Review Article: Sugery: Urological Surgery

Page 1 of 11

Surgical principles of penile cancer for penectomy and inguinal

lymph node dissection: a narrative review
Nathaniel D. Coddington1, Kirk D. Redger2, Ty T. Higuchi2
1
Division of Urology, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA; 2Division of Urology,
Department of Surgery, University of Colorado, Aurora, CO, USA
Contributions: (I) Conception and design: ND Coddington, TT Higuchi; (II) Administrative support: TT Higuchi; (III) Provision of study materials
or patients: ND Coddington, TT Higuchi; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI)
Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Ty T. Higuchi, MD. Division of Urology, Department of Surgery, University of Colorado, 12605 E. 16th Ave, Aurora, CO 80045,
USA. Email: [email protected].

Abstract: 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 penile-
preserving 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.

Keywords: Penile cancer; penectomy; inguinal lymph node dissection (ILND)

Received: 29 August 2020; Accepted: 27 January 2021; Published: 25 September 2021.

doi: 10.21037/amj-20-159
View this article at: http://dx.doi.org/10.21037/amj-20-159

Introduction as 2.8–6.8 per 100,000 have been reported (1,2). The rise
in obesity and associated obesity-related acquired buried
Penile cancer is a rare and serious disease with an estimated
penis will likely increase penile cancer rates; as one study
2,080 new cases and 410 deaths reported in the United demonstrated a 53% increase in penile cancer incidence
States in 2019. Major risk factors include infectious for every five-unit increase in body mass index (BMI) (2,3)
(HPV, HIV) and inflammatory (smoking, poor hygiene, (Figure 1). However, widespread HPV vaccination has the
lichen sclerosis and balanitis) conditions, as well as lower potential to lower penile cancer rates, though this has not
socio-economic status. While penile cancer is rare in the yet been established in the literature (4).
developed world, with rates as low as 0.3–0.6 per 100,000 Surgery forms the cornerstone of therapy for penile
in the United States and United Kingdom, penile cancer is cancer. Early local and regional disease is surgically
less uncommon in developing nations, where rates as high curable, but advanced regional disease portends a poor

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
Page 2 of 11 AME Medical Journal, 2021

A B

Figure 1 Patient with biopsy-proven high grade penile cancer confined to the glans on MRI. (A) Frontal view: concealment with cicatrix (B)
Lateral view: prominent escutcheon contributing to concealment.

A B

Figure 2 Total penectomy and perineal urethrostomy for (A) high grade penile cancer invading the corpora cavernosa. (B) Immediate post-
operative image of total penectomy and perineal urethrostomy.

prognosis. The extent of inguinal node metastases is the a review on the current state of surgical care for penile
most important prognostic factor with survival dropping cancer, both primary and inguinal nodal disease, selected
sharply with increasing disease burden. The reported 5 from the published literature. We present the following
year cancer-specific survival for pN3 is 0–17% compared article in accordance with the Narrative Review reporting
to 17–60% for pN2, 79–89% for pN1 and 85–100% for checklist (available at https://amj.amegroups.com/article/
pN0 (5,6). Prompt surgical intervention is key and a delay view/10.21037/amj-20-159/rc).
of 6 months can drastically reduce survival in patients with
early microscopic lymph node disease (7). Unfortunately,
Oncologically safe margin
it is well known that penile cancer presentation is delayed
due to fear and stigma and this delay can be up to one year Partial penectomy and total penectomy remain the standard
or even longer (8). Penile cancer patients may benefit from of care for penile cancer (Figures 2,3). Surgical techniques
referral to academic centers, as patients at academic centers for these procedures have been previously well described
are significantly more likely to undergo guideline-based (10,11). The decision to perform partial versus total
inguinal lymph node dissection (ILND) than community penectomy depends the volume of disease, grade of the
centers (48.4% vs. 26.6%) with higher node yield (18.5 tumor, ability to obtain clear margins and body habitus. For
vs. 12.5) (9). Principles of surgical management continue patients with concealed penis, it is highly recommended
to evolve, with increased focus on minimizing morbidity to resect the surrounding tissue including the cicatrix
without compromising oncologic safety. Here-in we provide and perform perineal urethrostomy (Figure 1). In our

