Suprapubic antegrade endoscopic inguinal lymphadenectomy with great saphenous vein preservation for penile cancer: a stepwise technique (with video)

Abstract

Objective

To assess the feasibility and safety of suprapubic incision antegrade endoscopic inguinal lymphadenectomy with preservation of the great saphenous vein and its branches in penile cancer treatment.

Methods

Between February 2023 and July 2024, penile cancer patients undergoing suprapubic incision endoscopic inguinal lymphadenectomy with great saphenous vein and branch preservation were recruited from the Urology Departments of Huai’an First Hospital Affiliated to Nanjing Medical University and Xuzhou Cancer Hospital. Fifteen patients (mean age: 67.4 ± 8.85 years) were included, all having undergone partial penectomy. Postoperative pathology confirmed tumor stages ≥ T1b, and no distant metastasis was observed. In the supine position, a subcutaneous space was created under direct vision, followed by establishment of endoscopic working channels. Dissection encompassed superficial and deep inguinal lymph nodes while preserving the great saphenous vein trunk and branches. Anatomical boundaries were defined as: upper border—line between external ring upper edge and anterior superior iliac spine; outer border—line from anterior superior iliac spine to 20 cm inferior; inner border—medial thigh from pubic tubercle to 15 cm inferior; lower border—line connecting lower edges of inner and outer boundaries.

Results

All patients underwent successful bilateral inguinal lymphadenectomy. Mean operation duration was 96 ± 18.8 min, with mean blood loss of 41.3 ± 16.2 ml. Average lymph node yields were 7.3 ± 3.9 (left) and 9.5 ± 4.4 (right). Drainage tubes were indwelling for 7.7 ± 2.0 days, with total drainage volume of 274.7 ± 126.4 ml, and mean hospital stay was 8.7 ± 1.8 days. All wounds achieved grade A healing. Postoperative complications included 1 lymphocele and 1 lymphorrhea, both resolved with symptomatic management. During 9–25 months of follow-up, no cases of wound infection, subcutaneous hematoma, lower limb edema, skin necrosis, or local/distant metastasis were observed.

Conclusions

Suprapubic incision antegrade endoscopic inguinal lymphadenectomy with great saphenous vein and branch preservation exhibits definite therapeutic efficacy and minimal complications, justifying cautious clinical implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-025-04159-5.

Introduction

Penile cancer, as a rare malignant tumor of the genitourinary system, accounts for less than 1% of adult malignant tumors in developed countries [1]. However, in developing regions, the incidence of the disease is significantly higher. In some African and South American countries, the incidence of penile cancer can be as high as 10% of male cancers [2, 3].

The disease mainly spreads through the lymphatic pathway, first involving the inguinal lymph nodes, and then extending to the pelvic and retroperitoneal lymph nodes. Clinically, involvement of inguinal lymph nodes is relatively common [4]. For patients with inguinal lymph node metastasis or those without inguinal lymph node enlargement on clinical examination but have other high-risk factors, inguinal lymph node dissection is currently recognized as the preferred treatment method. This surgery aims to remove possible metastatic foci, reduce the risk of disease recurrence, and improve the survival rate and quality of life of patients [5].

The mainstream surgical approaches for inguinal lymph node dissection are currently open surgery and standard endoscopic surgery. Although these procedures have shown important value in clinical practice, they still have certain limitations. Open surgery is prone to complications such as incision infection, skin flap necrosis, and subcutaneous hematoma after surgery, which limits its clinical application [6]; while standard approach endoscopic surgery may cause lymphatic leakage, lymphocele, lower limb edema, and other conditions [7, 8]. Therefore, exploring a more advantageous new surgical method is still an important clinical research direction.

In view of this, we innovatively performed suprapubic approach antegrade endoscopic inguinal lymph node dissection with preservation of the great saphenous vein and its branches. This surgical procedure has small trauma and pays attention to preserving the great saphenous vein and its branches, aiming to optimize the surgical effect and reduce complications. The report is as follows.

