One-quarter of patients with penile cancer now display baseline inguinal lymph node spread.¹ Overwhelming evidence suggests the presence and extent of inguinal node disease as the single most prognostic indicator in determining long-term survival, and early lymphadenectomy can achieve cure and offer the greatest benefit to survival.² Both the National Comprehensive Cancer Network and the European Association of Urology with the American Society of Clinical Oncology recommend bilateral inguinal lymph node dissection (ILND) in high-risk penile cancer (pathologic stage T1b or greater) with nonpalpable or palpable nonbulky nodes and bulky nodal disease following neoadjuvant chemotherapy.

Standard ILND has traditionally been performed via an open approach; however, the procedure is complex and morbid, serving as a potential deterrent to both patient and treating surgeon. In 2009, the leg endoscopic groin lymphadenectomy was pioneered as a minimally invasive method to perform superficial and deep groin dissection for therapeutic purposes.³ Following prospective analysis, major complication rates approached 21%, half those observed in open ILND, while continued refinement of videoendoscopic and robotic-assisted techniques has further decreased complication rates by 89%.⁴,⁵ The most common problems found following robotic dissection included lymphoceles and surgical site infections requiring antibiotics and/or incision and drainage, with < 10% affected across studies.⁶ Rates of skin edge necrosis were extremely low (< 2%) as well.⁶

Although studies question prolonged operative times, lymph node yield has remained sufficient and even comparable to open technique, postoperative recovery is shorter, and recurrence-free and survival rates have not decreased.⁷,⁸ Median lymph nodes obtained videoendoscopically range from 12 to 15 across studies, meeting suggestions for adequate yield, with no significant differences compared to open.⁸,⁹ In addition, local recurrence rates approach 7%, while 5-year progression-free and overall survival rates range from 70% to 74% and 67% to 73%, respectively, which were all identical to open outcomes.¹⁰ Overall, robotic approach features a simpler transition for primarily robotic surgeons, 3D views, greater magnification of tissues, easier dissection of the saphenofemoral junction secondary to instrument wrist articulation, and less neuromuscular fatigue for the surgeon.

However, ILND remains underutilized. Among high-risk penile cancer patients analyzed, the rate of ILND was 27.2%, with palpable adenopathy and treatment at academic facility being the sole factors associated with surgery regardless of demographics or primary pathology.¹¹ This highlights how surgeon concern regarding complexity and morbidity might be at the center of underutilization, especially with 60% of urologic oncologists surveyed in 2020 preferring open approach.⁶ Due to cited benefits and step-by-step videoendoscopic protocol availability, we anticipate ILND utilization to increase as robotic technique continues to offer greater accessibility and familiarity.