INGUINOSCOPY FOR VULVAR CANCER

Daniel Dargent

Objective: Development of a new surgical technique in order to reduce the complications of groin lymph node dissection without impairing the chances of survival.


Material and Methods: The surgical technique is based on video-endoscopic subcutaneous dissection. The gasless technique with a lifting system holding the skin of the femoral triangle is used. Dissection of all superficial and deep femoral nodes is performed through two small skin incisions with endoscopic instruments under video control. The femoral vessels are cleared. The great saphenous vein, superficial pudendal and superficial epigastric vessels, and the circumflex artery are preserved. From December 1995 to May 1999, 41 endoscopic groin dissections were performed in 25 cases of vulvar cancer and in 3 cases of lower third vaginal neoplasia. Vulvar cancers were stage I in 12 cases, stage Il in 9 cases and stage III in 4 cases; the size of the lesion was between 10 to 65 mm. The vaginal cancers were stage Il in 2 cases and stage III in 1 case. The dissection was performed on the ipsilateral side of the tumor in 9 patients, on the contra lateral side in 6 cases (in case of clinically suspected inguinal nodes a traditional open dissection was performed), and on both sides in 13 patients.

Results: The mean duration of the endoscopic dissection was 62 minutes (range 43 – 120). The mean number of lymph nodes removed was 7 (range 2-15). The only peri-operative complication was an injury to the femoral vein requiring the opening of the skin for suturing. The mean hospital stay was 11 days, but in case of endoscopic groin dissection performed alone, it was only 3.5 days. We had 4 cases of metastatic nodes: two were positive on frozen section leading to a classical inguinal and external iliac open dissection, and 2 were observed on the final pathology report. We had 1 recurrence. It occurred 3 months after inguinoscopy and was localized under the skin, between the vulva and the inguinal area. No wound breakdown or lymphedema were observed. Only 7 lymphocyts requiring needle aspiration occurred. Conclusion: This surgical technique decreased the risk of post-operative complications of groin dissection. Its value in oncologic field needs to be further studied in particular in association with sentinel node study.

The development of surgery in the field of oncology is currently distinguished by the effort to decrease the aggressiveness and the morbidity of surgical treatment without lowering the chances of survival. The application of laparoscopy in the field of gynecologic oncology is not only a way to achieve these goals but also to improve the surgical staging of gynecologic malignancies. Over the years, the diffusion of medical education among the population, the spreading of prevention together with an increased occurrence of vulvar neoplasia related to the Human Papova Virus infections have led to a raising incidence of smaller vulvar cancers, in particular in young patients to whom body image and sexual function are so important. The surgical treatment of these vulvar cancers is associated with an important morbidity mainly due to the post-operative complications related to the inguinal lymphadenectomy (wound breakdowns and infections, leg lymphedema,..). These major complications are frequent after the “en bloc” radical vulvectomy. Even if the risk is reduced when performing radical vulvectomy with separate incisions, the complication rate is about 15 to 20 % of the cases (1- 7). In order to lower this rate, several authors have proposed different surgical approaches: Di Saia (8) recommended performing only ipsilateral inguinal superficial lymph node dissection; Levenback (9) proposed to perform vulvar mapping in order to only remove the sentinel lymph node of the vulvar cancer. However, several authors, arguing that the inguinal lymphadenectomy has a therapeutic value, have criticized the diffusion of elective lymphnode dissection. We developed a video-endoscopic surgical technique attempting to significantly reduce the rate of groin dissection complications (in particular concerning lymphedema and wound breakdown) (10). The video-endoscopic inguinal lymph node dissection also called ” inguinoscopy ” allows a complete superficial and deep inguinal lymphadenectomy. This technique should not reduce the chances of survival.

Technique of the inguinoscopy

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The patient is placed in a dorsal lithotomic position and the lower extremities are abducted without flexure. The landmarks of the femoral triangle are identified and traced with a marker. A vertical micro-incision is made 2 cm below the apex of the femoral triangle and the subcutaneous tissue is dissected. The opening of the space of the femoral triangle is performed with scissors in the plane above the superficial fascia.

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We use the gasless technique with a Laparofan (Origin©) inserted through the micro-incision and lifting the skin of the femoral triangle.

The laparoscope is then inserted and two incisions are made under video control on each side, 2 cm from the edges of the triangle. (Picture 4) The incisions allow insertion of two 5 mm trocars, through which grasping or atraumatic forceps and scissors are introduced into the operating field The instruments are used to tear the fibrous tissue connecting the deep layer of the superficial fascia and the superficial layer of the fascia lata.

laparofit

The primary objectives of surgical dissection are to locate and dissect the lymph nodes situated under and within the arch of the great saphenous vein, as well as those above the arch along the same vertical axis. The great saphenous vein or an accessory saphenous vein are usually found first. Dissection of the lymph nodes follows the path of the saphenous vein, starting from the lowest part and moving up past the arch to the area where are lying the lymph nodes situated at the confluence of the external pudendal veins, the superficial epigastric vein, and the superficial circumflex vein.

dissection node

It has to be noted that all blood vessels effluent to the convex side of the arch can be respected. After dissecting the superficial lymph nodes, one of the lateral incisions is enlarged and a 10 mm trocar is inserted, in order to place the coelio-extractor in the operative field. The lymph nodes are then removed.

