In recent years, efforts to reduce morbidity from lymphadenectomy for penile cancer were based on surgical procedures to reduce the area of lymph node dissection. The proposition of extensive video-endoscopic inguinal lymphadenectomy, a technique still experimental, is to reduce the morbidity of conventional surgery without affecting the maximum chance of oncological control of locoregional disease. Therefore the initiative of using the help of a robot to facilitate the implementation of this procedure is very welcome.
The authors present an excellent study on their initial experience with robotic assisted video-endoscopic inguinal lymphadenectomy (RAVEIL). I understand that for better comparison of the dissection area with open surgery these authors have opted to use an additional incision in the inguinal fold. However this area is the least vascularized area of the field of dissection because the lymph nodes are resected above and below this additional incision. It would be better to make an incision at the upper limit of the dissection. This approach was used in open surgery with low complication rates. The rate of necrosis (10%) and wound breakdown (10%) seems high for a minimally invasive approach. Possibly, when no additional incision is used to complement the procedure these rates will become lower.
Antonio A. Ornellas
Hospital Mario Kröeﬀ, RJ, Brazil, and Department of Urology, Brazilian National Cancer Institute, RJ, Brazil