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
AME Medical Journal, 2021 Page 3 of 11

A B margins on oncologic outcomes. Philippou et al. reviewed

179 patients undergoing conservative surgery for penile
cancer. They found that the mean distance from the tumor
edge to the skin margin was 5.23±5.78 mm and to the deep
margin was 4.5±5.3 mm; 12 patients (6.7%) had a positive
margin. Importantly, they identified that tumor grade, stage,
and lymphovascular invasion were predictors of recurrence.
Patients with isolated local recurrence had an overall
5-year disease specific survival of 91.7% (14). Similarly,
Sri et al. reported that in 332 patients surgical margins of
5 mm did not increase the risk of local recurrence, but a
margin of <1 mm, cavernosal invasion, and lymphovascular
invasion significantly increased local recurrence risk (15).
Figure 3 Partial penectomy for (A) melanoma invading the glans Collectively, these studies have influenced current guidelines
and distal urethra. (B) Distal penile reconstruction following partial to recommend 5 mm margins in lieu of the previous 2
penectomy. cm recommendation (16). Although smaller margins are
recommended, surgeons should use intraoperative frozen
sections to guide the degree of resection, and any positive
experience, these patients do not have enough phallic length margin or high-risk features on final pathology should
to perform a partial penectomy. mandate further resection.
Originally, surgical resection with at least a 2 cm tumor-
free margin was recommended to insure an oncologically
How do you determine which surgical procedure
safe margin and prevent local recurrence. In addition, the
to perform?
decision to proceed with a partial versus total penectomy
depends on whether an adequate penile stump for Choosing which surgical procedure to perform on penile
functional upright urination could be preserved, typically cancer patients can be challenging. The grade of the lesion,
3–4 cm (Figure 3). Collectively, these clinical decision points location, circumcision status, morphology, tumor quantity,
led to more aggressive resections that cause considerable and relationship to surrounding structures (urethra,
psychological distress and altered body image. corpora spongiosum, corpora cavernosa) must be taken in
The 2 cm tumor-free margin was recommended to consideration when determining the most appropriate
arbitrarily and not based on histopathological evaluation surgical procedure. In addition, one also must consider
or local recurrence. This recommendation was challenged patient age, comorbidities, body habitus, loss of penile
by two landmark papers. First, Agrawal et al. evaluated length, and psychological ramifications.
serial 5 mm margins in 64 penectomy specimens for An initial histologic diagnosis with a punch, excisional,
microscopic migration away from visible tumor and found or incisional biopsy is recommended to determine the risk
that 81% of the tumors did not extend beyond the visible of lymph node involvement (17). Further evaluation of
tumor margin and only 3 extended beyond 5 mm—all the primary penile lesion can be performed with magnetic
were high grade lesions. No skip lesions were identified in resonance imaging (MRI) or ultrasound to determine the
any of the specimens examined (12). A subsequent study depth of invasion. Lont et al. emphasized that physical
by Minhas et al. evaluated surgical margins in 51 patients examination alone is a reliable method to determine tumor
treated with penile sparing techniques—glansectomy, size and predict corpus cavernosal infiltration with a high
partial penectomy, and wide local excision. 92% of patients sensitivity (86%) and positive predictive value (100%);
had <20 mm margin and 48% had <10 mm. There were 3 further imaging is warranted when physical examination
positive margins (3%) and 2 patients (4%) with high grade is inconclusive (18). Another approach to penile cancer
tumors developed tumor recurrence at 26 months (13). treatment is to start with penile-preserving surgery as
These papers concluded that a 2 cm tumor-free margin was primary treatment to allow more accurate staging—as
unnecessary and less penile resection was required. biopsies can under-stage the disease and lead to insufficient
Subsequent studies have evaluated the safety of surgical treatment (19).

