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The European Association of Urology (EAU) recommends a risk-adapted approach to removal of inguinal lymph nodes during surgery for penile cancer. In this way, men who are unlikely to derive a survival benefit from the procedure will be spared the associated morbidity. Recently, two groups have tested the real-world utility of the EAU guidelines.

The guidelines recommend inguinal lymphadenectomy for patients at high risk of occult metastasis; that is, those with pT2–pT4 and grade 3 disease, or evidence of lymphovascular invasion. Following an anecdotal observation that few such patients actually undergo the recommended procedure, Timothy Johnson and his US-based collaborators interrogated the Surveillance, Epidemiology and End Results (SEER) database.

Lymph nodes had been removed from just one-quarter of the 593 high-risk SEER-registered patients. Survival at 5 years was improved by excision of at least eight nodes. Johnson et al. conclude that better adherence to the EAU guidelines in the US would enhance patient outcomes.

Simon Horenblas and his Europe-based team have come to a somewhat different conclusion. They studied 342 men with clinically node-negative invasive penile squamous cell carcinoma. Almost three-quarters were at high risk of occult metastasis according to the EAU stratification.

Nevertheless, Horenblas' team performed complete ipsilateral lymphadenectomy only when dynamic sentinel node biopsy was positive. During a median follow-up period of 31 months, occult nodal involvement was detected in one-fifth of patients; sentinel node biopsy had been negative in six of these men.

Adherence to the EAU recommendation would have resulted in removal of lymph nodes from almost 200 patients who showed no evidence of occult metastasis during follow-up. The authors conclude that sentinel node biopsy is currently a superior means of identifying patients who will benefit from lymph node dissection.