Abstract
Introduction: In penile cancer, guideline-concordant invasive nodal staging in clinically node-negative (cN0) patients must balance diagnostic value against perioperative harm. We quantified early perioperative outcomes within a guideline-concordant nodal staging pathway, comparing primary dynamic sentinel node biopsy/sentinel lymph-node excision (DSNB/SLNE) with completion inguinal lymph-node dissection (ILND) performed after sentinel node positivity in a stage-restricted pT1b+ cohort. Methods: Single-center retrospective observational cohort study at a tertiary referral center, January 2013–December 2024. Of 127 screened patients undergoing any groin procedure, 98 had complete datasets; the primary analysis was restricted to pT1b+ disease (n = 61). Primary outcomes were 30-day major complications (Clavien-Dindo ≥III) and length of stay (LOS). Secondary outcomes were type-specific complications, unplanned readmission, and reoperation. Outcomes were captured per procedure using distinct 30-day windows. Paired within-patient analyses used exact McNemar and Wilcoxon signed-rank tests; unpaired sensitivity analyses used Fisher’s exact and Welch’s t tests. Results: In the pT1b+ cohort, 61 patients underwent primary SLNE/DSNB, and 30 subsequently underwent completion ILND after sentinel node positivity. For perioperative analyses, procedures were evaluated at the procedure level (61 SLNE procedures; 30 completion ILND procedures). Major complications occurred in 4/61 (6.7%) after SLNE versus 8/30 (26.7%) after completion ILND (absolute difference 20.0 percentage points; Fisher’s exact p = 0.0175). In paired analyses (n = 30), discordant events favored SLNE (matched OR 0.12, 95% CI 0.02–1.00; exact McNemar p = 0.039). LOS was longer after completion ILND; the paired median within-patient difference was +6 days (Wilcoxon p = 0.000238), and unpaired analyses showed a mean difference of approximately +8.68 days (Welch’s t-test p = 0.00273). Completion ILND had higher 30-day rates of lymphocele, reoperation, readmission, infection, impaired wound healing, skin necrosis, and sepsis. Conclusion: In a guideline-aligned cN0, pT1b+ pathway, primary DSNB/SLNE was associated with substantially lower early perioperative burden than completion ILND after sentinel node positivity while identifying the subgroup requiring therapeutic escalation. These findings quantify the additional morbidity associated with escalation after positive sentinel staging rather than a head-to-head comparison of equivalent primary strategies.
