Improvement of laparoscopic inguinal lymph node dissection for Penile cancer

Improvement of laparoscopic inguinal lymph node dissection for Penile cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Improvement of laparoscopic inguinal lymph node dissection for Penile cancer yifei ban, faren xu, tiejun liang, nannan yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3318499/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The prognosis of Penile cancer patients is closely related to the metastasis of inguinal lymph nodes. Timely inguinal lymph node dissection is an important part of the treatment of Penile cancer. The tumor control effect of laparoscopic inguinal lymph node dissection is similar to that of open surgery, but the complications are significantly reduced; And there are different methods in terms of surgical approach, dissection approach and Great saphenous vein preservation. We adopt the transabdominal subcutaneous anterograde approach and improve the laparoscopic inguinal lymph node dissection. This article introduces the procedures and technical improvement points of the improved laparoscopic inguinal lymph node dissection through the subcutaneous approach. Penile cancer Laparoscopy Inguinal lymph node dissection Great saphenous vein preservation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Background Penile cancer is a relatively rare malignant tumor of the urinary system. The incidence rate of Penile cancer in China has reached 0.6 per 100000 [1]. It is easy to diagnose clinically, most of which are squamous cell carcinomas, which mainly metastasize through the inguinal lymph nodes. In addition to the grading and staging of the primary tumor, the prognosis of Penile cancer is also affected by the presence of metastasis in the inguinal lymph nodes [2] Timely lymph node dissection is closely related. Inguinal lymph node dissection is the best treatment for Penile cancer patients with inguinal lymph node metastasis or Penile cancer patients with high risk factors but negative clinical inguinal lymph node examination, It can increase the 5-year survival rate of patients with Penile cancer from 30% -40% of those who have already metastasized and resected to 80% -90% [3-4]. Before 2018, our hospital mainly used open surgery. Although the open inguinal lymph node dissection had a definite effect, the postoperative skin flap healed poorly and necrosis, incision infection, subcutaneous hematoma, lymphocyst formation, lymphatic leakage, lymphedema, lower limb edema, abnormal pain The incidence of complications such as cellulitis [5] is high. In recent years, with the progress of science and technology, laparoscopic minimally invasive technology has been widely used in inguinal lymph node dissection. The dissection effect is equivalent to open surgery, because of its small trauma and Great saphenous vein preservation, the complications are significantly reduced [6-7] At present, we have improved the laparoscopic inguinal lymph node dissection and Great saphenous vein preservation by using the transabdominal subcutaneous anterograde approach, with satisfactory results. 2. Clinical data 58 patients with Penile cancer who underwent bilateral inguinal lymph node dissection in our hospital's Urology department from October 2014 to October 2022 were the subjects of the study. The operation was carried out in accordance with the Chinese Guidelines for Diagnosis and Treatment of Diseases in Urology (2014) and the hospital grading operation management system. All patients signed the informed consent form, and the study was reviewed and approved by the hospital's medical ethics committee. Among them, 28 patients were treated with open surgery (open group) before October 2018, and 30 patients were treated with laparoscopic surgery (endoscopic group) Postoperative and follow-up status: Statistical methods were processed using SPSS 22.0 statistical software, and the counting data was expressed as mean ± standard deviation (‾x ± s). t-test was used, and P < 0.05 was used as the difference with statistical significance(Table 1and2). 3. Laparoscopic surgery method General anesthesia was used. The patient was in a supine position, with the head and lower arms 10 °~15 °high. The lower limbs were separated, straightened slightly, rotated outwards about 45 °, and the knees slightly flexed and rotated outwards. A longitudinal incision was made 1cm below the umbilicus, and the skin and Subcutaneous tissue (Camper, Scarpa fascia) were cut to confirm the anterior sheath of Rectus abdominis muscle Use the index finger to move forward obliquely outward and downward on the anterior sheath of the Rectus abdominis muscle, passively separate a long tunnel along the surface of the Abdominal external oblique muscle aponeurosis to the Inguinal ligament, use the self-made airbag to expand to establish the subcutaneous space, and place 12 mm Trocar as the lens hole in this incision. CO2 gas is used to establish the subcutaneous pneumoperitoneum space, and the pressure is maintained at 12 ~ 15 mm Hg, Then place 5 mm、10 mm and 5 mm Trocar at the midpoint of the umbilical pubic line, the midpoint of the umbilical cord and the right anterior superior iliac spine, and the midpoint of the umbilical cord and the left anterior superior iliac spine. Four puncture holes are left on both sides(Figures 1 and 2). The scope of inguinal lymph node dissection: the upper boundary is 1 cm above the Inguinal ligament, the inner boundary is to the outer edge of the adductor longus, the outer boundary is to the inner edge of the Sartorius muscle, and the lower boundary is to the tip of the femoral triangle. Mark the scope of bilateral inguinal lymph node dissection with a marker. 