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
Page 4 of 11 AME Medical Journal, 2021

Biopsy-proven penile
cancer
(per punch, incisional, or
excisional biopsy)

Consider MRI or penile ultrasound to

determine
depth of invasion
T1 T1
Tis or Ta T2 or greater
(Grade 1-2) (Grade 3-4)

-Topical therapy
-Laser ablationa -Laser ablation
-Circumcisionb -Mohs surgeryc -Wide local excision -Glansectomye
c e d
-Mohs surgery -Glansectomy -Partial penectomy -Partial penectomyd
-Glans resurfacing -Wide local excision -Total penectomy -Total penectomy
-Glansectomye -Partial penectomy
-Wide local excision

a
CO2,Nd:YAG
b
Lesion confined to prepuce
c
select cases
d
Provided functional penile stump + negative margins
e
urethral involvement isolated to glans

Figure 4 Algorithm for diagnosis and treatment of primary penile cancer lesion.

We prefer to biopsy the lesion first and then proceed to male, circumcision can have a multifactorial role in treating
penile-preserving procedures to allow for complete excision the disease, completely excising a previously biopsied
of the primary tumor with maximal preservation of a primary lesion or serve as an initial staging procedure (19).
functional and cosmetic penis. Penile-preserving procedures Circumcision also allows for topical treatment of the glans,
are indicated for Tis/Ta/T1 and some T2 tumors with when indicated, and close clinical examination during
favorable histology (11) (Figure 4). Established options follow-up visits. Circumcision can be used in conjunction
include circumcision for preputial lesions, laser ablation, with wide local excision and a portion of the disease-free
wide local excision, glans resurfacing, glansectomy, and shaft skin can be used to reconstruct glandular defects
Mohs micrographic surgery. (Figure 5).
Circumcision in properly selected patients does not
compromise overall survival but does carry an increased
Circumcision
risk of local recurrence. These recurrences can be safely
For lesions confined to the prepuce of an uncircumcised managed with repeat excision without the need to convert

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
AME Medical Journal, 2021 Page 5 of 11

A B

Figure 5 Low grade penile cancer confined to the prepuce and distal shaft skin of an uncircumcised male. (A) Circumcision line 5 mm
margins marked in blue. (B) All skin and deep margins negative and final reconstruction using shaft to cover glans defect.

to partial or radical penectomy (20,21). However, this does laser therapy, they require a staging inguinal procedure (26).
necessitate closer follow-up; poor patient compliance is a
contraindication.
Wide local excision

Wide local excision is a class of procedures in which

Laser ablation
superficial lesions on the glans, prepuce, and penile shaft
Laser ablation uses coherent electromagnetic radiation to are excised with a small margin. Small defects can be
destroy tissue. Available technologies include carbon dioxide closed primarily, while larger defects will require split or
(CO2) lasers (wavelength: 10,600 nm; tissue penetration: full thickness skin grafts (27). Full thickness grafts have
0.1 mm) and neodymium-doped yttrium aluminum garnet historically produced better cosmesis with less tissue
(Nd:YAG) lasers (wavelength 1,064 nm; tissue penetration: contraction. Some surgeons advocate for using a zig-zag
3–4 mm). A dilute preparation of acetic acid can be applied incision to reduce circumferential contracture and 2-0 PDS
to areas of concern prior to ablation to induce aceto- tacking sutures to fix the graft to Buck’s fascia (28).
whitening of tissues which tend to be associated with HPV
infection—a sensitive but non-specific reaction (22).
Glans resurfacing and glansectomy
The CO2 laser is efficiently absorbed by water, resulting
in rapid vaporization of superficial tissue with some deeper The glans penis is the most common site of penile cancer
necrosis due to photothermal coagulation of protein (23). with 50% of newly diagnosed lesions isolated to the glans
For superficial lesions, the laser is swept over the tissue at a and 80% isolated to the glans and prepuce (29). The least
fixed distance and steady speed with 5 mm margins around invasive treatment of these lesions is glans resurfacing. This
the visible tumor. involves surgical removal of the epithelial and subepithelial
In contrast, the Nd:YAG laser penetrates more deeply— tissue, either in a wedge or from the entire glans. Deep
causing more extensive photothermal coagulation and frozen biopsies are taken from the underlying spongiosum—
necrosis. This results in an adherent tissue coagulum which with special attention paid to areas below the visible tumor.
can be either excised or allowed to slough off on its own (24). A split-thickness skin graft, unmeshed and taken from non-
In both cases a smoke evacuator and appropriate personal hair bearing skin, is then applied and quilted in place with
protective equipment (PPE) must be used to minimize the fine absorbable suture (30).
risk of aerosolized HPV transmission to OR personnel (25). A recent 19 patient prospective cohort, the largest yet
Circumcision is performed if not previously in order to published, showed excellent cosmetic, functional, and
facility treatment and monitoring. Local recurrence is oncologic outcomes with this technique, though no formal
common, up to 48%, but inguinal recurrence is rare with comparison with alternatives can be made (30).
only 2% reported in pTa/Tis and 5% for pT1a primaries. Glansectomy is indicated for larger or more advanced
While properly selected pT1b and pT2 can be treated with lesions, including T2 lesions with urethral involvement

