A focused systematic review and meta-analysis of robot-assisted inguinal lymphadenectomy versus open inguinal lymph node dissection in penile cancer

Clinical Snapshot

Key Findings

• P Value: P = 0.047 (borderline significance)

• Effect Size: OR = 0.52 (favours RAIL)

• Primary Outcome: Total postoperative complications: RAIL associated with lower odds compared to OILND

• Nnt Or Sensitivity: NNT not calculable from available data; lymph node yield, skin-related complications, minor complications, and groins with positive nodes showed no statistically significant difference between approaches; continuous outcomes (operative time, estimated blood loss, drainage) showed extreme heterogeneity and are not reliably interpretable as pooled estimates

• Confidence Interval: 95% CI: 0.27 to 0.97

Clinical Application

RAIL requires specialised robotic platforms (e.g., da Vinci system), dedicated surgical training, and institutional infrastructure. Operative time appears generally longer with RAIL across individual studies, which has resource and scheduling implications. The procedure is technically demanding with a recognised learning curve. Feasibility is currently limited to high-volume tertiary referral centres. Penile cancer is rare in Australia, with approximately 200 new cases diagnosed annually (Cancer Australia data). Inguinal lymph node dissection is performed at a small number of tertiary urological oncology centres. Robotic surgical platforms are available at major public and private hospitals in metropolitan areas, but access is uneven across states and territories. RAIL is not specifically listed on the Medicare Benefits Schedule (MBS) as a distinct item; robotic-assisted procedures are generally billed under existing open or laparoscopic item numbers, creating funding ambiguity. The TGA has approved robotic surgical systems for use in Australia, but there is no specific TGA indication for RAIL in penile cancer. RACGP and Urological Society of Australia and New Zealand (USANZ) guidelines do not currently endorse RAIL over OILND given the absence of high-quality evidence. The rarity of penile cancer in Australia means that accumulating sufficient local RCT evidence will require multi-centre collaboration, potentially through the ANZUP Cancer Trials Group. Adult males with penile cancer (any stage) requiring inguinal lymph node dissection at centres with robotic surgical capability and appropriately trained urological oncology surgeons

Abstract

This focused systematic review and meta-analysis evaluated robot-assisted inguinal lymphadenectomy (RAIL) versus open inguinal lymph node dissection (OILND) in penile cancer, aiming to provide robot-specific comparative estimates rather than a broad minimally invasive synthesis. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched through December 2025 for comparative studies. All meta-analyses were conducted using STATA 18, employing random-effects modeling. Binary outcomes were summarized using odds ratios (ORs), and continuous outcomes were presented as weighted mean differences (WMDs), with all estimates accompanied by 95% confidence intervals (CIs). Risk of bias in the included non-randomized comparative studies was assessed using the ROBINS-I tool. Four retrospective comparative studies involving 276 patients were included, and no randomized controlled trials were identified. A lower odds of total postoperative complications was observed with RAIL (OR = 0.52, 95% CI: 0.27, 0.97; P = 0.047), but this borderline finding should be interpreted cautiously given the small number of retrospective studies and potential residual confounding. Across individual studies, operative time generally tended to be longer with RAIL, whereas findings for estimated blood loss and drainage-related outcomes were inconsistent. Lymph node yield, skin-related complications, minor complications, and groins with positive nodes did not differ significantly between approaches. According to the GRADE assessment, the certainty of evidence was low for most pooled outcomes and very low for skin-related complications and lower-limb edema/lymphedema. RAIL may be associated with lower overall postoperative complications than open surgery, but the evidence remains low certainty and insufficient to establish a definitive morbidity-reduction benefit. In addition, several continuous perioperative variables showed extreme between-study heterogeneity and were not clinically interpretable as reliable pooled effects.

References

1. 1.Wen, Z., Zhou, M.-G., Wang, T., & Du, P. (2026). A focused systematic review and meta-analysis of robot-assisted inguinal lymphadenectomy versus open inguinal lymph node dissection in penile cancer. Journal of Robotic Surgery. https://doi.org/10.1016/j.euf.2023.01.018