Advanced Metastatic Inguinal Lymph Node Disease N1N3 Large or Fixed Nodes

The step wise metastatic involvement of lymph nodes in patients with penile cancer begins at the level of the inguinal lymph nodes. In contrast to early stage disease where lymph nodes are either impalpable or small and palpable, in advanced disease the lymph nodes may form large palpable lesions which are adherent to the overlying skin or fixed to the underlying fascia or muscle. Inevitably these large masses are associated with extracapsular extension of tumor and therefore in order to gain local control the overlying skin and subcutaneous tissue must be excised. With metastatic lymph nodes deep to the skin primary closure of the defect is possible aided by mobilization of the superior and inferior skin flaps. However, larger defects following resection of inguinal metastatic disease associated with skin ulceration often requires the use of pedicled skin flaps in order to cover the resulting defect.

Bulky ulcerating inguinal N3 disease can undergo palliative resection of the tumor and overlying skin followed by coverage of the defect using a pedicled skin flap. This allows palliation with regard to symptoms such as pain and sepsis and also reduces the risk of femoral vessel hemorrhage due to malignant infiltration. When circumstances demand a large area of inguinal soft tissue sacrifice, primary closure may be obtained by scrotal skin rotation flaps,14 an abdominal wall advancement flap,15 or a myocutaneous flap based on the rectus abdominis or tensor fascia lata1617 for more extensive defects. These techniques will be described later in the chapter.

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