Pelvic Lymph Node Dissection for Penile Cancer: Answering the Conundrum of When and How It Should Be Conducted

Abstract

Extent of lymphatic metastases is an important prognostic factor in penile cancer patients, and patients with pelvic lymph node involvement have particularly bad long-term survival. Pelvic lymph node dissection (PLND) in pelvic node positive cases with micro-metastatic disease exclusively may have some curative potential with surgery alone, but for penile cancer patients with clinically enlarged or suspicious pelvic lymph nodes on cross-sectional imaging with CT, MRI, or PET-CT, neoadjuvant systemic chemotherapy is recommended followed by post-chemotherapy lymphadenectomy in responders. PLND can be done at the same time as inguinal lymph node dissection (with use of intraoperative frozen section) or in a delayed fashion through an open, midline, infraumbilical incision, or using robotic-assisted or laparoscopic technology. Since no crossover from inguinal to pelvic LNs has ever been reported, the use of unilateral versus bilateral PLND is still considered controversial in clinically indicated settings. There is increasing evidence, however, that bilateral PLND may be appropriate for certain high-risk penile cancer patients with a large volume of inguinal metastatic disease. In this chapter, we summarize the indications, technique, and controversies of pelvic lymph node dissection for advanced penile cancer, and we present novel evidence with regards to its use.