regimen, delayed skin grafting is
ity from lymphedema is not. Patients who undergo inguinal seldom necessary.
128 SECTION IV ■ PENIS: MALIGNANCY

FIGURE 20-10.

FIGURE 20-11.

FIGURE 20-12.
 CHAPTER 20 ■ ILIOINGUINAL LYMPHADENECTOMY 129
progressively exposed. For veins that are avulsed flush with
apertures in the pelvic wall, apply sponge pressure. Because
these veins cannot be clamped, use a 3-0 suture swaged on
an intestinal needle to oversew the site.

POSTOPERATIVE PROBLEMS

Necrosis of the edges of the skin flaps is not uncommon.

Lymphadenectomy often interrupts the blood supply cours-
ing from deep subcutaneous tissue. Small defects may be
debrided and allowed to heal by second intention. Later
application of split-thickness skin grafts may be necessary for
defects that will not readily close by granulation. Wound infec-
tion begins in areas of devascularization and in dead spaces;
it is difficult to really cleanse the bacteria from the skin in
this area. Seromas are not rare and are minimized by the use
of surgical drains. Lymphoceles can form but are inhibited
by ligating all lymphatics and by tacking the skin flaps down
to the muscle, providing adequate suction drainage, and
placing proper dressings. Treat them with intermittent aspi-
ration or by continuous closed percutaneous aspiration.
FIGURE 20-13. Lymphorrhea, however, is rare. Early cautious mobilization of
the patient can reduce the chance of deep vein thrombosis
(DVT) without jeopardizing healing of the wound. Preop-
erative and postoperative low molecular weight heparin and
INTRAOPERATIVE PRECAUTIONS venous compression stockings can reduce the incidence of
DVT and pulmonary embolus. Prolonged lymphatic drain-
Careful dissection prevents venous bleeding. Do not clamp age may be exacerbated by heparin, however. Lymphedema of
blindly. Do not place clamps on the thin-walled pelvic veins; the leg is to be expected, and waist-high elastic stockings
rather, isolate and pass ligatures or use medium-size surgical should be fitted before the patient begins ambulation. Have
clips. If a vein is torn, control bleeding with sponge sticks him keep the leg elevated when sitting and when in bed.
placed above and below the rent to allow suturing Diuretics may help. Paresthesia medial to the operative site
with swaged 5-0 arterial polypropylene suture as the rent is can also be expected but is not disabling.