4. Operation process along the surface of the Abdominal external oblique muscle aponeurosis and between the Scarpa fascia, skin external compression helps to locate, fully free and expose the Inguinal ligament. Close to the surface of the Inguinal ligament, downward free, pull the spermatic cord by an assistant and other methods to find the root of the confirmed and free Great saphenous vein, that is, the Great saphenous vein flows into the femoral vein. Along the root of the Great saphenous vein, close to the fascia lata of the thigh inward and outward downward respectively, free, Establish and expand the necessary range for internal and external lymph node dissection(Fig. 3 、4), The internal boundary is the spermatic cord, and then free along the root of the Great saphenous vein to confirm the position of the femoral blood vessel. Cut the anterior sheath of the femoral blood vessel to free the root of the Great saphenous vein, the femoral vein, the femoral tube and the surface of the Femoral artery. Just clean the inside of the femoral vein and the femoral Endolymph node (Cloquet lymph node)(Fig. 5), and send the cleaned deep group of lymph nodes for rapid pathological examination. If positive, perform pelvic lymph node cleaning. Free down along the root of the Great saphenous vein, Fully free the whole Great saphenous vein and its 5 subordinate branches, and first free and cut off the superficial iliac circumflex vein and the genitals Internal vein. Sweep the superficial lymph nodes between Camper's fascia and Scarpa's fascia along the skin. The superficial lymph nodes between Camper fascia and Scarpa fascia were cleaned along the skin. When sweeping, the shallow layer should be close to the skin; The deep layer should cling to the fascia of the external abdominal oblique muscle and fascia lata, until the top of femoral triangle removes all the lymphoid adipose tissue on the fascia surface.During surgery, it is necessary to preserve the blood supply to the skin while ensuring the curative effect of the tumor. It is recommended not to cut through the skin as much as possible to prevent damage to the skin and nourish the blood, leading to poor postoperative incision healing. Identify, free and ligate the Superficial vein of the abdominal wall, the medial Superficial vein of the thigh, and the lateral Superficial vein of the thigh, and retain the main trunk of the Great saphenous vein. In case of thicker Lymphatic vessel, delay cauterization to minimize the incidence of postoperative Lymphatic leakage. With the Great saphenous vein as the boundary, divide the lymph nodes of the superficial group to be cleaned into two pieces, and take out the specimen bags respectively. The surgical wound is complete, the negative pressure drainage ball is placed at the lowest part of the incision, the external negative pressure suction is connected, and the groin area is properly pressurized and bound, The negative pressure drainage method can effectively reduce the daily drainage volume, shorten the placement time of the drainage tube, and reduce the subcutaneous hydrops, Cellulitis and other adverse complications caused by long-term tube placement [ 8 ] 5. exploration, improvement, experience in surgical techniques and Discussion There are currently two clinical approaches for laparoscopic inguinal lymph node dissection: retrograde dissection through the subcutaneous approach of the lower limb femoral triangle and antegrade dissection through the subcutaneous approach of the lower abdomen [ 9 ]. The reverse sweeping approach through the lower limb femoral triangle subcutaneous approach is more widely used, which is characterized by relatively simple operation, short Learning curve, but limited space. Each side needs 3 puncture holes, which is more traumatic. In addition, for those with deep group lymph node positive who need pelvic lymph node dissection, they can not do both, and they need to change their positions and reset the puncture holes. In 2011, some Chinese scholars tried to use the abdominal subcutaneous approach to clean inguinal lymph nodes anterograde, The puncture points are located at the lower edge of the umbilicus, the midpoint of the umbilical pubic line, and the inner side of the anterior superior iliac spine [ 10 ]. However, due to the long surgical path and high surgical difficulty, it was not accepted by the mainstream at that time. With the improvement of technology, the transabdominal subcutaneous approach has gradually been accepted and applied in clinical practice. Research has shown that the recent surgical effects of the transabdominal subcutaneous and femoral triangular approaches are comparable, but the transabdominal subcutaneous approach has more advantages, not only with fewer incisions The risk of postoperative lower limb lymphedema is lower, and pelvic lymph node dissection can also be considered. On this basis, we adopted a subcutaneous anterograde approach through the abdomen to change the transverse incision at the lower edge of the umbilical wheel to a 1cm vertical incision below the umbilical, which is convenient for both sides to retain observation lenses placing; On the left and right sides, the midpoint of the line between the umbilicus and the anterior superior spine of the right ilium was used instead of the traditional mirror body swing expansion to establish the layer. The index finger was used to obliquely separate a long tunnel outward and downward on the surface of the anterior sheath of the Rectus abdominis muscle and the aponeurosis of the Abdominal external oblique muscle, to reach the Inguinal ligament. After a slight expansion on the left and right, the self-made balloon was used to expand to establish the subcutaneous space; The establishment and confirmation of anatomical markers play a very important role in laparoscopic Minimally invasive procedure. Laparoscopic inguinal lymph node dissection has the following five important anatomical markers: the anterior sheath of Rectus abdominis muscle, the aponeurosis of Abdominal external oblique muscle, the fascia lata, Inguinal ligament, and the beginning of the Great saphenous vein. The operator must learn to identify and use them, which can guide the whole operation and achieve twice the result with half the effort. The anterior sheath of Rectus abdominis muscle, the aponeurosis of Abdominal external oblique muscle, It extends downward to the thigh fascia lata, and the whole operation plane is on its surface. When establishing the observation hole under the umbilicus, cut the skin, subcutaneous Camper and Scarpa fascia layer by layer to reach the front sheath of the Rectus abdominis muscle, and then obliquely downward to the aponeurosis of the Abdominal external oblique muscle. With the flexibility and good touch of the fingers, it can be used as a subcutaneous tunnel, laying the foundation for the establishment of the subcutaneous space; In the process of lymph node