Minimally Invasive Management of Inguinal Lymph Nodes in Penile Cancer: Recent Progress and Remaining Challenges

Simple Summary Penile cancer is an uncommon malignancy that affects less than 1% of men in the Western world. However, it is often aggressive, and the survival of patients is mainly dependent on the presence and spread of nodal metastasis. Penile cancer has an expected pattern of spread to the inguinal lymph nodes in a stepwise fashion; therefore, inguinal lymph node dissection has been an integral part of penile cancer staging and treatment. Minimally invasive inguinal lymph node dissection with the use of laparoscopy and robotics has demonstrated decreased morbidity with successful outcomes. Moreover, sentinel lymph node biopsy has become the preferred method for evaluation of inguinal lymph node metastasis in penile cancer patients with nonpalpable inguinal lymph nodes. Here, we extensively evaluate the recent developments in the management of inguinal lymph nodes in penile cancer, review the advantages and shortcomings of the available treatment strategies, and discuss the remaining challenges and future perspectives.Abstract The diagnosis of occult inguinal lymph node metastasis in clinically node-negative invasive penile squamous cell carcinoma (PSCC) has remained a challenge, with substantial perioperative complications. The recent refinements in the technique of dynamic sentinel lymph node biopsy (DSLNB) demonstrated high diagnostic accuracy with considerably lower morbidity compared to conventional open modified/superficial inguinal lymph node dissection (ILND). Although DSLNB, if available, has been endorsed as the preferred method for nodal staging in patients with invasive PSCC and no palpable inguinal lymphadenopathy in the recent penile cancer guidelines, its utilization has been quite limited so far. Laparoscopic and robotic-assisted ILND have emerged as alternatives for nodal staging in this patient population and are shown to improve the rate of wound infections and postoperative pain. For management of nodal metastasis in patients with clinically palpable inguinal lymph nodes, minimally invasive ILND has shown promising results as well. Nonetheless, given the rarity of PSCC and the absence of prospective studies and clinical trials, nodal staging and treatment of nodal metastasis in clinical practice will likely continue to vary across the medical centers in the following years. In this review, we first summarize the evolution of DSLNB and minimally invasive ILND and discuss the advantages and drawbacks of each management strategy. We further discuss the remaining challenges and future perspectives in the management of inguinal lymph nodes in patients with PSCC.