Management of Bulky Inguinal and Pelvic Nodes 

( At the 2021 American Urological Association (AUA) Summer School session on the updates in the management of penile cancer, Dr. Christopher Protzel from the University of Rostock discussed the management of bulky inguinal and pelvic lymph nodes. Dr. Protzel started with a case presentation of a 49-year-old male, former smoker, with no medical comorbidities who presented after a partial penectomy with poorly differentiated squamous cell carcinoma infiltrating the corpus cavernosum (pT3), negative margins, with palpable inguinal lymph nodes. In patients with palpable lymph nodes, there are several diagnostic options available. Fine needle aspiration cytology has a sensitivity of 93% and specificity of 91%, whereas PET/CT has a sensitivity of 75%. In cases of palpable lymph nodes, dynamic sentinel node biopsy should not be utilized.

Dr. Protzel notes that according to the EAU guidelines, patients with palpable inguinal lymph nodes (cN1/cN2) should undergo a radical inguinal lymphadenectomy (strong recommendation). For patients with fixed inguinal lymph nodes (cN3), patients should have neoadjuvant chemotherapy followed by radical inguinal lymphadenectomy for those that respond to chemotherapy (weak recommendation).

In 2009, Dr. Protzel lead a collaborative effort to analyze the existing published data on the surgical management of inguinal nodes in penile cancer regarding morbidity and survival.1 They noted that all patients with histologically proven lymph node metastases should undergo radical inguinal lymphadenectomy. However, radical inguinal lymphadenectomy is not without significant morbidity, including wound infection, skin necrosis, wound dehiscence, lymphedema, and lymphocele, as highlighted in the following table: 


Dr. Protzel’s approach to radical inguinal lymph node dissection is to utilize perioperative antibiotics, subtle handling of skin flaps, and post-operative utilization of closed wound vacuum systems for up to 7 days.

The aforementioned patient from the case presentation subsequently underwent four cycles of TIP neoadjuvant chemotherapy following by a restaging CT scan that showed an excellent partial response:


Based on an adequate response to neoadjuvant chemotherapy, Dr. Protzel notes that the next step in management should be a salvage inguinal lymphadenectomy:1


With regards to indications for pelvic lymphadenectomy, Dr. Protzel emphasized that patients with 2 or more positive inguinal nodes and those with extranodal tumor extension should undergo pelvic lymphadenectomy. However, Dr. Protzel concluded his presentation highlighting that there are several difficult scenarios in the management of advanced penile cancer, such as (i) what to do with one positive inguinal lymph node in “high-risk” tumors, and (ii) characterizing the extent of a pelvic lymphadenectomy when one is clinically indicated. 

Presented by: Christopher Protzel, University of Rostock, Rostock, Germany

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the AUA2021 May Kick-off Weekend May 21-23.


  1. Protzel C, Alcaraz A, Horenblas S, et al. Lymphadenectomy in the surgical management of penile cancer. Eur Urol. 2009 May;55(5):1075-1088.