dissection, it is carried out along the surface of the fascia lata of the thigh. The Inguinal ligament is the upper boundary mark of the inguinal lymph node dissection, and the portal of the inguinal lymph node dissection. At the beginning of the operation, it must be searched and confirmed to find the direction and avoid invalid subcutaneous dissociation. The beginning of the Great saphenous vein is the place where the Great saphenous vein joins the femoral vein. Under the laparoscopic vision, it is mostly located on the medial side of the Inguinal ligament, near the spermatic cord, During the operation, the assistant can repeatedly pull the spermatic cord to identify. The identification of the beginning of the Great saphenous vein is the opening of the femoral vessel sheath、the dissection of deep lymph nodes、the establishment of the inner and outer lateral fossae、and the establishment of sufficient shallow lymph node dissection scope to lay the foundation. Open the inguinal lymph node dissection, from the surface to the inside, first clean the shallow lymph nodes, and then clean the deep lymph nodes. Laparoscopic inguinal lymph node dissection adopts first deep group lymph nodes and then shallow group lymph nodes, which is characterized by: first deep group lymph nodes and then shallow group lymph nodes dissection, which is conducive to the separation of the branches of the Great saphenous vein and the preservation of the main trunk of the Great saphenous vein. When the main trunk of the Great saphenous vein and its branches are ligated and resected during traditional inguinal lymph node dissection for Penile cancer, the superficial venous return of the lower limbs is blocked and the resistance of blood microcirculation is increased, As a result, the return of Interstitial fluid is blocked, and the production of local lymph liquid is increased, leading to lower limb edema after surgery. The symptoms of lower limb edema can be alleviated only after effective collateral circulation is established. If the trunk of the Great saphenous vein can be preserved, the Superficial vein of the lower limbs can keep flowing back smoothly, and the obstacle of Interstitial fluid flowing back of the lower limbs can be alleviated through body compensation, thus reducing the occurrence of lower limb edema and other complications after Great saphenous vein resection [ 11 ]. The starting part of the Great saphenous vein is located on the medial side of the Inguinal ligament. The superficial lymph nodes were dissected first and then the deep lymph nodes were dissected across the beginning of great saphenous vein, but the superficial lymph nodes could not be completely dissected.Therefore, we made improvements during the operation: taking the starting part of the Great saphenous vein as the starting part of the operation, first open the femoral vessel sheath under the laparoscope vision, free the starting part of the Great saphenous vein, and pay attention to the protection of the main trunk of the Great saphenous vein, Deep group lymph node dissection was performed, and then shallow group lymph nodes were cleaned, and gradually dissociated along the longitudinal direction of the root of the Great saphenous vein. Five branches of the Great saphenous vein were separated in order: the superficial iliac circumflex vein, the internal pudendal vein, the Superficial vein of the abdominal wall, the medial femoral Superficial vein, and the lateral femoral Superficial vein. The superficial group lymph node specimens were taken out in blocks and times. The operation process was consistent with visual physiology and anatomy principles. Deep group lymph node dissection was performed first, At the same time, it is conducive to rapid freezing of pathology during surgery, determining whether to perform pelvic lymph node dissection. Laparoscopic inguinal lymph node dissection solves thorny problems such as skin necrosis and incision infection during open surgery, 6.conclusions Timely inguinal lymph node dissection can significantly improve the prognosis of Penile cancer patients. Research shows that three months after Penile cancer surgery is considered the appropriate time for inguinal lymph node dissection [12]. Open inguinal lymph node dissection has been abandoned due to many complications. Laparoscopic lymph node dissection has good tumor control effect and fewer surgical complications, It has been widely used in clinical practice. Compared with the traditional retrograde approach through the femoral triangle, the modified antegrade approach under the lower abdomen subcutaneously removes the deep group of lymph nodes first and then the shallow group of lymph nodes, which can better preserve the trunk of the Great saphenous vein and further reduce the incidence of postoperative lower limb edema and other complications. However, this approach is currently carried out in a small number of cases, and still needs more clinical cases to verify and optimize the operation process. It is believed that with the popularity of robots, The operation is more refined and standardized [13]. Laparoscopic minimally invasive inguinal lymph node dissection will have more accurate tumor control effect and fewer complications, thus further improving the survival time and quality of life of Penile cancer patients. Declarations The operation was carried out in accordance with the Chinese Guidelines for Diagnosis and Treatment of Diseases in Urology (2014) and the hospital grading operation management system. All patients signed the informed consent form, The informed consent was obtained from all subjects and/or their legal guardian(s),and the study was reviewed and approved by the hospital's medical ethics committee. The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Availability of data and materials： The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Consent for publication: Not applicable, Competing interests: None. funding : None BYF wrote the main manuscript text、table and XFR.LTJ.YNN.prepared figures 1-5. All authors reviewed the manuscript. Aknowledgements: Thank all patients and operating room colleagues Authors’information: Yifei Ban Urology, Xinchang County People's Hospital, Zhejiang Province, xinchang,china,post code:312500 ID: [email protected] References Wang Yonghua, Wang Ke, Chen Yuanbin, et al.Mutational landscape of penile squamous cell carcinoma in a chinese population [J].Int J Cancer, 2019, 145(5):1280-1289. Li Kai, Sun Jian,Wei Xuedong, et al. Prognostic value of lymphovascular invasion in patients with squamous cell carcinoma of the penis following surgery[J].BMC Cancer,2019,19(1): 476. SINGHA,JAIPURIA J,GOELA,etal. Comparing outcomes of obotic and open inguinal lymph node dissection in patients with carcinoma of the penis[J].J Urol,2018,199(6):1518-1525. LEONEA,DIORIO GJ,PETTAWAY C,etal. Contemporary management of patients with penile cancer and lymph node me-tastasis[J].NatRevUrol,2017,14(6):335-347. Wills A, Obermair A.A review of complications associated with the surgical treatment of vulvar cancer[J].Gynecol Oncol,2013,131(2):467-479. Catalona WJ.Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenousveins:technique and preliminary results[J].J Urol, 1988,140 (2):306-310. NABAVIZADEH R,MASTER V. Minimally invasive approaches to the inguinal nodes in cN 0 patients[J].CurrOpinUrol,2019,29(2):165- 172. Mattson JN,Emerson J,Kulkarni A,etal.Evaluation of superficialversusdeepinguinal lymphnode dissection in squamous cell carcinoma of the vulva[J].Gynecol Oncol,2019,154 (1): 219. Abbott.AM,Grotz TE, Rueth NM,et al.Minimally invasive.inguinal. lymph node dissection(MILND) for melanoma:experience from two academic centers[J]. Ann Surg Oncol, 2013, 20(1): 340-345. XU H,WANG D,WANG Y,etal. Endoscopic inguinal lymph adenectomy with a novel abdominal approach to vulvarcancer:description of technique and surgicaloutcome[J].J Minim Inva sive Gynecol,2011,18(5):644-650. ZamboniP, Marcellino MG, Cappelli M, et al.Saphenous vein sparing surgery: principles, techniques and results[J].J Cardiovasc Surg(Torino),1998,39(2):151-162. Moch H, Cubilla AL, Ulbright TM, et al.The 2016 WHO clasification of tumours of the urinary system and male genital organs[J]. EurUrol, 2016,70(1):93-105. FAVORITO L A. The future of inguinallymphadenecotmy in penile cancer: laparoscopic or robotic?[J]. Int Braz JUrol, 2019, 45(2): 208-209.DOI: 10.1590/S1677-5538.IBJU 2019.02.01. Tables Table 1 Comparison of intraoperative conditions between two groups of patients group n Lymph node dissection (piece) Intraoperative bleeding volume (ml) operative time（min） Laparoscopic group 30 9.22±0.30 145.5±36.74 162.2±3.84 Open surgery group 28 8.96±0.28 190.4±40.86 154.8±3.42 p-value ≥0.05 0.05 Table 2 Comparison of postoperative complications between two groups of patients [side (%)] group n cellulitis Lymphocyst lymphorrhagia Edema of Lower Extremities Incision infection skin necrosis amount to Laparoscopic group 30*2 2(3.3) 2(3.3) 3(5 .0) 4(6.7) 3(5 .0) 2(3.3) 16(26.7) Opensurgery group 28*2 3(5.3.) 3(5.3.) 10(17.8) 3(5.3.) 10(17.8) 9(16.0) 38(67.8 p-value <0.05 ≥0.05 <0.05 ≥0.05 <0.05 <0.05 <0.05 Note: The percentages in the table are calculated by side, with 60 sides in the endoscopic group and 58 sides in the open group. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3318499","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":230886871,"identity":"ea40650b-2995-4463-b840-3082e12629eb","order_by":0,"name":"yifei 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Background","content":"\u003cp\u003ePenile cancer is a relatively rare malignant tumor of the urinary system. The incidence rate of Penile cancer in China has reached 0.6 per 100000 [1]. It is easy to diagnose clinically, most of which are squamous cell carcinomas, which mainly metastasize through the inguinal lymph nodes. In addition to the grading and staging of the primary tumor, the prognosis of Penile cancer is also affected by the presence of metastasis in the inguinal lymph nodes [2] Timely lymph node dissection is closely related. Inguinal lymph node dissection is the best treatment for Penile cancer patients with inguinal lymph node metastasis or Penile cancer patients with high risk factors but negative clinical inguinal lymph node examination, It can increase the 5-year survival rate of patients with Penile cancer from 30% -40% of those who have already metastasized and resected to 80% -90% [3-4]. Before 2018, our hospital mainly used open surgery. Although the open inguinal lymph node dissection had a definite effect, the postoperative skin flap healed poorly and necrosis, incision infection, subcutaneous hematoma, lymphocyst formation, lymphatic leakage, lymphedema, lower limb edema, abnormal pain The incidence of complications such as cellulitis [5] is high. In recent years, with the progress of science and technology, laparoscopic minimally invasive technology has been widely used in inguinal lymph node dissection. The dissection effect is equivalent to open surgery, because of its small trauma and Great saphenous vein preservation, the complications are significantly reduced [6-7] At present, we have improved the laparoscopic inguinal lymph node dissection and Great saphenous vein preservation by using the transabdominal subcutaneous anterograde approach, with satisfactory results.\u003c/p\u003e"},{"header":"2. Clinical data","content":"\u003cp\u003e58 patients with Penile cancer who underwent bilateral inguinal lymph node dissection in our hospital\u0026apos;s Urology department from October 2014 to October 2022 were the subjects of the study. The operation was carried out in accordance with the Chinese Guidelines for Diagnosis and Treatment of Diseases in Urology (2014) and the hospital grading operation management system. All patients signed the informed consent form, and the study was reviewed and approved by the hospital\u0026apos;s medical ethics committee. Among them, 28 patients were treated with open surgery (open group) before October 2018, and 30 patients were treated with laparoscopic surgery (endoscopic group) Postoperative and follow-up status: Statistical methods were processed using SPSS 22.0 statistical software, and the counting data was expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u0026oline;x\u0026thinsp;\u0026plusmn;\u0026thinsp;s). t-test was used, and P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was used as the difference with statistical significance(Table 1and2).