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
Page 6 of 11 AME Medical Journal, 2021

isolated to the glans. A circumferential subcoronal incision resection (39). Complications may include hemorrhage,
is made and the glans is dissected off the tips of the corpora prolonged lymphatic secretion, lymphocele, cellulitis,
cavernosa, either above or below Buck’s fascia depending on wound dehiscence or necrosis. Concerns regarding
the lesion location (27,31). Frozen sections from both the morbidity may explain the apparent reluctance to perform
urethra and corporal bodies guide the extent of excision. an ILND , even if indicated by current guidelines. In 2011,
Split-thickness skin grafts can be used to cover the corporal Thuret at al. showed only ~30% adherence to National
tips similar to the technique described above. Alternatively, Cancer Institute guidelines which is concerning as delay
a urethral advancement flap can be created by releasing the has been shown to decrease survival (40). When comparing
penile urethra to the penoscrotal junction in order to gain watchful waiting followed by lymphadenectomy at time of
enough mobilization for 2 cm of urethral advancement. palpable disease with immediate lymphadenectomy in men
The urethra is widely spatulated along the ventral side, with positive nodes, Kroon et al. found a 3-year CSS of 84%
then secured to the tunica albuginea with absorbable suture versus 35% in favor of immediate lymphadenectomy (7).
(20,32,33). Upfront radical ILND is offered to patients with non-
Several other techniques for glans reconstruction bulky palpable inguinal lymph nodes, whereas patients with
have been described—including buccal mucosa graft bulky or initially unresectable nodal disease should referred
augmentation, scrotal flaps, and myofascial flaps (34,35). to medical oncologist to consider neoadjuvant therapy prior
to resection (41).
Patients with clinically negative nodes have been shown
Mohs micrographic surgery
to harbor metastatic disease in anywhere from 11 to 62%
Mohs micrographic surgery is extensively used for treatment of patients (42). While patients with early metastatic
of cutaneous malignancies, especially in cosmetically disease benefit from immediate resection, many patients
sensitive areas. During Mohs, the bulk of the tumor is with negative pathology might be exposed to a morbid
resected as in wide local excision but without a margin. procedure without benefit (7). Current guidelines stratify
Thin slices are taken from the resection bed and carefully patients based on the primary lesion, with high risk
examined microscopically by the operating surgeon and/ tumors proceeding to invasive node assessment with either
or support staff. Additional smaller slices are taken from diagnostic sentinel lymph node biopsy (DLNB) or modified
areas with residual disease until negative margins are ILND (mILND). If positive on DLNB, the surgeon then
achieved across the resection bed. Urethral involvement is proceeds to radical resection of the inguinal nodes (17).
typically managed with ventral meatotomy combined with This allows patients with negative groins to be spared the
urethrotomy to allow for circumferential tissue resection. morbidity of radical ILND without delaying care for those
Reconstruction can then be performed using methods who will go on to develop palpable disease.
described above to close the resulting defect.
The spongy nature of penile tissue, as well as difficulty
Radical ILND
detecting pre-malignant HPV infected cells on frozen
section, has made application of this technique to penile Radical inguinal lymphadenectomy remains standard
cancer somewhat challenging. This has resulted in higher of care for palpable, resectable node disease (43).
recurrence rates than reported for Mohs with other This involves the removal of all lymphatic tissues in a
cutaneous malignancies, although comparable with other quadrilateral area circumscribing the femoral triangle.
organ sparing penile techniques (36-38). This area is defined by 4 points: the anterior superior iliac
spine, the superior margin of the inguinal canal, a point 20
cm inferior to the anterior superior iliac spine, and a point
Management of inguinal nodes
15 cm inferior to the pubic tubercle (44). An incision is
Radical ILND has traditionally been associated with high made 2 cm below and parallel to the inguinal ligament—
morbidity, with early reports suggesting a near 100% extending the full width of the ultimate dissection. The
complication rate. This has decreased with standardized key step in this surgery is dissecting generous skin flaps
reporting of surgical complications and improvements in below Scarpa’s fascia from the superior to the inferior
technique and post-operative management. A 2009 review limits of the dissection. We recommend tagging the
reported a major complication rate of 20–30% for radical Scarpa’s fascia with silk sutures assist in the dissection.

