Inguinal lymphadenectomy is the therapeutic nodal operation for penile squamous cell carcinoma — it can be curative when disease is limited to the inguinal nodes. Indications and nodal staging logic (DSNB, when to operate) are covered in the Penile Cancer topic; this page is the operative reference.
Indications
- Clinically node-positive disease (palpable nodes).
- Clinically node-negative disease with high-risk primary features (pT ≥2, lymphovascular invasion, or grade ≥3).
- cN3 (fixed nodal mass) — neoadjuvant chemotherapy first, then radical inguinal lymphadenectomy in responders.
Relevant Anatomy
- Penile lymphatics — the superficial system drains the prepuce and shaft skin to the superficial inguinal nodes; the deep system drains the glans to the superficial and deep inguinal nodes. Spread proceeds to the inguinal chain, then iliac/pelvic nodes; penetration of Buck's fascia or the tunica albuginea allows lymphatic dissemination.
- Regional nodal metastasis is the single most important prognostic factor; once pelvic nodes are involved, long-term survival is <10%.
- Spread can be unilateral or bilateral with crossover between groins, but inguinal-to-contralateral-pelvis spread, right-to-left pelvic spread, and penis-to-pelvis skip lesions have never been reported. Spread beyond the true pelvis to the retroperitoneum represents systemic disease.
Pre-operative Preparation
- Antibiotics — broad-spectrum (e.g. ampicillin/gentamicin or ampicillin/ciprofloxacin). Treat pre-existing groin cellulitis with oral antibiotics first; if the primary tumour is infected, stage the lymphadenectomy to control the infected source first.
- DVT prophylaxis — compression boots only; low-dose heparin may increase lymphatic leakage.
- Equipment — LigaSure and bipolar forceps; Metzenbaum/suture scissors; tonsil, hemostat, right-angle, and Babcock clamps; DeBakey, Russian, and Adson forceps; metal clips; sutures (2-0 silk ties for lymphatics, 4-0 Prolene for vascular injury, 2-0 Vicryl); Weitlaner/Senn/rake retractors; and multiperforated closed-suction drains (10–15 Fr).
- Position — frog-leg (thighs abducted and externally rotated) with cushioned support under the flexed knee.
- Incision — oblique, ~2–3 cm below and parallel to the inguinal ligament (groin crease). If overlying skin is involved by tumour or breakdown, use an elliptical incision around the involved skin.
Standard Radical Inguinal Lymphadenectomy
Removes both the superficial and deep inguinal nodes; indicated for clinically node-positive disease.
Boundaries: superior — inguinal ligament/external oblique aponeurosis and spermatic cord; medial — anterolateral border of adductor longus; lateral — sartorius muscle; inferior — apex of the femoral triangle/fossa ovalis; floor — pectineus (deep) or fascia lata (superficial).
- Prep and landmarks. General anesthesia, 16-Fr Foley, frog-leg position, chlorhexidine-alcohol prep (lower SSI than povidone-iodine). Mark the ASIS, pubic tubercle, inguinal ligament, femoral artery (midpoint of the ligament), and fossa ovalis (3–4 cm inferolateral to the pubic tubercle).
- Skin flaps. Raise superior (~8 cm) and inferior (~6 cm) flaps beneath Camper's fascia to the external oblique aponeurosis. Leave 6–8 mm of subcutaneous tissue on the skin to prevent necrosis, preserve the superficial blood supply, and handle flap edges gently (hooks/Army-Navy, never crushing forceps). Camper's fascia can stay with the skin (penile lymphatics run beneath it). Reflect the spermatic cord medially.
- Superficial dissection. Control lymphatics meticulously with clips/suture/LigaSure (the saphenous vein is the first landmark). Remove tissue above the fascia lata — most nodes lie in the central and medial zones, organized into five groups (central at the saphenofemoral junction; superomedial, inferomedial, superolateral, inferolateral around their named veins). Ligate the superficial epigastric, superficial circumflex iliac, external pudendal, and accessory saphenous veins (all draining into the great saphenous). In the standard operation the great saphenous vein is divided at the saphenofemoral junction (this raises lower-extremity morbidity; it is spared in the modified operation and may be spared with minimal disease).
- Deep dissection. Enter the fascia lata at the saphenous opening. Identify the femoral artery and vein at the apex of the femoral triangle and dissect their anterior surfaces without skeletonizing (avoids femoral nerve and deep femoral artery injury — the nerve runs beneath the iliacus fascia lateral to the artery). Continue to the femoral canal (medial to the femoral vein) for continuity with any pelvic dissection. The deep nodes are typically 3–5 within the femoral sheath; the node of Cloquet — the most proximal femoral-canal node, the boundary between inguinal and pelvic nodes — is removed.
- Frozen section of the nodal packet guides whether to proceed to a more radical dissection; the contralateral side can be done while awaiting results.
- Sartorius flap (for deep dissections) — transpose the sartorius 180° medially (released from the ASIS) to cover the femoral vessels and nerves, suturing it to the inguinal ligament and adjacent thigh muscles with 2-0 Vicryl.
- Closure. Irrigate, place closed-suction drains along the femoral axis brought out inferiorly (to prevent lymphocele), and suture skin flaps to the underlying muscle to reduce dead space (seroma). Large defects may need scrotal rotation, abdominal advancement, or myocutaneous flaps. Close subcutaneous tissue with 2-0 Vicryl and skin with non-absorbable suture or staples.
Modified Complete Inguinal Lymphadenectomy
Lower morbidity than the standard operation; indicated for clinically node-negative, high-risk primaries (pT ≥2, lymphovascular invasion, or grade ≥3). Five defining features: a shorter incision; limited dissection (excluding tissue lateral to the femoral artery and caudal to the fossa ovalis); saphenous vein preservation; no sartorius transposition; and thicker skin flaps. It should still include the central and superior zones plus the deep inguinal nodes.
- Boundaries: superior — inguinal ligament; medial — adductor longus; lateral — saphenous and femoral vein; inferior — fossa ovalis; floor — pectineus (deep)/fascia lata (superficial).
- Technique — as for the standard operation, with a ~10 cm incision ~1.5–2 cm below the inguinal crease (from just lateral to the femoral artery to the adductor longus); identify and preserve the saphenous vein (sacrificing some branches). Convert to a radical lymphadenectomy if frozen section shows positive nodes.
Post-operative Care
- Compression stockings, sequential compression devices, early ambulation, and physiotherapy immediately; bed rest 2–3 days only with a myocutaneous/large flap.
- Minimize lymphedema with thigh-high wraps/stockings and foot-of-bed elevation; fitted stockings while ambulatory, reassessed at 6 months (chronic compression and a lymphedema specialist if leg volume rises).
- Keep the wound clean and dry (dry gauze in the groin crease for obese patients to prevent fungal overgrowth).
- Remove closed-suction drains when output is <30–50 mL/day on consecutive days (typically 3–17 days); an oral suppressive cephalosporin can continue until drains are out. Remove sutures/staples on day 15.
Adverse Events
Wound infection, skin flap necrosis, wound dehiscence, hemorrhage, seroma/lymphocele, lymphedema, DVT, and sepsis — complication rates reported as high as 50%. Reduce them with clips (not electrocautery) for lymphatics, inguinal pressure dressings, antibiotics, and compression stockings. A palliative indication is a strong risk factor for complications.
Minimally Invasive Approach
Endoscopic (video-endoscopic) inguinal lymphadenectomy achieves a similar node yield with lower morbidity than contemporary open series.