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"3. Laparoscopic surgery method","content":"\u003cp\u003eGeneral anesthesia was used. The patient was in a supine position, with the head and lower arms 10 \u0026deg;~15 \u0026deg;high. The lower limbs were separated, straightened slightly, rotated outwards about 45 \u0026deg;, and the knees slightly flexed and rotated outwards. A longitudinal incision was made 1cm below the umbilicus, and the skin and Subcutaneous tissue (Camper, Scarpa fascia) were cut to confirm the anterior sheath of Rectus abdominis muscle Use the index finger to move forward obliquely outward and downward on the anterior sheath of the Rectus abdominis muscle, passively separate a long tunnel along the surface of the Abdominal external oblique muscle aponeurosis to the Inguinal ligament, use the self-made airbag to expand to establish the subcutaneous space, and place 12 mm Trocar as the lens hole in this incision. CO2 gas is used to establish the subcutaneous pneumoperitoneum space, and the pressure is maintained at 12\u0026thinsp;~\u0026thinsp;15 mm Hg, Then place 5 mm、10 mm and 5 mm Trocar at the midpoint of the umbilical pubic line, the midpoint of the umbilical cord and the right anterior superior iliac spine, and the midpoint of the umbilical cord and the left anterior superior iliac spine. Four puncture holes are left on both sides(Figures \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and 2). The scope of inguinal lymph node dissection: the upper boundary is 1 cm above the Inguinal ligament, the inner boundary is to the outer edge of the adductor longus, the outer boundary is to the inner edge of the Sartorius muscle, and the lower boundary is to the tip of the femoral triangle. Mark the scope of bilateral inguinal lymph node dissection with a marker.\u003c/p\u003e"},{"header":"4. Operation process","content":"\u003cp\u003ealong the surface of the Abdominal external oblique muscle aponeurosis and between the Scarpa fascia, skin external compression helps to locate, fully free and expose the Inguinal ligament. Close to the surface of the Inguinal ligament, downward free, pull the spermatic cord by an assistant and other methods to find the root of the confirmed and free Great saphenous vein, that is, the Great saphenous vein flows into the femoral vein. Along the root of the Great saphenous vein, close to the fascia lata of the thigh inward and outward downward respectively, free, Establish and expand the necessary range for internal and external lymph node dissection(Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e、4), The internal boundary is the spermatic cord, and then free along the root of the Great saphenous vein to confirm the position of the femoral blood vessel. Cut the anterior sheath of the femoral blood vessel to free the root of the Great saphenous vein, the femoral vein, the femoral tube and the surface of the Femoral artery. Just clean the inside of the femoral vein and the femoral Endolymph node (Cloquet lymph node)(Fig.\u0026nbsp;5), and send the cleaned deep group of lymph nodes for rapid pathological examination. If positive, perform pelvic lymph node cleaning. Free down along the root of the Great saphenous vein, Fully free the whole Great saphenous vein and its 5 subordinate branches, and first free and cut off the superficial iliac circumflex vein and the genitals Internal vein. Sweep the superficial lymph nodes between Camper\u0026apos;s fascia and Scarpa\u0026apos;s fascia along the skin. The superficial lymph nodes between Camper fascia and Scarpa fascia were cleaned along the skin. When sweeping, the shallow layer should be close to the skin; The deep layer should cling to the fascia of the external abdominal oblique muscle and fascia lata, until the top of femoral triangle removes all the lymphoid adipose tissue on the fascia surface.During surgery, it is necessary to preserve the blood supply to the skin while ensuring the curative effect of the tumor. It is recommended not to cut through the skin as much as possible to prevent damage to the skin and nourish the blood, leading to poor postoperative incision healing. Identify, free and ligate the Superficial vein of the abdominal wall, the medial Superficial vein of the thigh, and the lateral Superficial vein of the thigh, and retain the main trunk of the Great saphenous vein. In case of thicker Lymphatic vessel, delay cauterization to minimize the incidence of postoperative Lymphatic leakage. With the Great saphenous vein as the boundary, divide the lymph nodes of the superficial group to be cleaned into two pieces, and take out the specimen bags respectively. The surgical wound is complete, the negative pressure drainage ball is placed at the lowest part of the incision, the external negative pressure suction is connected, and the groin area is properly pressurized and bound, The negative pressure drainage method can effectively reduce the daily drainage volume, shorten the placement time of the drainage tube, and reduce the subcutaneous hydrops, Cellulitis and other adverse complications caused by long-term tube placement [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e"},{"header":"5. exploration, improvement, experience in surgical techniques and Discussion","content":"\u003cp\u003eThere are currently two clinical approaches for laparoscopic inguinal lymph node dissection: retrograde dissection through the subcutaneous approach of the lower limb femoral triangle and antegrade dissection through the subcutaneous approach of the lower abdomen [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. The reverse sweeping approach through the lower limb femoral triangle subcutaneous approach is more widely used, which is characterized by relatively simple operation, short Learning curve, but limited space. Each side needs 3 puncture holes, which is more traumatic. In addition, for those with deep group lymph node positive who need pelvic lymph node dissection, they can not do both, and they need to change their positions and reset the puncture holes. In 2011, some Chinese scholars tried to use the abdominal subcutaneous approach to clean inguinal lymph nodes anterograde, The puncture points are located at the lower edge of the umbilicus, the midpoint of the umbilical pubic line, and the inner side of the anterior superior iliac spine [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, due to the long surgical path and high surgical difficulty, it was not accepted by the mainstream at that