Patients and methods

Research subjects

This study enrolled 15 patients with penile cancer who underwent bilateral inguinal lymph node dissection at Huai’an First Hospital Affiliated to Nanjing Medical University and Xuzhou Cancer Hospital from February 2023 to July 2024. All patients underwent suprapubic incision antegrade endoscopic inguinal lymph node dissection with preservation of the great saphenous vein and its branches. The age of the patients ranged from 54 to 80 years (67.4 ± 8.85 years). All patients underwent whole-abdominal lymph node assessment and evaluation of organ metastasis status via CT or PET-CT. Preoperative imaging (CT/PET-CT) revealed enlarged inguinal lymph nodes in 5 patients, with 4 of these showing palpable enlarged inguinal lymph nodes. All patients had tumors located in the distal penis and were diagnosed with squamous cell carcinoma via biopsy of the primary penile lesion, following which partial penectomy (with a resection margin of at least 0.5 cm beyond the tumor edge) and reconstruction were performed. According to the pathological results, 10 patients were in pT1b stage, 4 in pT2 stage, and 1 in pT3 stage. Subsequently, suprapubic incision antegrade endoscopic inguinal lymph node dissection was carried out. Sentinel lymph node biopsy was performed simultaneously in 4 patients with palpably enlarged inguinal lymph nodes, and only 1 case suggested inguinal lymph node metastasis.

Inclusion criteria

(1) Pathologically diagnosed of penile squamous cell carcinoma; (2) Pathological T stage reaching T1b or higher, or clinical N stage reaching cN1-cN2, or positive sentinel lymph node biopsy; (3) Patients unable to adhere to long-term close follow-up. Exclusion criteria: (1) Patients who cannot tolerate surgery due to poor physical condition or cardiac/pulmonary dysfunction; (2) Patients with severe hematological diseases; (3) Acute inflammation or old scars in the inguinal region; (4) Preoperative imaging (CT/PET-CT) showing distant metastasis.

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committees of Huai’an First Hospital Affiliated to Nanjing Medical University and Xuzhou Cancer Hospital. Informed consent was obtained from all patients.

Preoperative preparation

Intravenous antibiotics were administered daily for 2 days preoperatively, and the perineal area was cleansed. Liquid diet was provided one day before surgery. The surgical site was shaved on the morning of the operation.

Surgical method

Surgical Position and Trocar Placement All included patients underwent partial penectomy with reconstruction following a diagnosis of penile cancer confirmed by local biopsy, which was subsequently followed by endoscopic inguinal lymph node dissection via a suprapubic approach. General anesthesia was routinely used, and patients were placed in a supine position with both lower limbs slightly separated and externally rotated. The surgeon stood on the opposite side of the lymph nodes to be removed, the scopist was on the same side as the surgeon, and the monitor was positioned at the foot of the bed, facing the surgeon. For the observation port, a 2-cm transverse incision was made at the midline, three finger-breadths above the pubic symphysis. The skin and subcutaneous fat layers (including Camper’s fascia and Scarpa’s fascia) were incised to reach the surface of the anterior rectus sheath. The space on the surface of the anterior sheath was bluntly dissected with fingers, and a dilating balloon was inserted and inflated with approximately 200 ml of air. Following adequate dilation, a 10-mm trocar was inserted as the observation port. For right inguinal lymph node dissection, a 5-mm trocar was inserted approximately 2 cm medially and superiorly to the right anterior superior iliac spine; guided by fingers to avoid structures such as the spermatic cord in the scrotum, a 5-mm trocar was inserted at the lowest point of the midline at the bottom of the scrotum. The line connecting this insertion point and the point approximately 2 cm medially and superiorly to the anterior superior iliac spine was parallel to the course of the inguinal ligament, and the trocar was fixed with silk thread after insertion. For the left side, a 5-mm trocar was placed approximately 2 cm medially and superiorly to the left anterior superior iliac spine, and the trocar insertion position at the bottom of the scrotum remained unchanged. The port site configuration is illustrated in Fig. 1, with details shown in Fig. 2.

Fig. 1.

Diagram of port sites for suprapubic antegrade endoscopic inguinal lymphadenectomyA. 10-mm Trocar observation port above the pubic symphysis; B&D. 5-mm Trocar operating ports at the left/right anterior superior iliac spine; C. 5-mm Trocar operating port at the lowest point of the scrotum

Fig. 2.

Approach and trocar layout of antegrade endoscopic inguinal lymphadenectomy via supra-pubic approach (left side)A. Supra-pubic incision approach; B. Creating the surgical space with a self-made balloon; C. Layout of surgical instruments and Trocars during the operation; D. Position of the Trocar at the bottom of the scrotum after inflation; E. Patient position, surgeon's standing position, and monitor location

Lymph Node Dissection Range The dissection range is defined as follows: the upper boundary is the line connecting the upper margin of the external inguinal ring to the anterior superior iliac spine; the lateral boundary is the line extending 20 cm inferiorly from the anterior superior iliac spine; the medial boundary spans from the pubic tubercle to a point 15 cm inferiorly on the medial thigh; and the inferior boundary terminates at the apex of the femoral triangle.