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The dissection continues by opening the fascia lata surrounding the arch of the great saphenous vein and identifying the femoral artery and vein, in order to locate, free, and resect the deep inguinal lymph nodes. These nodes are found on the medial aspect of the femoral vein, above and below its junction with the great saphenous vein. The highest of the deep femoral nodes is the Cloquet’s node.

 dissection deep 

After completion of the lymphadenectomy, the operative field is washed with saline and a drain put in place.

Materials and methods – Instrument characteristics
Forty-one endoscopic groin dissections have been performed from December 1995 to May 1999 in our department by two of the authors (D.D. and P.M.). The indications for inguinoscopy were 25 cases of vulvar cancer (squamous or verrucous) and 3 cases of cancer of the lower third of the vagina. The vulvar cancers were stage I in 12 cases, stage II in 9 cases and stage III in 4 cases; the size of the lesion was between 10 to 65 mm. The vaginal cancers were stage II in 2 cases and stage III in 1 case. The dissection was performed on the ipsilateral side of the tumor in 9 patients, on contra lateral side in 6 cases (in case of clinically suspected inguinal nodes a traditional open dissection was performed) and on both sides in the 13 patients with central disease. Inguinal lymphadenectomy was performed concurrently with the primary surgical treatment in 19 cases and subsequent to treatment in 9 other cases.

Result
The mean duration of the endoscopic dissection was 62 minutes (range 43-120). The mean number of lymph nodes removed was 7.5 (range 2-15). We recorded one peri-operative complication: a small injury of the femoral vein occurred during the dissection of the deep femoral nodes. This incident was treated by suturing after realization of a small inguinal incision. The blood loss was contained and no transfusion was required. It has to be noted that in all the other inguinoscopy cases there has been no peri-operative complications and the bleeding was minimal. The mean hospital stay was 11 days (range 2-20), but in cases of isolated endoscopic groin dissection it was only 3.5 days (range 2-5). Local complications of these procedures included the presence of a lymphocyst in 7 cases; all were treated by needle puncture. No wound breakdown was observed. Histopathological examination showed metastases in 4 cases. Two cases were positive on frozen sections requiring to open for a complete inguinal and external iliac dissection. Two cases of microscopic metastases were observed on final histological examination. No patient was lost to a median follow-up of 27 months (range 3-41). Three months after a negative inguinoscopy, we observed 1 recurrence due to a missed lymph node (node located in the skin bridge between the vulva and the inguinal area) The recurrence was treated by a wide surgical excision and radiotherapy. The patient is alive without evidence of disease 25 months after the recurrence. None of the patients had lymphedema at the examination between the 6th and 9th week and during the follow-up except the one with the recurrence.