time. With the improvement of technology, the transabdominal subcutaneous approach has gradually been accepted and applied in clinical practice. Research has shown that the recent surgical effects of the transabdominal subcutaneous and femoral triangular approaches are comparable, but the transabdominal subcutaneous approach has more advantages, not only with fewer incisions The risk of postoperative lower limb lymphedema is lower, and pelvic lymph node dissection can also be considered. On this basis, we adopted a subcutaneous anterograde approach through the abdomen to change the transverse incision at the lower edge of the umbilical wheel to a 1cm vertical incision below the umbilical, which is convenient for both sides to retain observation lenses placing; On the left and right sides, the midpoint of the line between the umbilicus and the anterior superior spine of the right ilium was used instead of the traditional mirror body swing expansion to establish the layer. The index finger was used to obliquely separate a long tunnel outward and downward on the surface of the anterior sheath of the Rectus abdominis muscle and the aponeurosis of the Abdominal external oblique muscle, to reach the Inguinal ligament. After a slight expansion on the left and right, the self-made balloon was used to expand to establish the subcutaneous space; The establishment and confirmation of anatomical markers play a very important role in laparoscopic Minimally invasive procedure. Laparoscopic inguinal lymph node dissection has the following five important anatomical markers: the anterior sheath of Rectus abdominis muscle, the aponeurosis of Abdominal external oblique muscle, the fascia lata, Inguinal ligament, and the beginning of the Great saphenous vein. The operator must learn to identify and use them, which can guide the whole operation and achieve twice the result with half the effort. The anterior sheath of Rectus abdominis muscle, the aponeurosis of Abdominal external oblique muscle, It extends downward to the thigh fascia lata, and the whole operation plane is on its surface. When establishing the observation hole under the umbilicus, cut the skin, subcutaneous Camper and Scarpa fascia layer by layer to reach the front sheath of the Rectus abdominis muscle, and then obliquely downward to the aponeurosis of the Abdominal external oblique muscle. With the flexibility and good touch of the fingers, it can be used as a subcutaneous tunnel, laying the foundation for the establishment of the subcutaneous space; In the process of lymph node dissection, it is carried out along the surface of the fascia lata of the thigh. The Inguinal ligament is the upper boundary mark of the inguinal lymph node dissection, and the portal of the inguinal lymph node dissection. At the beginning of the operation, it must be searched and confirmed to find the direction and avoid invalid subcutaneous dissociation. The beginning of the Great saphenous vein is the place where the Great saphenous vein joins the femoral vein. Under the laparoscopic vision, it is mostly located on the medial side of the Inguinal ligament, near the spermatic cord, During the operation, the assistant can repeatedly pull the spermatic cord to identify. The identification of the beginning of the Great saphenous vein is the opening of the femoral vessel sheath、the dissection of deep lymph nodes、the establishment of the inner and outer lateral fossae、and the establishment of sufficient shallow lymph node dissection scope to lay the foundation. Open the inguinal lymph node dissection, from the surface to the inside, first clean the shallow lymph nodes, and then clean the deep lymph nodes. Laparoscopic inguinal lymph node dissection adopts first deep group lymph nodes and then shallow group lymph nodes, which is characterized by: first deep group lymph nodes and then shallow group lymph nodes dissection, which is conducive to the separation of the branches of the Great saphenous vein and the preservation of the main trunk of the Great saphenous vein. When the main trunk of the Great saphenous vein and its branches are ligated and resected during traditional inguinal lymph node dissection for Penile cancer, the superficial venous return of the lower limbs is blocked and the resistance of blood microcirculation is increased, As a result, the return of Interstitial fluid is blocked, and the production of local lymph liquid is increased, leading to lower limb edema after surgery. The symptoms of lower limb edema can be alleviated only after effective collateral circulation is established. If the trunk of the Great saphenous vein can be preserved, the Superficial vein of the lower limbs can keep flowing back smoothly, and the obstacle of Interstitial fluid flowing back of the lower limbs can be alleviated through body compensation, thus reducing the occurrence of lower limb edema and other complications after Great saphenous vein resection [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. The starting part of the Great saphenous vein is located on the medial side of the Inguinal ligament. The superficial lymph nodes were dissected first and then the deep lymph nodes were dissected across the beginning of great saphenous vein, but the superficial lymph nodes could not be completely dissected.Therefore, we made improvements during the operation: taking the starting part of the Great saphenous vein as the starting part of the operation, first open the femoral vessel sheath under the laparoscope vision, free the starting part of the Great saphenous vein, and pay attention to the protection of the main trunk of the Great saphenous vein, Deep group lymph node dissection was performed, and then shallow group lymph nodes were cleaned, and gradually dissociated along the longitudinal direction of the root of the Great saphenous vein. Five branches of the Great saphenous vein were separated in order: the superficial iliac circumflex vein, the internal pudendal vein, the Superficial vein of the abdominal wall, the medial femoral Superficial vein, and the lateral femoral Superficial vein. The superficial group lymph node specimens were taken out in blocks and times. The operation process was consistent with visual physiology and anatomy principles. Deep group lymph node dissection was performed first, At the same time, it is conducive