Surgical Steps (1) Dissection of Superficial Lymph Nodes: Dissect and remove the superficial lymph nodes to expose Scarpa’s fascia. Incise this fascia and dissect deeply until reaching the inguinal ligament; (2) Vascular Exposure and Lymph Node Clearance: Dissect distally along the inguinal ligament to expose the femoral artery and vein. Remove the soft tissues and lymph nodes anterior to and on both sides of the femoral vessels; (3) Great Saphenous Vein Preservation: Further dissect distally and laterally to isolate the great saphenous vein and its tributaries, then clear the surrounding lymph nodes and adipose tissues within the previously described scope. When dissecting the tissues lateral to the femoral artery below the fossa ovalis, pay attention to avoiding injury to the adjacent femoral nerve; (4) Specimen Removal and Drainage: The postoperative specimen is removed through the suprapubic incision, and the negative pressure drainage tube is placed in the trocar port at the anterior superior iliac spine. The surgical procedure for the contralateral side is the same. The great saphenous vein and its tributaries are preserved intact as much as possible throughout the operation. For detailed information, please refer to Figs. 3 and 4.

Fig. 3.

 Flow diagram for steps of suprapubic antegrade endoscopic inguinal lymphadenectomy

Fig. 4.

Steps and outcomes of antegrade endoscopic inguinal lymphadenectomy via supra-pubic approach A. Dissection of lymph nodes during the operation; B. Scope of surgical dissection (marked with a Marker pen) and the incision at the bottom of the scrotum after the operation; C. Preservation of the main trunk of the great saphenous vein and its tributaries during the operation (left side); D. Position of the drainage tube after the operation

Postoperative Management Elastic bandages are used to wrap the surgical site for support and compression, thereby reducing swelling and bleeding. Patients are encouraged to ambulate early. Routine negative-pressure drainage is implemented, with close monitoring of the drainage volume. The drainage tube is removed when the volume is less than 50 ml for 48 consecutive hours. If the postoperative pathology shows pN2 or higher, further pelvic lymphadenectomy or chemoradiotherapy will be performed electively.

Results

All 15 patients successfully underwent the surgery the surgery. Postoperative lymph node pathological staging showed pN0 in 6 cases, pN1 in 4 cases, and pN2 in 5 cases. The operative duration was 72–128 (96 ± 18.8) minutes. The average number of dissected lymph nodes was 2–14 (7.3 ± 3.9) on the left side and 4–20 (9.5 ± 4.4) on the right side. Intraoperative blood loss was 20–80 (41.3 ± 16.2) ml. The total postoperative drainage volume was 145–580 (274.7 ± 126.4) ml. The drainage tube removal time was 5–11 (7.7 ± 2.0) days, and the postoperative hospital stay was 6–12 (8.7 ± 1.8) days. The main trunk of the great saphenous vein was preserved in all patients, with 4–5 tributaries retained (calculated based on the side with fewer tributaries preserved). The perioperative data of the 15 patients are summarized in Table 1. During a follow-up period of 9–25 months, no complications such as lower limb edema, local skin necrosis, subcutaneous hematoma, scrotal edema, testicular edema, or erectile dysfunction were observed in any patient. One patient developed a lymphocele, and one had lymphatic leakage, both of which were cured and discharged after symptomatic treatment. No local or distant metastasis was found in any patient during the follow-up.

Table 1.

Perioperative data of 15 patients

Number	Age(year)	pT staging	cN staging	pN staging	cM staging	Number of dissected lymph nodes (right)	Number of dissected lymph nodes (left)	Number of preserved great saphenous vein tributaries
1	55	pT1b	cN0	pN0	cM0	5	2	4
2	67	pT2	cN1	pN2	cM0	13	12	4
3	63	pT1b	cN0	pN0	cM0	8	5	4
4	58	pT1b	cN0	pN0	cM0	8	6	4
5	74	pT1b	cN0	pN1	cM0	8	7	4
6	76	pT3	cN2	pN2	cM0	20	9	5
7	78	pT2	cN1	pN2	cM0	14	11	4
8	59	pT1b	cN0	pN1	cM0	12	2	4
9	61	pT1b	cN0	pN0	cM0	5	2	5
10	64	pT1b	cN0	pN0	cM0	4	6	4
11	77	pT1b	cN0	pN1	cM0	9	7	5
12	54	pT2	cN1	pN2	cM0	14	8	4
13	80	pT1b	cN0	pN1	cM0	5	13	5
14	72	pT2	cN1	pN2	cM0	8	14	5
15	73	pT1b	cN0	pN0	cM0	9	6	5
Total	67.4 ± 8.85	-	-	-	-	9.5 ± 4.4	7.3 ± 3.9	4.4 ± 0.5