Discussion
For early stage vulvar cancer, the use of conservative (less aggressive) surgery is a concept that has recently evolved. This changing trend has been pursued in two ways (Burke, et al., 1990). Firstly, it has been demonstrated that reduction of the size of vulvar resection by performing a radical resection adjusted to the extension of the lesion is a safe approach that decreases the alterations in body image and sexual function. The second point is a reduction of the fields of lymph node dissections, in order to decrease the postoperative complications related to the lymphadenectomy: wound breakdown and infections, leg lymphedema… These major complications are frequent (more than 60 % of cases) after an “en bloc” radical vulvectomy. Their rate is about 15 to 20 % of cases even when performing radical vulvectomy with separate incisions (Hacker,1992; Hopkins, et al.,1993; Sutton, et al., 1991; Cavanagh,1990 ). In order to lower the rate of these complications, different authors have shown that ipsilateral groin lymph node dissection is sufficient for small lateral vulvar cancers (Stehman, et al.,1992). In these cases Di Saia (1979) recommended performing only ipsilateral inguinal superficial lymph node dissection, whereas the femoral lymphadenectomy with the pelvic lymphadenctomy is performed only if the frozen sections of the superficial nodes are positive. These results are supported by studies of the natural history of vulvar cancer. Vulvar carcinoma invades locally and spreads by embolization to regional lymph nodes without significant involvement of the intervening tissues ( Hacker, et al.,1984). The nodes primarily involved are the superficial inguinal lymph nodes ( Andrews, et al., 1994). But limiting the dissection to superficial groin in stage I and II disease has been challenged by the results of a Gynaecologic Oncology Study Group, which showed a higher rate of ipsilateral groin recurrence (Stehman, et al.,1992). Further progress in less aggressive surgery has been recently related in a study concerning the evaluation of the regional lymph nodes. The team of Anderson (Levenback, et al.,1994; 2000) has proposed to perform vulvar mapping in order to only remove the sentinel lymph node in the vulvar cancer. Nevertheless several authors who believe that the inguinal lymphadenectomy has a therapeutic value criticize this minimal approach. Monaghan (1992) reported an improvement of about 14 % in the 5-year survival rate when performing inguinal lymphadenectomy compared to surgery without lymph node dissection. Moreover he stated that the groin node dissection improves the survival by effectively removing micro metastases that are not clinically detectable. In order to benefit from the therapeutic value of groin dissection, we propose to perform an inguinal lymph node dissection through endoscopy. This surgical approach requires a good knowledge of endoscopic techniques and anatomy of the groin area. As this approach is no validated in term of oncologic efficiency, it has been performed only in patients with no obvious metastases since it is well known that the incidence of lymph node metastases in patients who have clinically negative nodes is low. In cases of advanced cancer, and in particular if there were ipsilateral clinically suspected inguinal nodes, we always performed a traditional open inguinal lymphadenectomy with frozen sections on the nodes. If the nodes were positive we realized an inguinoscopy on the contra lateral side. Our series also includes 3 cases of cancer of the lower third of the vagina. It has been demonstrated that lower vaginal cancers spread to the inguinal lymphatics (Manetta, et al., 1990): for this reason, surgical treatment of vaginal cancer of the lower third is similar to the one of vulvar cancer. We believe that the technique of inguinoscopy is reproducible and that it is not excessively time consuming. We have demonstrated that this technique reduces significantly the rate of groin dissection complications. The incidence of lymphocyst is low (17 %) and compares favourably with that of traditional open groin dissection (Hacker,1992). It is striking that we report no infection, wound breakdown and leg lymphedema. This is a consequence of the minimal skin incisions and endoscopic (no touch) technique, and preservation during inguinoscopy of all the superficial veins going to the arch of the saphenous vein. In accordance with our results, a recent report shows a 54% reduction of the incidence of leg lymphedema after preservation of the saphenous vein during inguinal lymphadenectomy (Zhang, et al., 2000). We observed only one recurrence. This recurrence was located in the skin bridge between the vulvar and the inguinal areas. This type of recurrence has been described after traditional groin dissection through separate incisions and its rate has been evaluated to be 2.4 % (Rose, 1999), comparable with our rate after endoscopic technique. It should be noticed that our patient with disease recurrence has been salvaged with surgical resection and radiotherapy. So in our opinion the endoscopic technique do not reduce the chances of survival, even if its therapeutic value has to be proven yet. At the same time, we are currently performing vulvar mapping during the endoscopic lymph node dissection in order to localize the sentinel lymph node and be sure to remove it. The main advantages of the endoscopic inguinal lymphadenectomy are the preservation of the great saphenous vein in order to lower the risk of lymphedema and the reduction of cutaneous incisions to decrease the risk of wound breakdown and infection. This new technique probably reduces the risk of post-operative lymphocysts due to the smaller cutaneous incisions. On the other hand, the disadvantages are the requirement of a surgical team trained in endoscopic techniques and specific surgical instruments. Moreover, the therapeutic value has to be proven through larger studies.

Author
Daniel Dargent
Daniel Dargent was born the son of Marcel Dargent, the director of the Centre Léon Bérard , a cancer research center in Lyon was. After studying medicine Daniel Dargent completed a specialist training , which he completed in 1959. In 1966 he was graduated . He worked under Pierre Magnin (1913-2001) at the gynecological clinic at the Hôpital Edouard Herriot, the University Claude Bernard , deputy director and 1970, Associate Professor of Obstetrics and Gynecology. After a brief spell as Head of the Department of Gynecology at the Hôtel-Dieu in Lyon, he returned to the Hôpital Edouard Herriot, where he led the Department of Gynaecological Oncology until his retirement in 2003 and initiated as professor at the Medical Faculty of the University. From 1992 to 1993was the president of the Societe Francaise de Gynecology. He was the founder of the Société francophone de chirurgie international pelvienne that emerged from the union of the Société de chirurgie endoscopique and the Société de chirurgie gynécologique pelvienne. In 1980, he was the founder of the Cercle Recamier, an organization dedicated to the teaching and dissemination of vaginal surgery named after the French gynecologist Joseph Recamier (1774-1852) . Daniel Dargent was a member of numerous scientific societies such as the Society of Pelvic Surgeons. Daniel Dargent was one of the first to perform laparoscopic procedure for oncological pathologies. In 1987 Dargent combined in cases of cervical cancer the laparoscopic retroperitoneal lymphadenectomy with the Schauta operation. In 1992, he performed the first assisted laparoscopic radical hysterectomy (LAVRH), further processed and standardized with the laparoscopic section of the posterior parametrium and the vaginal approach tot he anterior parametrium. [1] The method was created in 1998 by his pupil Marc Possover developed as nerve sparing LAVRH. [2] Dargents greatest innovation was the development of radical trachelectomy for the treatment of cervical cancer while preserving the fertility in 1994. In the surgical procedure only the cervix is removed while the body of the uterus body is maintained. [3] The intervention, which spread worldwide from Lyon, is also referred to as an operation by Dargent. Daniel died on 2005. This Article is a tribute to him and his greatness as surgeon and man.

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