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
AME Medical Journal, 2021 Page 7 of 11

A B

C D

Figure 6 Penile cancer with inguinal lymph node involvement. (A) MRI demonstrating pre-chemotherapy nodal status, and (B) post-
neoadjuvant chemotherapy (paclitaxel, ifosfamide, cisplatin ×4 cycles) nodal status. (C) Nodal disease eroding through the skin (red circle). (D)
Radical ilioinguinal lymphadenectomy with sartorious flap.

When dissection is carried superficial to Scarpa’s fascia, therapy versus grafts.

this may increase the risk of flap necrosis. The long
saphenous vein is identified at the apex of the femoral
mILND
triangle and ligated. Dissection is carried through the deep
fascia of the thigh (fascia lata) from the Sartorius to the mILND was first described by Catalona in 1988. He noted
adductor longus muscle and into the femoral triangle. The that anatomical studies of lymphatic drainage showed a
femoral vessels are identified at the apex of the femoral clear preference for the superiomedial nodes found along
triangle and used to guide the dissection proximally to the superficial external pudendal and superficial epigastric
the femoral canal, ligating perforating vessels as they vessels. Furthermore, there was little evidence for skip
are encountered. The saphenous vein is again ligated at metastases without first involving these nodes, as well as
its junction with the femoral vein. The femoral vessels those centrally within the fossa ovalis (43). As such, the
are exposed and care is taken to avoid the lateral surface modified template utilizes a shorter 10 cm incision made
of the femoral artery to protect the femoral nerve. The 2 cm below the inguinal ligament, starting at the pubic
sartorius muscle is commonly transposed to cover the tubercle. An 8 cm superior flap and 6 cm inferior flap are
femoral vessels to prevent hemorrhagic complications (44) created in similar fashion as described above. Deep nodes
(Figure 6). We also recommend resection of the overlying from the fossa ovalis, between the adductor longus and
skin if it is fixed to the underlying tissue, cancer is eroding the lateral border of the femoral artery, are excised. The
through the skin (Figure 6C), or previous biopsy was saphenous vein is preserved (5,43,44). If frozen specimens
taken through this region. In addition, if there is a large are positive, the procedure converted to a radical dissection.
skin defect present we employ negative pressure wound Surgical complications following mILND are less

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
Page 8 of 11 AME Medical Journal, 2021

