Minimally Invasive Laparoscopic Technique for Lymph Node Dissection in Penile Cancer: The Pelvic and Inguinal Single-Site Approach: PISA Technique.

BACKGROUND: Lymph node dissection(LND) remains the gold standard in the staging and treatment of locally advanced penile cancer(PC)1. OBJECTIVE: To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach2,for performing LND in PC, first described in Urology by our group in 20153: the Pelvic and Inguinal Single Access(PISA) technique (Fig. 1). MATERIAL: Between 2015 and 2018, 10 consecutive patients with different PC stages and indication of inguinal LND (cN0 and ≥pT1G3 or cN1/cN2)1 were operated by means of the PISA technique (Table 1). Intraoperative frozen section(FS)4 analysis was carried out routinely and if ≥2 inguinal nodes(pN2) or extracapsular nodal extension(pN3) are detected1,5, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. If this condition occurs bilaterally in the inguinal LND, the pelvic LND will be bilateral. The video shows the PISA technique in a step-by-step. Instrumental requirements: 30°laparoscopy optic, monopolar scissors,Ligasure (Covidien Surgical,Minneapolis,MN,USA) vascular sealant, extraction-bag, bipolar forceps and 5-mm endo-clip(Hem-o-lok)are required. RESULTS: Intraoperative and postsurgical variables are shown in Table 2. Inguinal LND was bilateral in all cases. Pelvic LND was required in 40% of patients. Total operative time was 120-170 minutes. Median estimated blood loss(EBL) was 66(30-100)cc, but no blood transfusion was required. No intraoperative complications were noted. 40% of patients had postoperative complications (10% major complication- symptomatic inguinal lymphocele). Median lenght of hospital stay(LOS)was 5.8(3-10) days. Median inguinal drain removal was 4.7 days. The pathological analysis outcomes are shown in Table 3. Mean number of lymph nodes removed by inguinal LND was 10.25(8-14). CONCLUSION: PISA technique allow a minimally invasive inguinal and pelvic LND using the same set of incisions and carry it out in the same surgical procedure. PISA technique in PC LND seems to be safe, with a low rate of major complications and preserving oncological efficacy.

Management of urologic cancers during the pandemic and potential impact of treatment deferrals on outcomes.

The COVID-19 pandemic-related constraints on healthcare access have raised concerns about adverse outcomes from delayed treatment, including the risk of cancer progression and other complications. Further, concerns were raised about a potentially significant backlog of patients in need of cancer care due to the pandemic-related delays in healthcare, further exacerbating any potential adverse outcomes. Delayed access to surgery is particularly relevant to urologic oncology since one-third of new cancers in men (20% overall) arise from the genitourinary (GU) tract and surgery is often the primary treatment. Herein, we summarize the prepandemic literature on deferred surgery for GU cancers and risk of disease progression. The aforementioned data on delayed surgery were gathered in the context of systemic delays present in certain healthcare systems, or occasionally, due to planned deferral in suboptimal surgical candidates. These data provide indirect, but sufficient insight to develop triage schemas for prioritization of uro-oncological cases. Herein, we outline the extent to which the pandemic-related triage guidelines had influenced urologic practice in various regions. To study the adverse outcomes in the pandemic-era, a survey of urologic oncologists was conducted regarding modifications in their initial management of urologic cancers and any delay-related adverse outcomes. While the adverse effects directly from COVID-19 related delays will become apparent in the coming years, the results showing short-term outcomes are quite instructive. Since cancer care was assigned a higher priority at most centers, this strategy may have avoided significant delays in care and limited the anticipated negative impact of pandemic-related constraints.

Therapeutic and Surgical Indications for Patients with Penile Cancer in the COVID-19 era.

PURPOSE: The aim of this work is to review and synthesize the existing evidence and recommendations regarding to the therapeutic and surgical indications as well as monitoring of patients with Penile Cancer in COVID-19 era and to propose an action protocol to facilitate decision-making. MATERIAL AND METHODS: A non-systematic review of the literature regarding the management of penile cancer during the COVID-19 pandemic was performed until April 30, 2020. We propose our recommendations based on this evidence. RESULTS: Penile cancer is an uncommon but aggressive disease. Prognosis is determined by several characteristics, being the most important the presence of lymph nodes, in which case, treatment should not be delayed. For these reasons, an initial evaluation is mandatory. Priority classifications, based on the oncological outcomes when treatment is delayed, have been made in order to separate deferrable disease from the one that needs high priority treatment. In penile cancer with low risk of progression, surgical treatment can be delayed, but other options must be considered, like topical treatment or laser therapy. In cases with intermediate risk of progression, surgical treatment may be delayed up to three months, but we must consider radiation therapy and brachytherapy as effective options. When feasible, follow-up should by telemonitoring. CONCLUSIONS: In the COVID-19 era, initial evaluation of the patient is mandatory. Histological diagnosis with local staging is necessary before offering any therapeutic option. In case of superficial non-invasive disease, topical treatment is effective in absence of lymph node involvement. In selected patients, radiotherapy is an organ-preserving approach with good results. Non-deferrable surgical treatment must be performed by an experienced surgeon and as an outpatient procedure when possible. When indicated, iLND should not be delayed since it is decisive for patient survival. Follow-up should be by telemonitoring.