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Single-Port Antegrade Robotic Lymphadenectomy: A Novel Minimally Invasive Approach to Treat Lymph Nodes in Men with Penile Cancer - Beyond the Abstract

Lymph node (LN) management plays a pivotal role in the prognosis of penile cancer (PenC). Inguinal lymphadenectomy (ILND), when performed early and thoroughly, significantly improves survival, particularly in patients with high-risk or node-positive disease. However, despite strong recommendations from international guidelines,1 LN dissection remains underutilized in clinical practice primarily due to its inherent morbidity.

In fact, open inguinal lymphadenectomy carries a well-documented risk of complications including wound infection, skin necrosis, lymphocele formation, and chronic lymphedema.2,3 Minimally invasive approaches, such as video endoscopic (VEIL)4,5,6 and robot-assisted (RAIL)7,8 ILND were introduced to reduce these complications. However, these are associated with a steep learning curve, are time-consuming, and most require bilateral groin incisions or extensive dissection of the lower abdomen to access both groins,9–13 and adoption has remained limited.

We developed a novel technique as a potential solution to these limitations. The Single-port Antegrade Robotic Lymphadenectomy (SPARL) combines oncological thoroughness with a patient-centered, minimally invasive approach that enables both inguinal and pelvic lymph node dissection via a single small abdominal incision, using the da Vinci SP robotic platform. (Figure 1).

Rationale for a New Approach

PenC follows a predictable lymphatic pathway from the superficial inguinal nodes to deep inguinal and pelvic stations .14 Proper LN staging is crucial for both prognostication and treatment planning. Yet, the morbidity of standard open ILND procedures can delay or even prevent patients from receiving potentially curative surgery.

Our aim with SPARL was to rethink the access route entirely: rather than a retrograde groin-based approach, we conceived an antegrade approach starting from an infraumbilical incision and proceeding downward to the femoral triangle, via the creation of a subcutaneous tunnel. This technique allows for comprehensive nodal removal with minimal disruption to the skin and soft tissue overlying the groin.

SPARL entirely relies on the da Vinci SP platform that, thanks to its articulating, fully wristed instruments and flexible endoscope, is uniquely suited to navigate tight subcutaneous planes, a task that is challenging for multiport or conventional laparoscopic systems.

Early Results from a Pilot Series

In our pilot study, we treated ten men with cT2–3 N0–2 M0 PenC. Half, having refused sentinel node biopsy, underwent SPARL for staging purposes (modified ILND), while the others received therapeutic LND (radical ILND), with one patient also requiring pelvic dissection.

Key perioperative outcomes included:

  • Median operative time: 197 minutes (IQR: 184–249)
  • Median LN yield: 12 for mILND and 16 for rILND
  • No intraoperative complications or conversions
  • Median hospital stay: 2 days
  • Postoperative complication rate: 20% (all managed conservatively, except one Clavien IIIa lymphocele)
Notably, no wound infections or skin necrosis were observed, even in obese patients or those with diabetes. These results are comparable or superior to those reported for VEIL and RAIL in similar cohorts.15

Clinical Impact and Innovation

The key advantage of SPARL lies in its single infraumbilical incision, which not only improves cosmetic outcomes while it also reduces the risk of wound dehiscence. This is especially relevant in obese or diabetic patients, which are at higher risk for PenC and skin-related complications.

Additionally, SPARL allows for a streamlined surgical workflow: once the inguinal dissection is complete, the same incision can be used to perform pelvic LND without redocking or repositioning. This contrasts with traditional approaches, where pelvic dissection typically requires a separate access.10,11,16

By minimizing incisions, tissue trauma, and postoperative morbidity, SPARL may also enable earlier initiation of systemic therapies, a critical consideration in node-positive patients who require adjuvant treatment.

Limitations and Future Work

As with any early-phase technique, SPARL must be interpreted within the context of its limitations. The initial study includes a small sample size (n = 10) and was conducted by a single experienced robotic surgeon at a high-volume cancer center. Longer-term oncologic outcomes were not available at the time of publication, and prospective comparative trials are needed to validate SPARL against current standards of care.

