“Light green up”: Indocyanine Green Fluorescence Imaging–guided Robotic Bilateral Inguinal Lymphadenectomy by the Hypogastric Subcutaneous Approach for Penile Cancer

BACKGROUND: Inguinal lymphadenectomy is of great significance in the management of penile cancer, which aims to mitigate the progression of lymph node metastasis. It is important to improve the efficiency of lymph node dissection and reduce surgical complications. OBJECTIVE: To detail a novel technique for robotic bilateral inguinal lymphadenectomy through the hypogastric subcutaneous approach by indocyanine green (ICG) fluorescence imaging, which promotes the identification and dissection of inguinal lymph nodes with considerable safety. DESIGN, SETTING, AND PARTICIPANTS: Ten eligible penile cancer patients who underwent ICG fluorescence imaging–guided robotic bilateral inguinal lymphadenectomy were prospectively enrolled (ICG group). Sixteen patients who underwent the surgery without ICG were retrospectively set as the control (non-ICG) group. Follow-up records for at least 12 mo were required. SURGICAL PROCEDURE: Inguinal lymphadenectomy was performed by the hypogastric subcutaneous approach. The ICG solution was subcutaneously injected into the prepuce at the beginning of surgery, and ICG fluorescence imaging–guided robotic-assisted bilateral inguinal lymphadenectomy was conducted. MEASUREMENTS: Clinical outcomes were collected. The primary study outcome measurement was the number of dissected inguinal lymph nodes. RESULTS AND LIMITATIONS: The numbers of inguinal overall, superficial, and deep lymph nodes retrieved were all higher in the ICG than in the non-ICG group (p < 0.05). No patients had severe perioperative complications. No difference was found in the overall complication rate and 12-mo survival between two groups (p > 0.05). CONCLUSIONS: ICG fluorescence imaging–guided robotic inguinal lymphadenectomy via the hypogastric subcutaneous approach is feasible and safe for patients with penile cancer, which is beneficial for dissecting more inguinal lymph nodes with few surgical complications. PATIENT SUMMARY: We developed a promising indocyanine green fluorescence imaging–guided technique to perform robotic bilateral inguinal lymphadenectomy on patients with penile cancer, which conduces to remove more inguinal lymph nodes with limited complications.