common, with a modern series reporting no complications assisted variants. The initial incision for the camera port is
in 86% to 93% of dissections (45,46). Minor lymphedema made just distal to the apex of the femoral triangle below
remains the most commonly reported issue. During Camper’s fascia. A combination of sharp and blunt dissection
the postoperative period for both modified and radical is used to develop the space needed for port placement.
lymphadenectomy we recommend lower extremity Two working ports are placed laterally and superiorly to the
compression (>40 mmHg) stockings, referral to camera outside the medial and lateral edges of the planned
occupational therapy, and the use of drains until the output dissection to create a triangular array with sufficient space
is less than 30 mL over a 48-hour period. to prevent instrument clash. If done robotically, an assistant
port can be placed between the camera and the medial
working port. Insufflation is established with CO2 at 10–
Dynamic sentinel lymph node biopsy
12 mmHg. Flap thickness is controlled by palpating
Dynamic sentinel lymph node biopsy is based on the same between the instrument and hand. Superficial nodes are
principle as the mILND—lymphatic spread of penile excised from proximal to distal off the iliac spine and the
cancer is orderly and its absence in the proximal draining pubic tubercle, sparing the saphenous vein. The deep nodes
nodes excludes its presence in more distal nodes. DSLNB are then excised working distal to proximal, from the apex
is typically performed at the time of penile surgery, though of the femoral triangle to the sapheno-femoral junction.
it can be delayed if there is ambiguity in the stage of the Node packets are removed with a laparoscopic bag (52,54).
primary lesion (47). Radio-labelled 99mTc-nanocolloid Early data with this approach has been promising.
is injected into the peritumoral tissue the day prior to A 2017 non-randomized prospective study published
the procedure and single-photon emission computed compared 51 robotic assisted-VEIL (RA-VEIL) to 100 open
tomography with computed tomography (SPECT/CT) lymph node dissection (OLND) and found significantly
images are captured to aid in surgical planning. Shortly lower rates of major complications (2% vs. 17%). Rates
before the procedure, blue dye is injected in the same of minor complications—including lymphocele, surgical
manner. Intraoperatively, a handheld gamma probe, site infection (SSI), cellulitis, and non-debilitating leg
in conjunction with visualization of the blue dye, are edema—were similar, experienced by more than 75% of
used to identify sentinel nodes (48). Studies on DSLNB patients in both groups. While not controlled, patients were
have consistently emphasized the need for experienced comparable in terms of comorbidities and disease status.
practitioners in high volume centers to minimize false Furthermore, they found equivalent nodal yields (12.5 vs.
negative biopsies (49). 13) and pathologic stage with no recurrence in either group
Recent advances have resulted in improved detection at 40-month follow-up. However, RA-VEIL had increased
outcomes. Routine fine needle aspiration of suspicious nodes operative time (55).
seen on ultrasound allows for the detection of extensively Another non-randomized prospective study from 2017
infiltrated nodes with obstructed lymphatic drainage. The compared OLND with VEIL in 42 patients with similar
addition of routine ultrasound with or without FNA prior findings: lower Clavien-Dindo Grade III and above wound
to DSLNB resulted in a 6% false negative rate and a similar complications (6% vs. 68%) with equivalent lymph node
complication rate (49,50). It has recently been shown that a yields and no groin recurrences in either groups (54).
new hybrid radioactive and fluorescent indocyanine green-
99mTc-nanocolloid resulted in marked improvement in
Conclusions
sentinel node visualization compared to the traditional blue
dye (51). Treatment for penile cancer continues to evolve as new
technologies become available. Surgery remains the
cornerstone for treating the primary lesion and inguinal
Video endoscopic inguinal lymphadenectomy (VEIL)
lymph nodes with emphasis placed on the preservation
Minimally invasive surgical techniques have been widely of function without compromising oncologic control.
adopted in the last two decades in effort to reduce Advances in imaging and diagnostics have been critical to
morbidity. VEIL was first described by Bishoff et al. in 2003 this endeavor both in regards characterizing the primary
(52,53). Since that time, several series have been published lesion and better identifying metastatic inguinal disease (56).
detailing their results with the technique and robotic- Molecular and genomic profiling studies have furthered our

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159
AME Medical Journal, 2021 Page 9 of 11

understanding of tumor biology, with multiple targeted- Attribution-NonCommercial-NoDerivs 4.0 International

therapy trials in progress (57). Still, the rarity of the disease License (CC BY-NC-ND 4.0), which permits the non-
limits our ability to conduct randomized controlled trials commercial replication and distribution of the article with
and there remain significant knowledge gaps of how the strict proviso that no changes or edits are made and the
best to treat this potentially debilitating disease. The original work is properly cited (including links to both the
International Penile Advanced Cancer Trial (InPACT) is formal publication through the relevant DOI and the license).
currently accruing patients and aims to answer several key See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
questions regarding management of nodal disease. Patients
with clinical evidence of inguinal lymph node metastases
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doi: 10.21037/amj-20-159
Cite this article as: Coddington ND, Redger KD, Higuchi
TT. Surgical principles of penile cancer for penectomy and
inguinal lymph node dissection: a narrative review. AME Med J
2021;6:29.

© AME Medical Journal. All rights reserved. AME Med J 2021;6:29 | http://dx.doi.org/10.21037/amj-20-159