Lymph node dissection(LND) remains the gold standard in the staging and treatment of locally advanced penile cancer(PC)<sup>1O.W. Hakenberg, E. Compérat, S. Minhas, A. Necchi, C. Protzel, N. Watkin. EAU Guidelines Penile Cancer. Available at: penile-cancer [Accessed on 8 December 2020]

Cliccare qui per andare alla sezione Riferimenti</sup>.

To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach<sup>2Xu H, Wang D, Wang Y, Li Y, Chen Y, Liang Z Endoscopic Inguinal Lymphadenectomy with a novel abdominal approach to vulvar cancer: description of technique and surgical outcome J Minim Invasive Gynecol 2011 ;  18 : 644-65010.1016/j.jmig.2011.06.011 [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup>,for performing LND in PC, first described in Urology by our group in 20153Subirá -Rios D., Lopez I, Urdaneta G. Moncada I. Robotic inguinal and pelvic lymphadenectomy in penis cancer a novel abdominal approach. 12th Meeting of the EAU Robotic Urology Section, Bilbao (Spain):ERUS 15-0053.

Cliccare qui per andare alla sezione Riferimenti: the Pelvic and Inguinal Single Access(PISA) technique (Fig. 1).

Between 2015 and 2018, 10 consecutive patients with different PC stages and indication of inguinal LND (cN0 and ≥pT1G3 or cN1/cN2)<sup>1O.W. Hakenberg, E. Compérat, S. Minhas, A. Necchi, C. Protzel, N. Watkin. EAU Guidelines Penile Cancer. Available at: penile-cancer [Accessed on 8 December 2020]

Cliccare qui per andare alla sezione Riferimenti</sup> were operated by means of the PISA technique (Table 1). Intraoperative frozen section(FS)<sup>4Chipollini J, Tang DH, Manimala N, Gilbert SM, Pow-Sang JM, Sexton WJ, e al. Evaluating the accuracy of intraoperative frozen section during inguinal lymph node dissection in penile cancer Urol Oncol 2018 ;  36 : 14.e1-14.e510.1016/j.urolonc.2017.08.018

Cliccare qui per andare alla sezione Riferimenti</sup> analysis was carried out routinely and if ≥2 inguinal nodes(pN2) or extracapsular nodal extension(pN3) are detected<sup>1O.W. Hakenberg, E. Compérat, S. Minhas, A. Necchi, C. Protzel, N. Watkin. EAU Guidelines Penile Cancer. Available at: penile-cancer [Accessed on 8 December 2020]

Cliccare qui per andare alla sezione Riferimenti,5Lughezzani G., Catanzaro M, Torelli T, Piva L, Biasoni D, Stagni S, e al. The relationship between characteristics of inguinal lymph nodes and pelvic lymph node involvement in penile squamous cell carcinoma: a single institution experience J Urol 2014 ;  191 : 977-98210.1016/j.juro.2013.10.140 [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup>, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. If this condition occurs bilaterally in the inguinal LND, the pelvic LND will be bilateral.

The video shows the PISA technique in a step-by-step. Instrumental requirements: 30°laparoscopy optic, monopolar scissors,Ligasure (Covidien Surgical,Minneapolis,MN,USA) vascular sealant, extraction-bag, bipolar forceps and 5-mm endo-clip(Hem-o-lok)are required.

Intraoperative and postsurgical variables are shown in Table 2. Inguinal LND was bilateral in all cases. Pelvic LND was required in 40% of patients. Total operative time was 120-170 minutes. Median estimated blood loss(EBL) was 66(30-100)cc, but no blood transfusion was required. No intraoperative complications were noted. 40% of patients had postoperative complications (10% major complication- symptomatic inguinal lymphocele). Median lenght of hospital stay(LOS)was 5.8(3-10) days. Median inguinal drain removal was 4.7 days. The pathological analysis outcomes are shown in Table 3. Mean number of lymph nodes removed by inguinal LND was 10.25(8-14).

PISA technique allow a minimally invasive inguinal and pelvic LND using the same set of incisions and carry it out in the same surgical procedure. PISA technique in PC LND seems to be safe, with a low rate of major complications and preserving oncological efficacy.