Number	Surgical time (min)	Intraoperative blood loss (ml)	Total drainage volume (ml)	Postoperative tube removal time (d)	Postoperative hospital stay (d)
1	92	20	145	5	7
2	100	30	300	9	10
3	86	40	450	10	11
4	73	80	150	5	6
5	116	60	180	6	8
6	128	50	175	7	9
7	74	30	270	8	10
8	80	40	330	9	9
9	93	20	375	10	10
10	118	50	580	11	12
11	126	55	150	5	6
12	72	25	210	7	7
13	85	35	200	7	8
14	95	45	365	9	10
15	102	40	240	7	8
Total	96 ± 18.8	41.3 ± 16.2	274.7 ± 126.4	7.7 ± 2.0	8.7 ± 1.8

Discussion

Penile cancer is a relatively rare tumor of the male reproductive system, with a significant impact on patients’ physical and mental health and quality of life. In recent years, numerous studies have thoroughly explored its epidemiology, prognostic factors, and treatment modalities. These studies have identified tumor size and lymph node status, among other factors, as significant influencers of patient prognosis. Additionally, early diagnosis and comprehensive treatment strategies are critical for improving patients’ quality of life [9–11]. Inguinal lymph node metastasis in penile cancer is one of the key prognostic factors affecting patient survival. Relevant research data indicate that approximately 20%−40% of all penile cancer patients develop inguinal lymph node metastasis. Notably, for patients undergoing inguinal lymph node resection alone, this surgical approach may itself achieve disease cure. Thus, inguinal lymph node dissection has become an essential component of standardized surgical treatment for penile cancer [12].

The optimal timing for inguinal lymph node dissection remains controversial. The National Comprehensive Cancer Network (NCCN) guidelines [13] take a relatively proactive stance, recommending inguinal lymph node dissection for patients with primary lesions pathologically staged T1b or higher. Conservative management is only applicable to low-risk penile cancer (PeIN, Ta, and T1a stages) with normal lymph nodes. All 15 patients included in this study had local tumor stages of T1b or higher, with no distant metastasis. Reports have indicated that some surgeons intentionally preserve the great saphenous vein or its tributaries during inguinal lymph node dissection. Findings showed that patients with preservation of only the great saphenous vein did not develop postoperative adverse events such as skin flap necrosis or infection. Furthermore, patients with preservation of both the great saphenous vein and its tributaries had a lower incidence of thrombosis, lymphatic leakage, and lymphocele. This underscores the importance of preserving the great saphenous vein system during such surgeries, as it not only helps reduce postoperative complications but may also positively influence patients’ postoperative recovery and final treatment outcomes [14]. Therefore, in this study, meticulous dissection was performed to protect relevant blood vessels, with successful preservation of the great saphenous vein and its branches in all patients.

The traditional surgical approach for inguinal lymph node dissection in penile cancer is open surgery, which is associated with numerous complications—including incision infection, skin flap necrosis, subcutaneous hematoma, lower limb edema, and lymphatic fistula—significantly limiting its clinical application [15]. To address this, endoscopic inguinal lymph node dissection has emerged, markedly reducing such complications. Currently, endoscopic techniques primarily include three approaches: the standard, subabdominal subcutaneous, and lateral approaches. The standard approach involves making an incision 3 cm below the apex of the femoral triangle, dissecting through the Scarpa’s fascia layer, insufflating the space, and inserting a trocar and endoscope. Although this technique provides a direct pathway, its limited operative space restricts eyepiece movement and assistant positioning [16–18]. The subabdominal subcutaneous approach uses an observation port 1 cm below the umbilicus, with trocars inserted at the midpoints of the umbilicopubic and umbilico-anterior superior iliac spine lines, making it suitable for inguinal and pelvic surgeries. However, it involves a long subcutaneous tunnel, slightly higher technical difficulty, and increased postoperative drainage [7, 19]. The lateral approach places trocars outside the sartorius muscle to facilitate dissection but is constrained by the narrow subcutaneous space, impeding manipulation [20]. Thus, we innovatively developed the suprapubic incision antegrade endoscopic inguinal lymph node dissection with preservation of the great saphenous vein and its branches. This approach combines advantages such as an optimal distance between ports, a short subcutaneous tunnel, and a large operative space, featuring minimal trauma and enhanced surgical maneuverability for the operating team.

