Penile Cancer Explained

The inguinal lymph nodes may be divided into two groups, deep and superficial, separated by the fascia lata. The superficial inguinal lymph nodes lie underneath the camper's fascia, and may be divided into five groups, superolateral, superomedial, infeoromedial, infeorolateral, central. The deep ileoinguinal glands are placed under the fascia lata, on the medial side of the femoral vein. The highest is the gland of cloket, or rosemular. The profilactic lymphadenectomy impatient with penicarsinoma is controversial for a significant incidence of morbidity. It is usually performed impatient with lymph node invasion, but without distant metastases.

Eleoinguinal lymphadenectomy should be performed impatient with clinically positive lymph nodes, and impatient with stage PT3, PT4- penicarsinoma. Lymphadenectomy can be performed in patient without evident clinical lymphenode invasion, with the stage Pg2 or high grade Pg1 tumors. Patient with metastatic inguinal disease should be treated with pelvic nod dissection. The boundaries of dissection described by DASLAV are superior to the inguinal ligament, laterally to the sartolius muscle, medially to the adducto-longus muscle. Inferiorly to the base of femora triangle, the dissection begins with a 12 cm elliptic incision, 1 cm below and parallel to the inguinal ligament.

Kampers fascia must be located because it represents the superficial boundary of the lymphadenectomy to preserve skin's blood supply. Superficial epigastric vein is now ligated and dissected in order to gain access to the deeper vascular structures. After the dissection of the external pudendal vein, the spermatic cord is located. The superior superficial lymphenotes are dissected up to the circumflex superficial iliac vessels that are previously ligated. The superior superficial lymphenotes are dissected first from the pubic bone, then from the iliac bone and finally from the inguinal ligament so that femoral vessels are revealed.

The dissection of the sub-inguinal lymphenotes proceeds superficially following the campers fascia, reaching the epics of the scarpa's triangle where the major saphenous vein and the lateral accessory saphenous vein are ligated. The major saphenous vein is dissected at the epics of the scarpa's triangle and the lymphenotes are removed from the fascia lata up to the ovalis posa. Superficial lymphadenectomy is completed. Underneath the fascia lata and medially to the femoral vein, deep ilioinquinal nodes are found. Removal of these lymphenotes, including the cloketz lymphenote, is shown here. The fascia lata covering the scarpa's triangle is removed.

The saphenous femoral nerve is located and preserved. As soon as the lymphadenectomy is completed, the sartallius muscle is dissected for a 10-12 cm length starting from the proximal end and sectioned from the iliac bone. The sartallius muscle is transposed over the femoral vessels and fixed to the inguinal ligament with an interuptured suture. A closed suction drain is placed. The skin incision is closed. Contralateral ilioinquinal lymphadenectomy and bilateral pelvic lymphadenectomy are performed if metastatic lymph node disease is found. The pelvic lymphadenectomy may be done laparoscopically. The boundaries of dissection, described by Catalona,

are superior to the inguinal ligament with a shorter skin incision, laterally to the femoral artery, inferiorly to the base of obalis fossa, and medially to the adductor lungus muscle. The dissection begins with a 10 cm elliptic incision approximately 2 cm below the groin crease. Campers fascia must be located because it represents the superficial boundary of the lymphadenectomy to preserve the skin's blood supply. The spermatic core is identified and reflected medially. Superior and inferior skin flaps are developed to the level of the external oblique aponeurosis and of the adductor lungus muscle respectively.

The greater saphenous vein and the lateral accessory saphenous vein are carefully dissected and preserved. Superficial epigastic vein and the superficial circumflex vein are ligated and transacted at the level of the superior boundaries of dissection. The superficial lymphatic tissue is superiorly removed. Lymphadenectomy is continued developing the plane from the fascialata up to the obalis fossa. The saphenous femoral junction is reached and the superficial circumflex vein is ligated and transacted. The greater saphenous vein is carefully dissected and preserved. The external pudendal vein and the superficial epigastic vein are clipped and transacted.

The superior and inferior groups of superficial lymphenose are easily removed. The deep inguinal nodes which are located below the fascialata and medially to the femoral vein are dissected from the inguinal ligaments superiorly and just distally to the fossa ovalis inferiorly. The specimen is clipped and transacted at the level of the femoral canal where the cloked lymph node is located. Boundaries of dissection are clearly seen. The femoral canal, the inguinal ligament, the spermatic cord, the abductor-langus muscle, the pectineus muscle and the inferior part of the fasal ovalis

with the preserved veins. The transposition of the sartovius muscle is unnecessary and the skin incision is closed after placing a closed suction drain.

The superior and inferior groups of superficial lymphenose are easily removed from the fasal ovalis inferiorly.