to rapid freezing of pathology during surgery, determining whether to perform pelvic lymph node dissection. Laparoscopic inguinal lymph node dissection solves thorny problems such as skin necrosis and incision infection during open surgery,\u003c/p\u003e"},{"header":"6.conclusions","content":"\u003cp\u003eTimely inguinal lymph node dissection can significantly improve the prognosis of Penile cancer patients. Research shows that three months after Penile cancer surgery is considered the appropriate time for inguinal lymph node dissection [12]. Open inguinal lymph node dissection has been abandoned due to many complications. Laparoscopic lymph node dissection has good tumor control effect and fewer surgical complications, It has been widely used in clinical practice. Compared with the traditional retrograde approach through the femoral triangle, the modified antegrade approach under the lower abdomen subcutaneously removes the deep group of lymph nodes first and then the shallow group of lymph nodes, which can better preserve the trunk of the Great saphenous vein and further reduce the incidence of postoperative lower limb edema and other complications. However, this approach is currently carried out in a small number of cases, and still needs more clinical cases to verify and optimize the operation process. It is believed that with the popularity of robots, The operation is more refined and standardized [13]. Laparoscopic minimally invasive inguinal lymph node dissection will have more accurate tumor control effect and fewer complications, thus further improving the survival time and quality of life of Penile cancer patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe operation was carried out in accordance with the Chinese Guidelines for Diagnosis and Treatment of Diseases in Urology (2014) and the hospital grading operation management system. All patients signed the informed consent form, The informed consent was obtained from all subjects and/or their legal guardian(s),and the study was reviewed and approved by the hospital\u0026apos;s medical ethics committee. The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003efunding\u003c/strong\u003e: None\u003c/p\u003e\n\u003cp\u003eBYF wrote the main manuscript text、table and XFR.LTJ.YNN.prepared figures 1-5. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAknowledgements: \u003c/strong\u003eThank all patients and operating room colleagues\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;information:\u003c/strong\u003e Yifei Ban Urology, Xinchang County People\u0026apos;s Hospital, Zhejiang Province, xinchang,china,post code:312500 ID:[email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang Yonghua, Wang Ke, Chen Yuanbin, et al.Mutational landscape of penile squamous cell carcinoma in a chinese population [J].Int J Cancer, 2019, 145(5):1280-1289.\u003c/li\u003e\n\u003cli\u003eLi Kai, Sun Jian,Wei Xuedong, et al. Prognostic value of lymphovascular invasion in patients with squamous cell carcinoma of the penis following surgery[J].BMC Cancer,2019,19(1): 476.\u003c/li\u003e\n\u003cli\u003eSINGHA,JAIPURIA J,GOELA,etal. Comparing outcomes of obotic and open inguinal lymph node dissection in patients with carcinoma of the penis[J].J Urol,2018,199(6):1518-1525.\u003c/li\u003e\n\u003cli\u003eLEONEA,DIORIO GJ,PETTAWAY C,etal. Contemporary management of patients with penile cancer and lymph node me-tastasis[J].NatRevUrol,2017,14(6):335-347.\u003c/li\u003e\n\u003cli\u003eWills A, Obermair A.A review of complications associated with the surgical treatment of vulvar cancer[J].Gynecol Oncol,2013,131(2):467-479.\u003c/li\u003e\n\u003cli\u003eCatalona WJ.Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenousveins:technique and preliminary results[J].J Urol, 1988,140 (2):306-310.\u003c/li\u003e\n\u003cli\u003eNABAVIZADEH R,MASTER V. Minimally invasive approaches to the inguinal nodes in cN 0 patients[J].CurrOpinUrol,2019,29(2):165- 172.\u003c/li\u003e\n\u003cli\u003eMattson JN,Emerson J,Kulkarni A,etal.Evaluation of superficialversusdeepinguinal lymphnode dissection in squamous cell carcinoma of the vulva[J].Gynecol Oncol,2019,154 (1): 219.\u003c/li\u003e\n\u003cli\u003eAbbott.AM,Grotz TE, Rueth NM,et al.Minimally invasive.inguinal. lymph node dissection(MILND) for melanoma:experience from two academic centers[J]. Ann Surg Oncol, 2013, 20(1): 340-345.\u003c/li\u003e\n\u003cli\u003eXU H,WANG D,WANG Y,etal. Endoscopic inguinal lymph adenectomy with a novel abdominal approach to vulvarcancer:description of technique and surgicaloutcome[J].J Minim Inva sive Gynecol,2011,18(5):644-650.\u003c/li\u003e\n\u003cli\u003eZamboniP, Marcellino MG, Cappelli M, et al.Saphenous vein sparing surgery: principles, techniques and results[J].J Cardiovasc Surg(Torino),1998,39(2):151-162.\u003c/li\u003e\n\u003cli\u003eMoch H, Cubilla AL, Ulbright TM, et al.The 2016 WHO clasification of tumours of the urinary system and male genital organs[J]. EurUrol, 2016,70(1):93-105.\u003c/li\u003e\n\u003cli\u003eFAVORITO L A. The future of inguinallymphadenecotmy in penile cancer: laparoscopic or robotic?[J]. Int Braz JUrol, 2019, 45(2): 208-209.DOI: 10.1590/S1677-5538.IBJU 2019.02.01.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Comparison of intraoperative conditions between two groups of patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.825396825396826%\" valign=\"top\"\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.08994708994709%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.523809523809526%\" valign=\"top\"\u003e\n \u003cp\u003eLymph node dissection (piece)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.174603174603174%\" valign=\"top\"\u003e\n \u003cp\u003eIntraoperative bleeding volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.386243386243386%\" valign=\"top\"\u003e\n \u003cp\u003eoperative time（min）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.825396825396826%\" valign=\"top\"\u003e\n \u003cp\u003eLaparoscopic group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.08994708994709%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.523809523809526%\" valign=\"top\"\u003e\n \u003cp\u003e9.22\u0026plusmn;0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.174603174603174%\" valign=\"top\"\u003e\n \u003cp\u003e145.5\u0026plusmn;36.