Introduction:

Background: Long-term survival in penile cancer is dependent on the presence and extent of lymph node metastases. Historically, inguinal lymph node dissection (ILND) has been performed via an open approach (O-ILND), but minimally invasive surgical alternatives (MIS-ILND) such as video-endoscopic and robot-assisted ILND are gaining traction. We aimed to compare the (1) perioperative outcomes, (2) complication rates, and (3) oncological efficacy between both approaches.

Methods:

We conducted a PRISMA-compliant meta-analysis including studies comparing O-ILND versus MIS-ILND for penile cancer. Only prospective or retrospective studies directly comparing O-ILND versus MIS-ILND (laparoscopic or robotic) for penile cancer (or at least a majority cohort of penile cancer) were included. Studies were assessed for risk of bias using the Newcastle-Ottawa Scale for cohort studies. Outcomes of interest were pooled in random-effects meta-analyses.

Results:

Sixteen articles were analyzed, with pooled analysis of 1054 patients. Three studies involved randomising patients to ipsilateral O-ILND and contralateral MIS-ILND. Baseline patient characteristics were similar in both groups. Amputative surgeries (partial and total penectomy) was the most common treatment for the primary penile cancer. In terms of perioperative outcomes, there was an observed trend towards longer operative time for the MIS-ILND approach (mean difference 28min; 95%CI -2 to 58 min, p=0.06), particularly with the robotic assisted technique. Total LN yield (mean 12.3, mean difference 0.3, 95% CI -0.3 to 0.9 nodes, p=0.13, I²=30%), and positive LN (RR 0.98, 95%CI 0.88-1.10, p=0.75, I²=5.5%) did not differ between groups. MIS-ILND had a significant lower complication rate, for minor (RR: 0.65, 95% CI 0.45 – 0.94, p: 0.02) and the difference was even more pronounced for major complications (RR: 0.25, 95% CI 0.12 – 0.53, p 0.002). Particularly, there was also lower wound infection rate with MIS-ILND (RR: 0.43 95% CI 0.22 – 0.82, p: 0.02), translating into shorter hospitalisation of average 4 days (MD -4, 95% CI -6 – -2; p: 0.05, I²=94%). Skin/flap necrosis, lymphedema, lymphocele and drainage time did not differ significantly. The follow up period varied across studies (range 12-96 months). Across thirteen studies, there was an observed lower overall recurrence rate with MIS-ILND (HR 0.77, 95% CI 0.64 – 0.92, p: 0.01, I²=0%), but there was no difference in local groin recurrence. Overall survival was also comparable between both groups. 

Conclusion:

Our findings support the increasing adoption of MIS-ILND, particularly in high-volume centres with the surgical expertise. The significant reduction in complications and hospital stay, without compromise in oncological control, suggests that MIS-ILND may improve perioperative outcomes and long-term survivorship experience for penile cancer patients.

Funding: N/A