In this study, all 15 surgeries were successfully completed, and the preliminary experience is summarized as follows: (1) When dissecting the superficial subcutaneous fascia layer, adipose tissue can be separated to ensure sufficient operative space and vision while maintaining skin flap blood supply; (2) During dissection of superficial lymph nodes, the upper margin of the dissection scope exceeds the inguinal ligament by approximately 3 cm, extending laterally to the lateral margin of the sartorius muscle, medially to the medial margin of the adductor longus muscle, and inferiorly to the apex of the femoral triangle to ensure complete lymph node dissection; (3) When dissecting deep lymph nodes, care should be taken to avoid injuring the femoral nerve lateral to the femoral artery; (4) Intraoperatively, the femoral vein was first dissected, then dissected distally to the sapheno-femoral junction. Adipose/lymphatic tissues around the junction were dissected and removed, followed by distal dissection of the great saphenous vein’s main trunk and its tributaries; (5) At the end of the operation, tissue gel can be sprayed in the operative area to reduce lymphatic leakage and exudation. Meanwhile, the operative area should be compressed with a bandage to ensure skin adherence to deep tissues, facilitating wound healing and reducing the possibility of skin flap floating; (6) Postoperatively, negative pressure drainage can be used to achieve sufficient drainage, reducing the incidence of inguinal lymphocele and subcutaneous infection; (7) The drainage tube should be removed if the drainage volume is less than 50 ml within 48 h postoperatively, and removal should not be too early; (8) Postoperative pneumatic therapy can be used to prevent lower limb venous thrombosis, with close observation of dorsalis pedis artery pulsation and skin temperature differences in both lower limbs. D-dimer and lower limb vascular ultrasound should be reviewed if necessary. The advantages of this surgical approach are summarized as follows: (1) Maximally preserving the great saphenous vein and its branches, protecting the femoral nerve, reducing postoperative lower limb edema, and minimizing postoperative lower limb pain and numbness; (2) Short subcutaneous tunnel, minimal surgical trauma, low postoperative pain, and less intraoperative carbon dioxide absorption; (3) Shorter distance between the operative manipulation and the surgical field, enabling more precise operation; (4) Convenient removal of specimens through the suprapubic incision; (5) The incision at the bottom of the scrotum is relatively hidden, offering aesthetic advantages.

In this study, the great saphenous vein trunk was preserved in all patients, with 4–5 tributaries retained. This was facilitated by the approach’s proximity to the operative field and enhanced surgical maneuverability, which aided in protecting the great saphenous vein and its tributaries. Additionally, this approach showed favorable outcomes in terms of operative duration, intraoperative blood loss, postoperative drainage volume, and length of postoperative hospital stay. During the 10–19-month follow-up period, no complications such as lower limb edema or local skin necrosis were observed. Only a few cases developed lymphocele or lymphatic leakage, which were cured with symptomatic treatment. These findings indicate that this approach is safe, feasible, and effective.

Conclusion

In conclusion, the suprapubic approach for antegrade endoscopic inguinal lymph node dissection, which preserves the great saphenous vein and its branches, may offer certain potential advantages. These include a reduced risk of lower limb edema, skin flap necrosis, and skin infection, along with relatively straightforward manipulation and more rapid postoperative recovery in applicable cases. Given the critical impact of the integrity of the great saphenous vein and its tributaries on therapeutic efficacy, we recommend emphasizing their thorough preservation during this procedure. However, considering the limitations of this study—such as the small sample size and short follow-up period—caution should be exercised in clinical application. Future research should expand the sample size and extend the follow-up duration to more comprehensively evaluate its long-term efficacy.

Abbreviations

NCCN

National comprehensive cancer network

PeIN

Penile intraepithelial neoplasia

CT

Computed tomography

PET-CT

Positron emission tomography- computed tomography

Authors’ contributions

BZ, YZ and HZ conceived the original idea and operated the patients. BZ, YXH and HTL undertook the initial research. BZ, YXH, HTL and GCW were involved in writing, YZ and HZ reviewed the manuscript, and all authors contributed to the final version.

This study received funding from the science and technology project of Huai’an Health Commission (HAB202107); the science and technology project of Xuzhou Health Commission (XWKYHT20230003); the education research project of Nanjing Medical University (2023ZC129).

Data availability

No data was used for the research described in the article.

Declarations

Ethics approval and consent to participate

The study was approved by the Research Ethics Committees of Huai’an First Hospital Affiliated to Nanjing Medical University and Xuzhou Cancer Hospital. The procedures used in this study adhere to the tenets of the Declarations of Helsinki. The patients have consented to the submission of the article for submission to the journal.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.