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.386243386243386%\" valign=\"top\"\u003e\n \u003cp\u003e162.2\u0026plusmn;3.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.825396825396826%\" valign=\"top\"\u003e\n \u003cp\u003eOpen surgery group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.08994708994709%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.523809523809526%\" valign=\"top\"\u003e\n \u003cp\u003e8.96\u0026plusmn;0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.174603174603174%\" valign=\"top\"\u003e\n \u003cp\u003e190.4\u0026plusmn;40.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.386243386243386%\" valign=\"top\"\u003e\n \u003cp\u003e154.8\u0026plusmn;3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.825396825396826%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.08994708994709%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.523809523809526%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.174603174603174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.386243386243386%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 Comparison of postoperative complications between two groups of patients [side (%)]\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.338624338624339%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.994708994708995%\" valign=\"top\"\u003e\n \u003cp\u003ecellulitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.65079365079365%\" valign=\"top\"\u003e\n \u003cp\u003eLymphocyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.613756613756614%\" valign=\"top\"\u003e\n \u003cp\u003elymphorrhagia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003eEdema of Lower Extremities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.582010582010582%\" valign=\"top\"\u003e\n \u003cp\u003eIncision infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.947089947089948%\" valign=\"top\"\u003e\n \u003cp\u003eskin necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.62962962962963%\" valign=\"top\"\u003e\n \u003cp\u003eamount to\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003eLaparoscopic group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.338624338624339%\" valign=\"top\"\u003e\n \u003cp\u003e30*2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.994708994708995%\" valign=\"top\"\u003e\n \u003cp\u003e2(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.65079365079365%\" valign=\"top\"\u003e\n \u003cp\u003e2(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.613756613756614%\" valign=\"top\"\u003e\n \u003cp\u003e3(5\u0026nbsp;.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003e4(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.582010582010582%\" valign=\"top\"\u003e\n \u003cp\u003e3(5\u0026nbsp;.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.947089947089948%\" valign=\"top\"\u003e\n \u003cp\u003e2(3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.62962962962963%\" valign=\"top\"\u003e\n \u003cp\u003e16(26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003eOpensurgery group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.338624338624339%\" valign=\"top\"\u003e\n \u003cp\u003e28*2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.994708994708995%\" valign=\"top\"\u003e\n \u003cp\u003e3(5.3.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.65079365079365%\" valign=\"top\"\u003e\n \u003cp\u003e3(5.3.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.613756613756614%\" valign=\"top\"\u003e\n \u003cp\u003e10(17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003e3(5.3.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.582010582010582%\" valign=\"top\"\u003e\n \u003cp\u003e10(17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.947089947089948%\" valign=\"top\"\u003e\n \u003cp\u003e9(16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.62962962962963%\" valign=\"top\"\u003e\n \u003cp\u003e38(67.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.338624338624339%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.994708994708995%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.65079365079365%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.613756613756614%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.121693121693122%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.582010582010582%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.947089947089948%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.62962962962963%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: The percentages in the table are calculated by side, with 60 sides in the endoscopic group and 58 sides in the open group.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Penile cancer, Laparoscopy, Inguinal lymph node dissection, Great saphenous vein preservation","lastPublishedDoi":"10.21203/rs.3.rs-3318499/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3318499/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe prognosis of Penile cancer patients is closely related to the metastasis of inguinal lymph nodes. Timely inguinal lymph node dissection is an important part of the treatment of Penile cancer. The tumor control effect of laparoscopic inguinal lymph node dissection is similar to that of open surgery, but the complications are significantly reduced; And there are different methods in terms of surgical approach, dissection approach and Great saphenous vein preservation. We adopt the transabdominal subcutaneous anterograde approach and improve the laparoscopic inguinal lymph node dissection. This article introduces the procedures and technical improvement points of the improved laparoscopic inguinal lymph node dissection through the subcutaneous approach.\u003c/p\u003e","manuscriptTitle":"Improvement of laparoscopic inguinal lymph node dissection for Penile cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-08 13:42:08","doi":"10.21203/rs.3.rs-3318499/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8670540e-b448-4204-b5dd-508e4168c243","owner":[],"postedDate":"September 8th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-09-26T13:29:27+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-08 13:42:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3318499","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3318499","identity":"rs-3318499","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}