Other unanswered questions include:

  • Impact on postoperative pain and analgesia requirements
  • Patient-reported outcomes (cosmesis, return to daily activity)
  • Cost-effectiveness
  • Learning curve and reproducibility across centers
Nevertheless, the preliminary data are encouraging and support further investigation in larger, multicenter studies.

Conclusion

SPARL introduces a new paradigm in the surgical management of regional lymph nodes for penile cancer. By combining the advantages of robotic precision, anatomically guided dissection, and single-port access, it offers a minimally invasive alternative that may increase adherence to guideline-recommended LN staging and treatment.

In a disease where surgical hesitation can be life-threatening, SPARL may lower the threshold for intervention, ultimately improving outcomes for a vulnerable and underserved patient population.


Figure 1. External view of the da Vinci SP robotic system being used to create the subcutaneous tunnel that originates from the single infraumbilical incision and provides access to the left groin for ipsilateral inguinal lymphadenectomy. 

Written by: Aldo Brassetti, MD, PhD, Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy

References:

  1. Brouwer OR, Rumble RB, Ayres B, et al. Penile cancer: EAU-ASCO collaborative guidelines update. JCO Oncol Pract. 2023;20:33–7.
  2. Mistretta FA, Mazzone E, Palumbo C, et al. Adherence to guideline recommendations for lymph node dissection in squamous cell carcinoma of the penis. Urol Oncol. 2019;37:578.e11–e19.
  3. Cindolo L, Spiess PE, Bada M, et al. Adherence to EAU guidelines on penile cancer translates into better outcomes: a multicenter international study. World J Urol. 2018;37:1649–57.
  4. Tobias-Machado M, Tavares A, Ornellas AA, et al. Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure. J Urol. 2007;177:953–7.
  5. Tobias-Machado M, et al. Can video endoscopic ILND achieve a lower morbidity than open dissection? J Endourol. 2008;22:1687–91.
  6. Tobias-Machado M, et al. Long-term outcomes after video endoscopic ILND. Int Braz J Urol. 2023;49:580–9.
  7. Josephson D, Jacobsohn K, Link BA, Wilson TG. Robotic-assisted endoscopic ILND. Urology. 2008;73:167–70.
  8. Elsamra S, Poch M. Robotic inguinal lymphadenectomy for penile cancer: the why, how, and what. Transl Androl Urol. 2017;6:826–32.
  9. Ji A, Lyu J, Bai Y, et al. Single-position robot-assisted vs laparoscopic antegrade bilateral ILND. Asian J Surg. 2022;45:1530–4.
  10. Yuan P, Yao K, Zhou Z, et al. ICG-guided robotic bilateral ILND by the hypogastric subcutaneous approach. Eur Urol Open Sci. 2022;45:1–7.
  11. Subirá-Ríos D, Moncada I, et al. Minimally invasive laparoscopic technique for pelvic and inguinal single-site dissection. Urology. 2021;153:351–4.
  12. Jindal T, Meena M. Laparoscopic and robotic video endoscopic ILND by the lateral approach. Asian J Endosc Surg. 2020;14:464–9.
  13. Sun D, Zhang H, et al. Comparison of antegrade and retrograde laparoscopic bilateral ILND. J Cancer Res Ther. 2024;20:2061–5.
  14. Thomas A, Necchi A, Muneer A, et al. Penile cancer. Nat Rev Dis Primers. 2021;7:11.
  15. Patel K, Salunke AA, Bakshi G, et al. VEIL/RAIL vs. open ILND in carcinoma of penis: a meta-analysis. Urol Oncol. 2021;40:112.e11–e22.
  16. Pompeo A, Tobias-Machado M, Molina W, et al. Simultaneous bilateral VEIL and PLND for penile cancer. Int Braz J Urol. 2013;39:587–92.
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