Robotic Surgery for Penile Cancer

Overview

Robotic surgery for penile cancer is a minimally invasive procedure in which robotic instruments assist the surgeon in removing the portion of the penis and the associated lymph nodes. This surgery is used in invasive squamous cell carcinoma of the penis (PSCC) that has spread to lymph nodes (both inguinal and pelvic).

It is preferred over traditional open surgery for removing the penis and inguinal lymph node dissection (ILND) as it offers a similar success rate, better precision, less pain, less blood loss and quick recovery time. Robotic surgery is also associated with significantly lesser morbidity. Robotic surgeries are also preferred for patients with complex and metastasised cancer of the penis and regional lymph nodes.

Alternate Name

Penectomy combined with robotic inguinal lymphadenectomy.

Body Location

Penis and regional lymph nodes (inguinal and pelvic)

Who is a good candidate for Robotic Surgery for Penile Cancer?

Robotic surgery for penile cancer is typically recommended for patients with early-stage disease who have small tumours that are confined to the penis and have not spread to other parts of the body.

Patients who are in good health, with no significant medical problems, are also good candidates for robotic surgery. This includes patients who do not have any major heart or lung conditions and who have normal kidney and liver function.

Procedure Type

Minimally invasive surgery

Preparation

Here are some of the pre-operative preparations that may be necessary for robotic surgery for penile cancer:

• Medical Evaluation- Before undergoing robotic penile cancer surgery, your doctor will recommend certain blood tests such as CBC (complete blood count), INR (International Normalized Ratio), and urine tests. You will be required to have a pre-anaesthesia checkup (PAC), including an electrocardiogram (ECG) and a chest X-ray, where a doctor will figure out whether you are suitable for the surgery. Your surgeon might also order a computerised tomography (CT) scan or a positron-emitting tomography (PET) scan to identify the cancer spread and plan the surgical procedure. However, metastasis is not reliably predicted from CT or PET scans. Additionally, the doctor might order a biopsy to understand the type and stage of penile cancer.
• Medication alterations- You will need to inform your doctor if you are on any medications. They might advise you to discontinue specific medications such as blood thinners, aspirin, etc., as they are linked with blood loss during surgery. You will also be given anti-anxiety medication to relax.
• Stop alcohol and smoking- You should quit alcohol use and tobacco use (especially smoking) before surgery to avoid complications.
• Fasting- You will be advised not to eat or drink anything post-midnight the day before the surgery.

How Performed

Penectomy combined with robotic inguinal lymphadenectomy is performed under general anaesthesia, and you will be asleep throughout the procedure. You will lie on your back with your legs in a frog-leg position. Multiple incisions are made in the inguinal region to insert various surgical tools, including robotic arms and a highly-magnified camera. The site is inflated for carrying the surgery and uses a surgical console to control robotic arms and a camera to create high-definition visuals on the computer screen. These visuals are 3-dimensional and aid the surgeon in examining the affected tissue precisely without disturbing the other sensitive nerves and tissues. In the case of complete penis removal, a permanent opening for urine output from the urethra is created in the perineum region between the anus and scrotum.

Follow-up

You will be given a follow-up schedule/chart, and you should visit your surgeon for all the follow-ups to ensure a complication-free recovery. Take special care to keep the incisions clean, and you may use soap and water to wash gently, as suggested by your surgeon. Do not rub the incisions and dry them by patting them with a soft clean cloth. You should avoid using the bathtub or swimming pools as these could lead to infections or excessive pressure on the incisions. You should start with light physical activity after the surgery, such as walking, and you can increase the distance slowly as you gain strength. However, you should avoid strenuous activities such as cycling, running, jogging, lifting weights, etc. Physical activity will help you recover quickly, but make sure not to overexert yourself and take plenty of rest and sleep. Avoid excessive bending as it will exert groin pressure and discomfort. Seek help from friends and family members. Avoid long road trips and driving for a few weeks. If you must, take breaks and walk around for some time before resuming the journey.

Risks

Robotic surgery is more efficient and safer than open surgery, but being a major surgery, penectomy combined with robotic inguinal lymphadenectomy is associated with the following risks:

• Infections on the incision site could occur, and you might require antibiotic treatment.
• Bleeding and blood loss can happen in the case of complex procedures.
• Damage to the adjoining or nearby organs/tissues requiring further medical intervention.
• Blood clot formation could occur.
• Hypersensitivity to anaesthesia is another potential side effect in sensitive individuals.

In addition, robotic surgery could have the following side effects:

• Inguinal lymphocele (collection of lymphatic fluid)
• Flap necrosis (death of reconstructed tissue due to loss of blood circulation)
• Seroma (collection of clear fluid near the incision site)
• Cellulitis
• Lymphorrhea (Lymphatic fluid leakage)
• Lymphedema

Recovery

Following the surgery, you will be kept under active monitoring. You will be shifted to the recovery room within a few hours to a few days, depending upon the complexity of the surgery. Considering your overall health and stability of vital parameters, you will be discharged from the hospital within a few days while a negative suction drain placed. You will be required to visit your surgeon after around 2-4 weeks to get the drain removed. Following drain removal, your surgeon will examine for any signs of infection and inflammation to ensure deviation-free recovery. The complete recovery may take a few months, and you can slowly return to your daily activities. During the recovery phase, good care is required, and you should avoid heavy work for a few months. Regular follow-ups are critical to an event-free recovery, as your surgeon will monitor your progress. Drink plenty of fluids and eat nutritious food to aid in quick recovery. You will need to wear a thigh-high Ted hose for four weeks following the surgery. Take your prescribed medications and avoid self-medication for quick relief. Always look for signs of complication and seek immediate medical attention if required.