Editing EAU & ASCO: Penile Cancer 2023 (section)

==== Options ====

===== Radical inguinal lymph node dissection =====
* '''Standard of care for patients with cN1–2 (or cN0 patients with a tumour positive sentinel node at DSNB)'''
* No widespread adoption of lymph node yield or density as quality marker
* '''Adverse events'''
** '''Significant morbidity due to impaired lymph drainage from the legs and scrotum'''
*** '''Overall complication rate: 21–55%'''
*** '''Most common complications''' 
**** '''Wound infections (2–43%)'''
**** '''Skin necrosis (3–50%)'''
**** '''Lmphoedema (3.1–30%)'''
**** '''Lymphocele formation (1.8–26%)'''
**** '''Seroma (2.4–60%)'''
* '''Approaches (2)'''
*# '''Open'''
*#* '''Standard for cN1–2 disease'''
*#** In patients with cN1 disease offer either ipsilateral:
*#*** Fascial-sparing inguinal lymph node dissection (ILND)
*#*** Open radical ILND; sparing the saphenous vein, if possible
*#** In patients with cN2 disease offer ipsilateral open radical ILND; sparing the saphenous vein, if possible
*# '''Minimally-invasive'''
*#* Offer minimally-invasive ILND to patients with cN1–2 disease only as part of a clinical trial.
*#* Although operative time is longer, LN yields can be similar to open ILND, length of hospital stay shorter in VEIL/RAVEIL and wound complications lower, though lymphocele and readmission rates were equivalent

===== Neoadjuvant chemotherapy =====
* '''Alternative approach to upfront surgery to selected patients who are candidates for cisplatin and taxane-based chemotherapy with (2):'''
*# '''Bulky mobile inguinal nodes or'''
*# '''Bilateral disease (cN2)''' 

====== Prophylactic pelvic lymph node dissection ======
* In most cases represents a staging procedure that can thus identify candidates for early adjuvant therapy, although in select patients may also provide a therapeutic benefit
* '''Indications (2)'''
*#'''≥3 inguinal nodes are involved on one side on pathological examination'''
*#'''Extranodal extension is reported on pathological examination'''

===== Clinical N3 Disease (fixed inguinal nodal pass or pelvic lymphadenopathy) =====
* '''Neoadjuvant chemotherapy (NAC) using a cisplatin- and taxane-based combination should be offered to chemotherapy-fit patients with pelvic lymph node involvement or those with extensive inguinal involvement (cN3), in preference to up front surgery.'''
** Bulky inguinal LN enlargement indicates extensive lymphatic metastatic disease for which few patients will benefit from surgery alone.
** Surgery as the initial treatment in patients with a fixed inguinal mass or clinically evident pelvic adenopathy (cN3) at presentation or recurrence is discouraged in routine management. 
*** Surgery alone will rarely cure patients with cN3 disease.
*** Even when technically feasible, upfront surgery often results in large skin/soft tissue defects, the need for myocutaneous flap reconstruction, prolonged hospital stays and is associated with high overall complication rates
** '''If responding to NAC and resection is feasible, offer surgery''' 
*** ≈50% with advanced (cN2–cN3) penile cancer respond to combination chemotherapy.
*** Responders that subsequently undergo consolidative inguinal/PLND have an OS chance of ≈50% at 5 years.
* If not candidate for conventional multi-agent chemotherapy, pre-operative chemo-radiation/radiation can be offered in an attempt to downsize tumours to improve resectability.
* Surgical resection 
** Timing
*** should proceed 5–8 weeks after completion of chemotherapy to provide time for haematologic recovery and other therapy related symptoms to improve.
** Technique
*** Inguinal LND in cN3 patients often requires resection of overlying skin to effectively remove a fixed bulky nodal mass
** Approach (1)
*** Open
**** Minimally-invasive techniques (i.e., robotic-, laparoscopic ILND) are considered inappropriate in cN3 inguinal metastases
** Pelvic lymph node dissection
*** Simultaneous PLND should be performed at the time of ILND if pelvic LN metastases were clinically evident at diagnosis.
*** Ipsilateral PLND should also be performed in a simultaneous (preferred) or delayed fashion in the setting of advanced bulky inguinal metastases without clinically evident pelvic metastases as well (i.e., prophylactic).