The surgical boundaries of lymphadenectomy field are the lateral border of adductor longus medially, lateral border of Sartorius muscles laterally, spermatic cord superomedially reaching to 2–3 cm above inguinal ligament with inferior border being apex of femoral triangle with complete removal of muscular fascia, skeletonization of the femoral vessels. The saphenous vein may be spared as this has shown to significantly decrease postoperative edema in similar procedures [26, 27] unless there is bulky disease (Fig. 5.3). In this case of minimal palpable disease resection of the muscular fascia was recently omitted in one series with oncologic control maintained and decreased complications rate [28]. During lymphadenectomy dissection lateral to and below the plane of the femoral artery should be avoided in order to avoid the motor branches of femoral nerve. Superficial branches of femoral artery supplying traveling through the lymphatic packets to supply the overlying subcutaneous tissue are carefully ligated and divided. After completing lymphadenectomy 1-2 closed suction drain are placed to avoid seroma formation. Recently we have covered drain entry sites with patches impregnated with chlorhexidine in order to prevent drain tract infections [29].

A superficial inguinal dissection as described by Bevan-Thomas is performed [25]. Lymphatic tissue above the fascia lata of the thigh is removed between the midpoint of the Sartorius and the adductor longus muscles and 2–3 cm above the inguinal ligament superiorly and inferiorly to 2–3 cm above the apex of the femoral triangle. The saphenous vein was dissected from the nodal packet and preserved (Fig. 5.4). Frozen section analysis of lymph nodes is performed and, if metastases are absent, the procedure is concluded. If metastasis is detected, a complete inguinal dissection is performed. An alternative strategy to stage the clinically negative inguinal field is to perform a dynamic sentinel node biopsy [30] through intradermal, peritumoral injection of a 99mtechnetium-labeled nanocolloid followed by immediate dynamic and static imaging was at 30 min, 90 min, and 2 h. The sentinel node was defined as a node on a direct lymphatic drainage pathway from the primary tumor, and its location(s) were marked on the skin.

Pelvic lymphadenectomy is usually preserved for cases with clinically positive pelvic nodes or high-risk pathologically positive inguinal nodes. Given that patients with clinically positive inguinal nodes are at risk to exhibit high-risk pathologic features [9], it is reasonable to perform simultaneous pelvic lymphadenectomy on the ipsilateral side in patients with proven metastases who present with clinically palpable lymph nodes. Lymphadenectomy is usually performed on the ipsilateral side(s) of inguinal nodal metastasis through midline suprapubic incision. In the setting of bilateral inguinal lymph node metastases one recent retrospective study showed that patients with four or more total inguinal nodes were at increased risk for bilateral pelvic metastases and should undergo a bilateral procedure [31]. Given the risk level, we would typically perform a bilateral pelvic dissection among those patients with bilateral inguinal metastases for surgical consolidation as many of these patients would have received neoadjuvant chemotherapy prior to surgery. The boundaries of pelvic lymphadenectomy are the bladder wall medially, genitofemoral nerve laterally, bifurcation of common iliac artery superiorly, and lymph node of Cloquet distally.

The ultimate goal of neoadjuvant chemotherapy is to improve survival by achieving cytoreduction of metastatic deposits prior to consolidative surgery. Patients who achieve an objective response to systemic therapy are ideal candidates for consolidative surgery. An elliptical skin incision with resection of the area of skin overlying bulky lymph nodes, tumor deposits fixed to the overlying skin, or ulcerated tumors is recommended to ensure complete removal of grossly palpable or visible residual disease with negative surgical margins (Fig. 5.5). Intraoperative frozen sections should be utilized to achieve thus goal. In the setting of bulky disease the saphenous vein and fascia lata are usually resected. Additional procedures occasionally used to ensure local control of advanced disease include excision of the inguinal ligament, spermatic cord and testicle, anterior abdominal wall or femoral vessels with subsequent vein patch or a bypass graft if these structures are grossly invaded by tumor [6].

Providing coverage to the skeletonized femoral vessels with vascularized muscle flaps along with bridging skin defects without tension are important steps to decrease postoperative morbidity following ILND by providing for rapid wound healing. A Sartorius muscle flap can be used by dividing the Sartorius muscle from anterior superior iliac spine and transposing it to cover femoral vessels. Other options include the vertical rectus abdominis muscle via raising a flap of muscle with or without the overlying ellipse of skin depending on size of skin defect (Fig. 5.6a, b). The anterolateral thigh musculocutaneus flap is another popular alternative for inguinal reconstruction that may be less morbid than the vertical rectus flap.

The above surgical considerations highlight the importance of preoperative planning when considering surgical consolidation among patients with advanced inguinal metastases. Multidisciplinary input from urologic, plastic, and vascular surgical teams helps insure optimal care for these patients.