Surgical management of the clinically negative and locally advanced inguinal region in patients with squamous penile cancer

The presence and extent of metastasis to the inguinal region are the most important prognostic factors for survival among patients with squamous penile cancer. These findings affect the prognosis of the disease more than tumor grade, gross appearance, and morphologic or microscopic patterns of the primary tumor. Unlike many other genitourinary tumors, which mandate systemic therapeutic strategies once metastasis has occurred, lymphadenectomy alone can be curative and should be performed. The biology of squamous penile cancer is such that it exhibits a prolonged locoregional phase before distant dissemination, providing a rationale for the therapeutic value of lymphadenectomy. However, owing to the morbidity of traditional lymphadenectomy, especially among those patients with a clinically negative groin, contemporary controversial issues include (1) the selection of patients for lymphadenectomy vs. careful observation, (2) the types of procedures to correctly stage the inguinal region with low morbidity, and (3) multimodal strategies to improve survival among patients with bulky inguinal metastases. In this chapter, we will focus on the surgical evaluation and management of the inguinal region among penile cancer patients with either no palpable adenopathy or those with suspected or proven advanced regional metastases.