Different inguinal lymphadenectomy for penile malignancy: a pairwise and Bayesian network meta-analysis

Abstract

Highlights The existing guidelines recommend the use of minimally invasive inguinal lymph node dissection (LND) primarily in clinical trials involving patients with penile cancer. This meta-analysis included 1674 patients from 29 studies to assess different inguinal LND. Video-endoscopic inguinal LND (VEIL) demonstrates superiority over open inguinal LND in terms of perioperative outcomes and complications. Robot-assisted VEIL presents a promising alternative for the treatment of penile cancer. Penile cancer is an uncommon yet aggressive tumor that can develop in the skin of the glans or the inner layer of the foreskin1. The current guidelines from the European Association of Urology (EAU) and the American Society of Clinical Oncology (ASCO) strongly advocate for offering surgical staging to all patients with a high likelihood of micrometastatic disease (T1b or higher) if no palpable/suspicious lymph nodes (cN0) are detected during physical examination1. Furthermore, inguinal lymph node dissection (ILND) remains the predominant surgical approach for patients diagnosed with penile cancer2. While open inguinal lymph node dissection (OILND) is the standard surgical procedure for patients with penile cancer, its application often has a high incidence of complications3. In recent years, minimally invasive techniques have gained prominence in genitourinary oncology surgery and have exhibited superior outcomes compared to open surgery in several trials4,5. The latest guidelines from the EAU endorse minimally invasive ILND solely for stage cN1–2 patients as part of clinical trials1. To provide the most current and comprehensive evidence-based analysis, we employed pairwise and Bayesian network meta-analysis (NMA) to compare perioperative outcomes, complications, and oncologic outcomes across various ILND approaches in patients with penile cancer. We conducted this study according to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Supplementary Table S1, Supplemental Digital Content 1, https://links.lww.com/JS9/D68) and Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2, Supplemental Digital Content 2, https://links.lww.com/JS9/D69)6,7. The study protocol has been prospectively registered in PROSPERO. As of 15 March 2024, two reviewers independently conducted searches across multiple databases (Supplementary Table S2, Supplemental Digital Content 3, https://links.lww.com/JS9/D70). The analyses included studies meeting the following criteria: (1) randomized controlled trials (RCTs) or cohorts comparing OILND, video-endoscopic inguinal LND (VEILND), or robot-assisted video-endoscopic inguinal LND (RAVEIL) for penile cancer, and (2) studies providing sufficient data on perioperative outcomes, complications, and oncological outcomes. The Newcastle–Ottawa Scale was used to evaluate the quality of the included cohort and case-control study, and studies with seven to nine points were regarded as high quality. The quality of the included randomized trials was evaluated with the Cochrane Collaboration’s tool for assessing the risk8. The Stata 12.0 was employed for the meta-analysis to compare continuous and dichotomous data, expressed as weighted mean difference and odds ratio, respectively. We performed subgroup analyses of the race of the included study population into Asian and non-Asian populations, and whether or not the saphenous vein was preserved in the ILND. In the NMA, local inconsistency testing was conducted using a node-splitting method. The surface under the cumulative ranking curve (SUCRA) was utilized to rank each intervention and determine the optimal treatment regimen, with higher SUCRA probability indicating a greater likelihood of being the best treatment option9. NMA calculations were performed using R 4.3.2 software with the “gemtc” package version 1.0.2. Our meta-analysis included 29 articles with 1674 patients (Supplementary Fig S1, Supplemen