Surgical principles of penile cancer for penectomy and inguinal lymph node dissection: a narrative review

Penile cancer is a rare and serious disease. Early local and regional disease is surgically curable, but advanced regional disease portends a poor prognosis—with inguinal node metastases being the most important prognostic factor. An initial histologic diagnosis with a punch, excisional, or incisional biopsy is recommended to determine the risk of lymph node involvement prior to proceeding with surgery. Magnetic resonance imaging (MRI) or ultrasound can used adjunctively to determine the depth of invasion. Total or partial penectomy with 5mm resection margins is the standard of care for primary disease, although penilepreserving procedures—such as circumcision for preputial lesions, laser ablation, wide local excision, glans resurfacing, glansectomy, and Mohs micrographic surgery—are initially indicated for tumors of lower grade, favorable histology, and favorable location. Inguinal lymphadenectomy is required for nodal disease, but has been associated with a high rate of complications. Patients with bulky or initially unresectable nodal disease should referred to medical oncologist to consider neoadjuvant therapy prior to resection. Dynamic sentinel lymph node biopsies, modified dissection templates, and minimally invasive surgical techniques have been adopted to decrease the morbidity of the procedure. Treatment for penile cancer continues to evolve as new technologies become available, but the rarity of the disease creates knowledge gaps in the best treatment approach. Currently, surgery remains the cornerstone for treatment of penile cancer.