Penile Cancer and Lymph Node Management: A Call for Standardization

In penile cancer, lymph node (LN) involvement represents the true biological turning point of the disease. More than any feature of the primary tumour, nodal status dictates prognosis, with five-year cancer-specific survival ranging from over 80% in node-negative patients to dramatically lower rates in those with advanced nodal disease. Once lymphatic spread occurs, the disease shifts from a locally controllable condition to a systemic threat. This makes LN management not a technical detail, but the central determinant of oncologic outcome.

A major unresolved issue is the persistent discordance among international recommendations on LN staging and treatment. Current guidance documents provide partially overlapping but often divergent indications regarding the timing of invasive nodal staging, the extent of inguinal lymph node dissection (ILND), the use of minimally invasive approaches, and the criteria for pelvic lymph node dissection (PLND). These differences are not theoretical. They translate into substantial variability in real-world practice, with heterogeneous pathways of care across centres and countries, ultimately affecting oncological outcomes and quality of care. This lack of alignment reflects the limited availability of high-level prospective evidence and the continued reliance on expert consensus in areas of clinical uncertainty.

Minimally invasive approaches, including endoscopic and robotic ILND, have improved perioperative recovery and reduced wound-related morbidity. However, these techniques do not alter the central biological principle of the disease: adequate and timely control of LN metastases remains critical. Surgical technology may reduce morbidity, but it cannot compensate for delayed or incomplete nodal management.

We believe that future efforts should focus on three main pillars: the development of universally accepted risk stratification models, the implementation of standardized surgical and pathological reporting, and the integration of minimally invasive and sentinel-based techniques into shared clinical pathways.

Only through true standardization and multidisciplinary collaboration can we improve oncological outcomes and reduce morbidity for patients affected by this challenging disease.

Written by: Savio Domenico Pandolfo, MD, Department of Urology, University of L'Aquila, L'Aquila, Italy; Department of Neurosciences, Science of Reproduction and Odontostomatology, Federico II University, Naples, Italy.

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