Introduction

The majority of penile cancers are squamous cell carcinomas (~95%) which typically show a step-wise lymphogenic spread prior to hematogenic dissemination. The primary draining lymph nodes are invariably located within the inguinal lymphatic region. Thereafter, dissemination usually continues to the pelvic nodes and/ or distant sites. At initial presentation, distant metastases are present in only 1-2% of the patients and are virtually always associated with clinically evident lymph node metastases.

The presence of nodal involvement is the single most important prognostic fac-tor.1-7 As the currently available noninvasive staging modalities have a low sensitivity in detecting the regional lymph node status (i.e. missing micrometastatic disease), the optimal management of clinically node-negative (cN0) patients has been the subject of debate.8 Approximately 20-25% of these cN0 patients have occult metastasis. Some clinicians manage these patients with close surveillance, while others will perform an inguinal lymphadenectomy.

Other approaches are dynamic sentinel node biopsy, modified lymphadenectomy and radical inguinal lymphadenectomy in those patients considered to be at risk for occult metastases, so called "risk-adapted approach".9 While close surveillance may lead to unintentional delay because of outgrowth of occult metastases in 20-25% of cN0 patients, elective as well as risk-adapted inguinal lymphadenectomy is considered unnecessary in 75-80% of such cases, because of the absence of metastases.10 Furthermore, lymphadenectomy is associated with a high morbidity rate. Up to 35-70% of patients have short- or long-term complications.11-14

Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

A. Muneer et al. (eds.), Textbook of Penile Cancer,

DOI 10.1007/978-1-84882-879-7_9, © Springer-Verlag London Limited 2012

The management of patients with metastatic inguinal nodal disease is clear. If deemed operable, these patients require an inguinal lymphadenectomy. In these patients, the therapeutic value of regional lymphadenectomy justifies the complications associated with this procedure. Surgery remains the cornerstone of therapy in patients with metastatic disease, with curative outcomes in approximately 80% of patients with one or two involved inguinal nodes without extranodal extension.1-7

However, controversy remains on the extent of surgery. There are a number of issues which include:

1. How extensive does the inguinal lymph node dissection have to be?

2. Should all patients with unilateral nodal involvement undergo bilateral lymph-adenectomy?

3. Should all of these patients also undergo a pelvic lymphadenectomy?

All these aspects will be discussed, together with the pattern of lymphatic dissemination and the role of staging.

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