Author reply Re: Kandasamy SG, Chandran KR, Pooleri GK. Minimal invasive approaches in lymph node management of carcinoma of penis: A review. Indian J Urol. 2022;38:15-21

We are grateful to the readers for highlighting the important issues related to videoendoscopic inguinal lymphadenectomy (VEIL). The letter needs to be read as an adjunct to our article[1] as our concerns in the articles were highlighted by the authors of the letter.

1. We agree that unnecessary violation of deep fascia for lymphadenectomy can be an overtreatment. In VEIL, the integrity of the skin is maintained and the dissection is limited to medial aspect of the femoral vessels, which can hypothetically reduce the chance of complication including lymphedema. It also gives a better sampling of lymph nodes and avoids a second surgery. The risk–benefit of the procedure needs to be assessed. As rightly mentioned in the letter, there is no comparative study between superficial lymphnode dissection and VEIL. Only focused studies addressing the issue can find an answer to the valid points raised in the letter

2. The possibility of extracapsular spread increases with the size of the lymph nodes. We are skeptical about the role of VEIL in patients with larger lymph node burden where there is a possibility of extracapsular extension. Skin resection is needed if there is any fixity or suspicion of extracapsular spread, and in those cases, VEIL should not be attempted.

There is a lack of evidence about VEIL in a number of areas. Even though it is an exciting procedure, it needs to be used selectively and we accept all the concerns highlighted by the readers. It is more appropriate in clinically node negative or low volume lymph node disease where the chance of extracapsular extension is less. Since the complication rates are low with VEIL, the risks and benefits related to the possible overtreatment need to be studied in focused studies comparing the respective study populations.